Preliminary Outcomes from PrEP Well: A Community-led, Multicomponent HIV Prevention Strategy Implemented in a Transgender Community Health Center

Transgender and nonbinary (TGNB) individuals are disproportionately impacted by HIV, particularly those who identify as racial/ethnic minorities and those who are socioeconomically disadvantaged. Pre-exposure prophylaxis (PrEP) is a highly effective medication to prevent HIV infection, but many TGNB individuals encounter barriers to PrEP uptake and adherence that limit fully realized preventive benefits. We developed PrEP Well, a multicomponent community-led program, to scale and sustain comprehensive PrEP services from a TGNB-led community organization that provides gender-affirming healthcare and social services. We used implementation science frameworks to evaluate initial program outcomes and contextual influences on program implementation. Preliminary data from August 2022 through January 2024 showed promising implementation and effectiveness outcomes. During that time, 113 primarily low-resourced TGNB clients were educated about PrEP and received an HIV test, of whom 60 (53%) attended a visit with a provider and received a PrEP prescription. At 30-day follow-up, urinalysis confirmed uptake of PrEP among 50 (83%) of the clients prescribed PrEP. At 90-day follow-up, 43 (72%) demonstrated continued use of PrEP and 40 (67%) showed protective levels of PrEP adherence. Qualitative interviews and surveys indicated that clients, staff, and leadership viewed the PrEP Well program as highly acceptable, feasible, and sustainable (including willingness to address persistent implementation barriers). Referral patterns and rates of PrEP uptake suggested increasing integration of PrEP Well into the TGNB community center over time. The PrEP Well program demonstrates the potential for TGNB communities to address HIV inequities by integrating community-led HIV prevention services with gender-affirming healthcare in TGNB-specific health centers.

Cultural adaptation of clinic-based pediatric hiv status disclosure intervention with task shifting in Eastern Uganda

BACKGROUND

HIV status disclosure remains a major challenge among children living with perinatally acquired HIV with many taking treatment up to adolescence without knowing their serostatus. This non-disclosure is influenced by factors like fear of the negative consequences of disclosure. Since HIV status disclosure has been found to have good effects including improving treatment adherence and better mental health outcomes, there is a need to design interventions aimed at improving disclosure rates among children living with HIV. This study aims at adapting a clinic-based pediatric HIV status disclosure intervention and tasking shifting from healthcare workers to caregiver peer supporters in Eastern Uganda.

METHODS

The adaptation process involved consultations with caregivers, healthcare workers involved in the care of children living with HIV, researchers in this field, intervention developers, and other experts and stakeholders. This was done through conducting FGDs with HCWs, caregivers, and peer supporters and consultations with researchers in the field of HIV. The original intervention manual was translated to Lusoga which is the commonly spoken dialect in this region. Collected qualitative data were analyzed using an inductive approach to develop themes and subthemes. Written informed consent will be obtained from all participants before participation in the study.

RESULTS

A total of 28 participants were involved in the FGDs, while two pediatricians and two HIV researchers/specialists were consulted. Six themes were generated in relation to all suggested changes to the original manual which were related to: (1) sociocultural beliefs/norms/perceptions (5 FGDs), (2) boosting caregiver's confidence for disclosure (5FGDs), (3) disclosure mode, environment, and person (4 FGDs), (4) health facility/system related changes (3 FGDs), (5) reorganization/paraphrasing (3FGDs) and (6) age appropriateness (2FGDs).

CONCLUSION

This study emphasized that whereas some aspects of intervention can apply to various contexts, there is a need for cross-cultural adaptation of interventions before being implemented in settings where they were not developed.

Barriers and facilitators in the implementation of nutrition interventions to prevent or treat malnutrition in older adults: A scoping review

Malnutrition among community-dwelling older adults (OAs) is prevalent, particularly in groups using healthcare services. Malnutrition burdens health, social, and aged-care systems in terms of expenses for hospital admissions and care in nursing homes and home care settings. Effective management requires early identification and multimodal interventions; however, studies report a significant gap between recommended nutrition interventions and current healthcare practices. Therefore, this study aimed to identify, present, and map existing evidence on barriers and facilitators in the implementation of nutrition interventions among OAs living in noninstitutional municipal healthcare settings. A scoping review following the Joanna Briggs Institute guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews checklist were conducted. The study included evidence from bibliographic databases and gray-evidence sources that identify barriers and/or facilitators from stakeholder perspectives that influence the implementation of nutrition interventions for malnutrition prevention or treatment among OAs (≥65 years) in noninstitutional municipal healthcare settings. Stakeholders were OAs, informal caregivers, or healthcare professionals (HCPs). Thirty-seven articles were included and 10 categories identified. Barriers were (1) lack of knowledge and awareness among HCPs, (2) lack of resources, (3) lack of collaboration and communication, (4) missing links between healthcare settings, and (5) poor insight among OAs and caregivers. Facilitators were (1) education and training of HCPs, (2) self-care, (3) person-centered care, (4) technology in nutrition care, and (5) social and psychological factors. Findings from this review indicate an imperative need for targeted implementation strategies for developing evidence-based nutrition home care practice.

Influence of context on engagement with COVID-19 testing: a scoping review of barriers and facilitators to testing for healthcare workers, care homes and schools in the UK

OBJECTIVE

The UK government's response to the COVID-19 pandemic included a 'test, trace and isolate' strategy. Testing services for healthcare workers, care homes and schools accounted for the greatest spend and volume of tests. We reviewed relevant literature to identify common and unique barriers and facilitators to engaging with each of these testing services.

DESIGN

Scoping review.

SEARCH STRATEGY

PubMed, Scopus and the WHO COVID-19 Research Database were searched for evidence published between 1 January 2020 and 7 November 2022. This was supplemented by evidence identified via free-text searches on Google Scholar and provided by the UK Health Security Agency (UKHSA).

DATA EXTRACTION AND SYNTHESIS

Data were extracted by a team of reviewers and synthesised thematically under the broad headings of perceptions, experiences, barriers and facilitators to engaging with the COVID-19 testing programme.

RESULTS

This study included 40 sources, including 17 from projects that informed UKHSA's decisions during the pandemic. Eight themes emerged and were used to categorise barriers and facilitators to engaging with the testing services for healthcare workers, care homes and schools: (1) perceived value, (2) trust in the tests and public bodies, (3) importance of infrastructure, (4) impact of media and social networks, (5) physical burden of the test, (6) perceived capability to undertake testing, (7) importance of relevant information and 8) consequences of testing.

CONCLUSIONS

Universal barriers and facilitators to engagement with the testing programme related to the core elements of each testing service, such as uncomfortable specimen collection and the influence of media and peers; these could be mitigated or leveraged to increase engagement across settings. However, the individuals involved, perceptions of value and available resources differed across services, leading to unique experiences between settings. Thus, consideration of context is crucial when designing and implementing a testing programme in response to a pandemic.

A call to action: Shared tertiary pedagogical frameworks for health care students to develop evidence-based knowledge and skills

AIM

To describe and discuss mechanisms for integration of evidence-based healthcare (EBHC) skills within nursing curricula informed by a conceptual model and the Sicily Statement.

BACKGROUND

The integration of evidence-based health care (EBHC) skills into health care education varies significantly across nursing programs. While common educational goals exist, educational disparities persist. The 2005 Sicily statement outlines foundational competencies for EBHC: formulating clinical questions, systematic evidence retrieval, critical appraisal and application of findings. Despite these competencies, EBHC is often viewed as peripheral in both undergraduate and postgraduate education.

METHODS

We compared congruency between a conceptual model for EBHC against the Sicily statement.

RESULTS

We emphasize the need for a unified approach to teaching EBHC, highlighting the JBI Model of EBHC as a comprehensive framework that aligns with the Sicily statement. The JBI Model encompasses evidence generation, synthesis, transfer and implementation, providing a structured method for embedding EBHC into health care curricula. By promoting a transdisciplinary pedagogical approach, the JBI Model seeks to enhance student engagement and competency in the EBHC skills and knowledge crucial for developing health care professionals equipped to adapt to evolving evidence and practice needs.

CONCLUSIONS

The authors call for an international methodology group to foster the adoption and evaluation of the JBI Model in diverse educational contexts, ultimately aiming to cultivate a workforce that is proficient in applying the best available evidence in clinical settings. The integration of EBHC into educational frameworks is positioned as essential for improving health care outcomes and promoting evidence-informed practice globally.

Exploring the Correlation Between Patient Safety Culture and Adverse Medical Events Using Failure Mode and Effect Analysis (FMEA)

Objective

This study aimed to explore the correlation between medical safety adverse events and patient safety culture through the lens of Failure Mode and Effect Analysis (FMEA).

Methods

Sixty patients from a hospital were selected as the research subjects, alongside 440 medical staff members (including clinical, medical technology, and management personnel) who participated in the study. The general demographic characteristics of medical staff, patient safety culture, and adverse medical safety events were investigated. FMEA was employed to analyze the relationship between medical safety adverse events and patient safety culture, using the risk priority number (RPN) as a key metric.

Results

A comparison of RPN values before and after FMEA intervention revealed that the RPN values of each failure mode significantly decreased post-intervention. Correlation analysis showed significant relationships between medication errors and several factors: "incident reporting frequency" (OR=0.706), "manager expectations and actions to promote patient safety" (OR=0.733), and "management support for patient safety" (OR=0.755). Pressure ulcers were significantly correlated with "manager expectations and actions to promote patient safety" (OR=0.729) and "shift and transfer" (OR=0.707). Falls were notably associated with "interdepartmental cooperation" (OR=0.735), "feedback and communication about errors" (OR=0.756), and "shift and transfer" (OR=0.660). Additionally, a strong correlation was identified between adverse events and "management support for patient safety" (OR=0.701).

Conclusion

Utilizing FMEA to analyze the correlation between medical safety adverse events and patient safety culture is effective in identifying specific dimensions of these events related to safety culture. This enables the development of targeted interventions to mitigate adverse events and enhance patient safety.

Unique and shared partner priorities for supporting engagement in knowledge mobilization in pediatric pain: a best-worst scaling experiment

BACKGROUND

Engaging in partnerships is key to the success of knowledge mobilization (KM) activities; however, how best to engage partners in KM activities in the context of paediatric pain and children's health more broadly is not well understood. There is limited guidance on what supports the development of effective partnerships in KM activities with a variety of partner types. The purpose of this study was to examine the preferences and priorities of three partner groups (i.e. health professionals, researchers and patient/caregiver partners) when it comes to supporting their engagement in KM activities within paediatric pain and children's health.

METHODS

We used a case 1 (object case) best-worst scaling (BWS) experiment, a stated preferences method to assess priorities and relative importance of factors related to supporting engagement in KM activities and compare their importance across the three partner groups. Participants completed 12 tasks requiring them to select items that were most and least important to supporting their engagement in KM activities. A total of 11 items, generated through a previous elicitation task, were included in the balanced incomplete block experimental design for the BWS. Difference scores and ratio values were calculated for each group and relative comparisons were observed across groups.

RESULTS

A total of 127 participants completed the BWS experiment. All partner groups agreed that items related to relationships within teams were among the most important, while pragmatic items related to executing KM were amongst the least important. While there was relative similarity in the items ranked as important, varying priorities also emerged for each group; fit of KM activities in the clinical context was particularly important among researchers, while flexible communication was relatively more important within the patient/caregiver group. Health professionals differed the least from the other groups.

CONCLUSIONS

Different partner groups prioritized strong relationships when it comes to supporting engagement in KM activities, reinforcing the importance of connections in KM processes. There was nuance, however, around how partner groups valued various aspects of relationships. Individuals leading KM initiatives in paediatric pain and children's health should discuss relationships and pragmatics with partners to ensure successful collaboration and impactful activities.

Supporting safe disclosure of sexual violence in healthcare settings: findings from a realist evaluation applying candidacy theory through a trauma-focused lens

OBJECTIVES

Most people who have experienced sexual violence (SV) will disclose the event(s) to someone. Key recipients of disclosure are those working in healthcare, and using sexual and reproductive health services can be an important step in accessing necessary medical care and being signposted to other services. Accessing this care and disclosing SV can be challenging. Evidence is lacking about how best to create a safe environment for disclosure to take place, how services can make changes to better facilitate this experience and what changes matter most.

DESIGN

Realist evaluation.

SETTING

Sexual and reproductive health settings.

PARTICIPANTS

1-1 interviews with service users who have disclosed SV (n=18), three focus groups with healthcare professionals and survey respondents (n=2007).

OUTCOME MEASURES

Initial programme theories of what works, for whom and in what context were tested and refined with empirical data from a national survey, 1-1 interviews and focus groups. The final steps are presented here, bringing strands of the study together and informed using substantive theory.

RESULTS

The key steps in using healthcare on disclosure of SV relate to self-identification as a worthy candidate irrespective of background or presentation, ensuring empowerment during navigation of services, initial access to sexual healthcare made straightforward, validation by healthcare professionals when receiving disclosures, choice and control for service users during a collaborative interaction with healthcare professionals and aftercare that reflects needs particularly of minoritised groups.

CONCLUSIONS

We propose a novel way of considering Dixon-Woods' candidacy theory seen through a trauma-informed lens for healthcare following SV, and how, by holding a trauma-informed lens to candidacy, steps of healthcare access and utilisation can be framed to ensure a safer environment for disclosure. This modified substantive theory marks the chosen endpoint of the realist evaluation and provides a transferable programme theory that can be considered in other settings.

The spillover effects of Medicare's comprehensive care for joint replacement (CJR) model in California

The Comprehensive Care for Joint Replacement (CJR) model, a bundled Medicare payment for lower extremity joint replacement (LEJR), was initially randomized across the United States, providing a unique opportunity to study the broad impact of this alternative payment model. This study aimed to determine the spillover effects of the CJR model on older patients in California covered outside of the traditional Medicare program. The study analyzed hospitalizations for hip and knee joint replacement in California between January 2014 and December 2017 from the California Patient Discharge Dataset. The study used event study and difference-in-differences models to estimate changes in discharge-related outcomes in hospitals in treated and control areas before versus after CJR implementation (April 2016). Main outcomes were hospital length of stay and home discharge rates. All LEJR patients admitted to the treated or control hospitals were included in the study regardless of their primary payers. Of 312,914 analyzed LEJR hospitalizations (mean [SD] age, 68.3 [11.3] years; 189,575 [60.6%] women; 15,374 [4.9%] black), 113,590 (36.3%) were covered by traditional Medicare (TM), 83,277 (26.6%) were covered by Medicare Advantage (MA), and 116,047 (37.1%) were without Medicare coverage. After program implementation, TM and non-Medicare patients in treated hospitals experienced reductions in length of stay (-4.0% & -1.0%, p < 0.05) and TM, MA and non-Medicare patients in treated hospitals experienced increases in home discharge rates (3.4%, 4.7% & 2.3%, p < 0.001) relative to patients in untreated hospitals. CJR affected health care for non-targeted populations. Evaluating the program based on traditional Medicare beneficiaries alone does not capture the entire effect of the program on older adults.

Characterization and Optimization of the Subsalve Helmet Ventilation Circuit in a High-Fidelity Acute Respiratory Distress Syndrome (ARDS) Lung Model

Purpose

The Subsalve helmet continuous positive airway pressure (CPAP) circuit is a low-cost, easy to implement non-invasive ventilation option for treatment of acute respiratory failure. The circuit is simple to set up and operate, and is designed to be used with any commonly available continuous positive airway pressure device.

Model Materials and Methods

Simulation of an acute respiratory distress syndrome (ARDS) patient allows optimization of treatment parameters without risk. The boundaries of safe and effective helmet CPAP treatment were measured in the TestChest® lung simulator with AQAI SIS software. The capabilities of the TestChest allow for representation of complex breathing patterns, simulation of muscular fatigue, and the ability to model patients with worsening ARDS. Treatment settings were tested by varying CPAP pressure and oxygen flow rate in a simulated ARDS patient.

Results

Moderate CPAP pressure led to significant increases in SpO2 (oxygen saturation) (10% increase at 14 cmH2O pressure) and maintained improvements compared to the control even at the latest stage of the disease. When oxygen was introduced, patient SpO2 increased proportional to the oxygen flow rate. 5 liters per minute (LPM) oxygen increased patient SpO2 by 3% in the severe ARDS model and 30 LPM oxygen increased SpO2 by 7%. Moderate pressure led to significant increases in SpO2 comparable to high concentrations of oxygen. CO2 does not accumulate in the helmet as long as the minimal flow rate (60 LPM of air) is maintained during treatment.

Conclusion

Our data demonstrate that the Subsalve helmet CPAP circuit, with limited oxygen availability, is an effective treatment strategy for ARDS patients in low-resource settings. Moderate positive end expiratory pressure (PEEP) is recommended to improve blood oxygenation. Subsalve has the potential to conserve critical resources in future epidemics.

Are we out of the woods yet? Youth-developed recommendations on recovery from the COVID-19 pandemic: A national Delphi study

OBJECTIVES

To generate concrete, youth-derived recommendations to support Canada's post-pandemic recovery from COVID-19 to support youth mental health and substance use (MHSU), economic, and educational recovery.

METHODS

Using a virtual, modified Delphi, participants rated recommendation items over three rounds, with the option to create their own recommendation items. A priori consensus was defined as ≥ 70% of the entire group, or subgroups of youth (e.g., age, race/ethnicity, gender and sexual identities), rating items at a 6 or 7 (on a 7-point Likert scale). Items were dropped in subsequent rounds if they did not achieve consensus. Qualitative responses were analyzed using content analysis for Round 1.

RESULTS

A total of 40 youths participated in Round 1, with good retention (97.5%) in subsequent rounds. Youths achieved consensus on eight recommendations to support post-pandemic recovery. Youths endorsed post-pandemic strategies that prioritize the implementation of effective, accessible, and low-cost MHSU services in schools, workplaces, and communities; the integration of MHSU education into school lessons; increased awareness about MHSU services in schools and workplaces; and the prioritization of health and well-being in schools and workplaces.

CONCLUSION

Findings indicate the need for stronger partnerships between schools, community-based MHSU services, and hospitals, and job opportunities that pay a living wage.

Developing a new pragmatic tool for assessing contextual fit and feasibility of evidence-based interventions towards effective implementation in global health

INTRODUCTION

Understanding the contextual fit and feasibility of evidence-based interventions (EBIs) constitutes an important aspect of implementation research to inform policy decisions for their uptake and sustainability in any given context (eg, setting, sector and population). Yet current methodologies, which attempt to assess contextual fit and feasibility of EBI as key preimplementation outcomes using a reductionist approach with summative scores, fall short in capturing the multiple forms of interactions and influences of constructs and contextual factors associated with EBI implementation in a real-world situation.

METHODS

Between 18 February 2023 and 5 August 2023, we designed a novel tool through an ongoing collaborative effort of researchers, global health practitioners, policy makers and populations from low- and middle-income countries and high-income countries using a five-step sequential process. This process included step 1 (stakeholder envisioning), step 2 (evidence synthesis), step 3 (evidence deconstruction), step 4 (stakeholder consensus and conceptual framework development) and step 5 (tool development, deployment and standardisation).

RESULTS

Following this process, a pragmatic contextual fit and feasibility (PCoF) tool was developed with acceptability and preference derived as potentially stable constructs for contextual fit outcome and willingness to use and resource availability for feasibility outcome. The assessment of contextual fit and feasibility outcomes with strong, somewhat, and weak ratings was determined by a total of nine real-world scenarios of construct interactions in either case. Strong, somewhat and weak ratings of contextual fit or feasibility accounted for one, seven and one construct interaction(s), respectively.

CONCLUSION

This initial development of PCoF is a step in the right direction for addressing the complexity associated with EBI implementation that is in part posed by contextual factors and cannot be completely explained by summative scoring and arbitrary rating approaches of existing tools. The use of PCoF as a research and policy decision-support tool, once extensively refined, validated and standardised across multiple contexts, has the potential to generate robust evidence on the contextual fit and feasibility of EBI and to meaningfully support researchers, policy makers and other stakeholders in informing the prioritisation, adaptation and equity-focused uptake and scale-up of EBI for improved population health and social outcomes.

"It's not just running the test": Operator experiences of implementing a decentralised hepatitis C point-of-care testing program in Australia

BACKGROUND

The decentralisation of hepatitis C virus (HCV) point-of-care testing is a core part of Australia's strategy to meet WHO elimination targets. However, little is known about the experiences of providers implementing these interventions and thus what is needed to improve integration. The study aim was to understand operator experiences, including the challenges and enablers, of implementing point-of-care testing as part of a National Point-of-Care Testing Program.

METHODS

Providers who were enrolled in the National Program and qualified to perform point-of-care testing were invited to participate in semi-structured qualitative interviews between April and August 2023. Data were analysed according to iterative categorisation and themes were organised according to Service delivery, Resources, and Governance-elements of the Health Systems Dynamics Framework.

RESULTS

Of the 31 participants, most were from New South Wales (n = 17), were practicing clinicians (n = 18), worked in outpatient or community health clinics (n = 21), and had no previous experience using a molecular point-of-care testing device (n = 24). Many participants struggled to deliver HCV testing and treatment according to national HCV management guidelines. Some participants avoided using the point-of-care testing device altogether. Others found it challenging to manage the administrative load of delivering the National Program, including planning outreach and following-up clients. These challenges were exacerbated by workforce shortages, difficult-to-navigate IT systems, and a lack of specific implementation advice from Program leadership.

CONCLUSIONS

This study illustrates several challenges to and enablers of adopting a decentralised HCV point-of-care testing program, highlighting the need to further explore what providers require to effectively implement these interventions.

Knowledge transfer interventions on cancer in Africa and Asia: a scoping review

BACKGROUND

Cancer is a growing public health concern in Africa and Asia, where access to effective healthcare and resources is often limited. There is an urgent need for evidence-based cancer control policies in Africa and Asia, along with systems for prevention, early detection, diagnosis and treatment, and palliative care. This emerging issue has garnered growing interest from international institutions but there has been little visible action, and the existing knowledge remains scattered and fragmented. This scoping review aims to explore the breadth and scope of evidence regarding knowledge transfer interventions to enhance cancer care in Africa and Asia.

METHODS

We conducted a systematic search of Embase, Emcare, ERIC, APA PsycInfo, Medline, and Google Scholar, supplemented by expert bibliographies and references. Peer-reviewed empirical studies in English or French from January 1978 to September 2024 were included. Data were organised using the AIMD (Aims, Ingredients, Mechanism & Delivery) framework. Study quality was presented using the Mixed Methods Appraisal Tool.

RESULTS

The scoping review examined seven articles providing evidence on five unique interventions. The interventions included target both decision-makers and health professionals and aim to strengthen evidence-based cancer control policies and implementation strategies. The interventions documented have all been initiated by external actors, mainly international institutions or researchers from high-income countries, in collaboration with African and Asian stakeholders. In addition, some researchers have been involved in participatory research projects designed to enable decision-makers to implement evidence-based cancer control policies and programmes.

CONCLUSIONS

This scoping review highlights a critical lack of evidence on knowledge transfer interventions in cancer care across Africa and Asia, partly due to limited funding for non-communicable diseases. It calls for the integration of knowledge transfer components into all cancer research and interventions, supported by robust evaluation strategies, to develop evidence-based, economically feasible, and culturally appropriate policies, guidelines and interventions that can be used in nations with limited healthcare resources to improve cancer outcomes.

Developing Implementation Science Capacity Within Health Departments Located in Ending the HIV Epidemic Priority Areas

BACKGROUND

Embedding implementation science (IS) research into health departments can foster relevant and robust research that is responsive to health department needs. However, few health department evaluators have formal IS training. Building internal health department capacity to conduct rigorous evaluation has the potential to catalyze improvements in Ending the HIV Epidemic (EHE) service delivery.

SETTING

In-person IS workshop for EHE evaluators held in Seattle, WA, May 2024.

METHODS

We conducted a needs assessment with EHE jurisdictions to identify their capacity and expertise in IS, and desire for additional training. Based on this assessment, we developed a 2.5-day workshop to equip health department epidemiologists/data managers/program coordinators with the background and tools needed to conduct evaluations of activities within their EHE programs. The workshop covered 9 core IS competencies.

RESULTS

There were 14 workshop participants, representing 25% of the 57 EHE jurisdictions. Participants felt that the workshop increased their IS technical skills [IS knowledge rating (0 to 5 scale) increased from a mean of 2.5 (day 1) to 4.2 (day 3)] and that the workshop helped them understand how implementation outcomes can strengthen their evaluation. They also noted that the workshop provided them with a useful framework to contextualize and evaluate EHE activities, with 83% of participants strongly agreeing that the content learned could be applied to their health department work.

CONCLUSIONS

IS short-courses are a promising strategy to increase health department evaluators' understanding of IS and to gain confidence in how to apply IS methods to their own EHE evaluations.

Building the Road to End the HIV Epidemic Through Coordinating and Capacity-Building Hubs to Enhance the Science of HIV Implementation REsearch (CHESHIRE): Reflections and Directions

BACKGROUND

Because implementation remains the biggest challenge to Ending the HIV Epidemic in the United States (EHE), since 2019, the National Institutes of Health (NIH) has funded 248 supplements to identify best practices for delivering evidence-based HIV interventions. NIH also funded a coordination center [Implementation Science (IS) Coordination Initiative "ISCI"] and 9 consultation hubs ("Hubs") to provide technical assistance and cross-project information sharing, measure harmonization, and data synthesis. This article describes this unique capacity-building model, lessons learned from the first 5 years, and opportunities created by this infrastructure.

METHODS

Beginning in FY20, Hubs were assigned 7-9 funded supplement projects in EHE priority jurisdictions. Primary Hub services included direct coaching, multiproject meetings, communities of practice, and technical webinars. ISCI and the Hubs met monthly to reflect on project support, discuss ways to enhance HIV IS broadly, and assess projects' use of Hub services.

FINDINGS

Hub engagement strategies included grouping projects by HIV intervention type, setting data reporting expectations early, and tailoring engagement based on EHE team IS expertise. Support and coordination provided by the Hubs and ISCI have developed generalizable IS knowledge from local knowledge (e.g., publications and tools). The network of ISCI, the Hubs, and EHE projects have also led to infrastructure for conducting multisite HIV implementation research.

IMPLICATIONS FOR DI SCIENCE

The Hub model is a novel, systemwide approach for rapidly improving IS capacity in a field. Implementation of this model will continue to be refined through an ongoing evaluation and as the funding transitions to regular, nonsupplement NIH funding mechanisms.

Exploring the efficacy and safety of lecanemab in the management of early Alzheimer's disease: A systematic review of clinical evidence

BackgroundAlzheimer's disease (AD) is a growing neurodegenerative disorder causing cognitive decline, memory loss, and functional impairment. Lecanemab has shown safety and efficacy in clinical trials.ObjectiveThis review aims to understand the clinical evidence of lecanemab's effectiveness and safety in managing early AD.MethodsA systematic search was conducted using the Scopus database and ClinicalTrials.gov. Studies from 2014 to 2024 on lecanemab's safety, efficacy, and clinical outcomes for AD were included. Data extraction involved two independent reviewers, with synthesis using qualitative methodology.ResultsFindings from 13 studies and 13 ongoing clinical trials were reported, showing that lecanemab substantially reduces amyloid plaque load in the brains of AD patients. The therapeutic regimens vary across reported studies and trials, ranging from 2.5 mg/kg biweekly, 5 mg/kg monthly, 5 mg/kg biweekly, 10 mg/kg monthly, and 10 mg/kg intravenously biweekly. The Clarity AD phase 3 trial, the AHEAD study, and the DIAN-TU-001 trials have reported positive study outcomes with robust efficacy and safety outcomes with minimal side effects. Completed and ongoing trials report on the onset of amyloid-related imaging abnormalities (ARIA) and the continuation of care status following the onset of ARIA in these patients. The common infusion-related reactions were observed in 26.4% of the lecanemab group compared to 7% in the placebo group.ConclusionsThe management of AD has evolved over the years with the introduction of novel therapeutic agents like lecanemab. While its safety profile is generally favorable, careful monitoring is essential.

Hmong Promoting Vaccines eHealth website: a community-based participatory research pilot to evaluate dissemination and implementation strategies for primary care and educational contexts

BACKGROUND

Human papillomavirus (HPV) vaccination rates among Hmong American adolescents are significantly lower than national averages, despite higher cervical cancer rates in this population. eHealth can improve vaccine uptake, especially in the COVID-19 era. Our community-based participatory research team developed and evaluated a culturally-tailored website ( https://hmonghpv.com ) featuring educational modules on HPV and HPV vaccines in Hmong and English for Hmong adolescents and their parents. This pilot study aimed to determine the most effective dissemination and implementation (D&I) strategies within schools and primary care clinics using community-engaged methods, including community-based participatory research (CBPR), an understudied area in D&I research. CBPR has been underutilized in D&I research, yet its participatory approach ensures that marginalized voices are included, offering valuable insights for implementing and sustaining culturally adapted interventions to enhance uptake and long-term impact.

METHODS

Our CBPR team included Hmong researchers, university researchers, a public health advocate, and a family medicine physician-researcher. We conducted pre- and post-implementation interviews with six user organizations and seven disseminator community-based organizations to guide the development and assessment of D&I strategies for the website. Using template analysis, we analyzed the pre-implementation data. We then partnered with the user organizations to co-design individualized D&I plans that they implemented during an eight-week pilot period. We used Google Analytics and a Qualtrics survey to assess website use post-implementation.

RESULTS

During implementation, user organizations promoted the website to 300 new users, who spent an average of nearly 12 min on the site. The most robust dissemination (n = 117) occurred in a Hmong charter school that integrated the website into their health education curriculum. Post-implementation interviews revealed that D&I plans that fit into clinic workflows and school curricula had the most robust implementation, and that clinic staff found discussing HPV vaccines most useful during adolescent preventive health visits. Challenges included time constraints, lower receptivity to vaccine conversations at non-preventive visits, and adolescents' preference for alternatives to paper handouts. Disseminator organizations showed strong interest in scaling the website for greater reach in Hmong and non-Hmong populations.

CONCLUSION

This pilot study demonstrated the feasibility of disseminating and implementing a culturally-tailored educational website for HPV education in educational and primary health care settings. Health education curricula in culturally-specific schools proved to be the most effective dissemination modality. A dissemination toolkit with support materials is available to facilitate using the website within educational and primary care contexts. Additionally, using a CBPR approach provided valuable implementation insights to enhance the intervention's contextual validity and sustainability.

Leveraging Implementation Science to End the HIV Epidemic in the United States: Progress and Opportunities for Federal Agencies

ABSTRACT

Implementation science has emerged and matured as an essential field for HIV treatment and prevention, designed to bridge the gap between research and practice by identifying opportunities to overcome barriers to implementation of effective interventions, and to accelerate the replication and scale-up of HIV care innovations. In this article, we describe activities and collaborations among the Centers for Disease Control and Prevention, the Health Resources and Services Administration, and the National Institutes of Health to optimize the impact of national federal funding opportunities aimed at identifying effective and replicable HIV care and prevention interventions, improving HIV health outcomes, and reducing HIV incidence in the U.S. These activities are outlined in the context of the Ending the HIV Epidemic in the U.S. Initiative, which was enacted across U.S. Department of Health and Human Services agencies, providing new funding and outlining an operational plan to further guide federal agencies in their specific roles and funding areas.In describing these activities and opportunities, we aim to demonstrate how implementation science is being increasingly leveraged to accelerate progress towards ending HIV through scale-up and dissemination efforts. Continued collaboration through federal implementation science will be instrumental in reaching Ending the HIV Epidemic goals.

Pre-Exposure Prophylaxis Awareness and Demand Creation: Overlooked Populations and Opportunities to Move Forward

BACKGROUND

Pre-exposure prophylaxis (PrEP) for HIV prevention has been available since 2012, but uptake remains disappointing and inequitable. Furthermore, there is little evidence on the effectiveness of interventions to increase PrEP demand among priority populations in the United States. The objectives of this article were to describe how consumer perceptions of PrEP vary by distinct population groups and identify gaps in PrEP awareness, knowledge, and interest.

METHODS

We synthesized evidence-based interventions to improve demand for PrEP in populations heavily burdened by HIV. The focus centered on consumer factors, how people's awareness of PrEP, especially people who are likely to benefit, influences PrEP uptake.

RESULTS

Awareness and equity in PrEP use among vulnerable populations in the United States remain low because of both demand-side obstacles and accessibility challenges. Designing an effective package of interventions to increase demand for PrEP involves integrating strategies that address awareness, knowledge, interest/motivation, and access.

CONCLUSIONS

The underutilization of PrEP among the 1.2 million individuals who could benefit from it highlights the need for effective demand creation to reduce disparities. To effectively increase awareness of the benefits of PrEP requires consideration of the characteristics of the target population and the structural inequalities that contribute to PrEP-related disparities. Demand creation activities can increase awareness, correct misconceptions, provide knowledge, and help people decide whether PrEP is a good fit for them. The utilization of implementation science frameworks is essential to address demand generation and supply-side barriers to PrEP use.

Two Pilots of an Implementation Science Training Program for HIV Prevention and Care Service Providers: Lessons Learned and Future Directions

BACKGROUND

Development, implementation, and dissemination of HIV-related implementation strategies require partnerships with affected communities, government agencies, and HIV service organizations. Implementation science (IS) training for partners is needed to ensure they can benefit from, and equally contribute to, implementation research (IR). Building IS knowledge and expertise in real-world practice increases providers' ability to offer evidence-based HIV interventions and effectively implement them at scale to achieve the goals of the national Ending the HIV Epidemic (EHE) initiative.

METHODS

National Institutes of Health funds the Implementation Science Coordination Initiative (ISCI) and the Sociostructural Implementation Science Coordination Initiative (SISCI) to support studies in the conduct of rigorous HIV IR through technical assistance, development of IS tools, and trainings for researchers and implementers. As part of these efforts, we created and evaluated 2 pilot IS training courses for HIV service providers: the Practitioner-Oriented Implementation Science Education (POISE) and the Implementation Practitioner Training (IPT). We discuss the importance of training for implementers, the development of our curriculum, lessons learned, and future directions for IS trainings.

CONCLUSIONS

Implementers play a critical role in IR, because they are the beneficiaries of the knowledge produced and are responsible for effectively implementing HIV interventions to achieve EHE goals. Few training courses in IS are specifically designed to meet the needs of those implementing HIV evidence-based interventions and little is known about how to design and deliver them to maximize training benefit. Both training pilots increased participants' ability to apply IS to their work. Participant input provides valuable feedback to improve future training.

Innovation in Providing Equitable Pre-exposure Prophylaxis Services in the United States: Expanding Access in Nontraditional Settings

BACKGROUND

Pre-exposure prophylaxis (PrEP) usage has slowly increased in the United States, but significant disparities persist across race, ethnicity, sex, gender, age, and geography. Determinants of PrEP inequities include stigma and medical mistrust, lack of patient-centered services, lack of access to clinical care, and organizational resistance to change-within a health care system that neglects these barriers.

METHODS

We describe 5 implementation strategies to providing PrEP in nontraditional settings to underserved populations, using an equity-based approach to address key structural determinants. The alternative settings used in these Ending the HIV Epidemic projects (community-based organizations, telePrEP, mobile clinics, pharmacies, emergency departments) were chosen for the setting characteristics and their serving structurally underserved populations.

RESULTS

Community-based organizations have earned trust within communities and can serve as hubs for comprehensive sexual health services, including PrEP. Telehealth, which expanded significantly because of COVID-19, can help overcome transportation and scheduling barriers to PrEP access. Mobile clinics can also broaden PrEP delivery by bringing tailored services directly to communities, often providing shorter wait times and extended hours. Pharmacists can prescribe PrEP in certain states through legislation or collaborative practice agreements, offering a convenient, community-based option. Emergency departments provide an alternative site for PrEP delivery, with the potential to reach individuals not currently engaged in regular care.

CONCLUSION

These alternative PrEP approaches can expand options for accessing PrEP and alleviate key barriers to care in traditional settings, although they may not eliminate all inequities. Offering more choices increases the likelihood that a broader population will be reached, thereby enhancing overall access to PrEP.

Improving Community-Engaged Implementation Science: Perspectives From "Ending the HIV Epidemic" Supplement Award Cases in the United States

BACKGROUND

Community-engaged research (CEnR) is fundamental to effective HIV prevention and treatment implementation, although limited in practice. We describe CEnR lessons learned by researchers in HIV-related implementation science to improve future CEnR.

SETTING

Academic-community research partnerships funded by the 2019-2021 National Institutes of Health Ending the HIV Epidemic (EHE) supplement awards.

METHODS

Seven individual awardees representing 8 EHE awards documented partnership characteristics and key CEnR experiences in an online form. Three semi-structured reflection sessions subsequently discussed experiences, identifying opportunities and barriers using qualitative thematic analysis, iterative dialogue, and illustrative case studies.

RESULTS

Awardees identified both partnerships newly established for the grant (60%) and preexisting collaborations (40%). Key perceived CEnR benefits included: new and better project ideas; improved project implementation; and priorities to guide future research. Prominent barriers included: administrative burdens resulting in delayed funding access that constrained partner engagement; limited grant timelines and funding for essential preimplementation partnership building; and limited recognition of key CEnR activities in academic success metrics. Adaptive responses to barriers included focusing short award periods on exploratory aims and building on extant community activities.

CONCLUSIONS

Systems-level redesign at the funder and university levels could improve CEnR equity, including accepting financial risk between grant award and funding receipt to facilitate completion of essential prework such as Institutional Review Board approvals and prevent the exclusion of the more financially constrained community partners or forcing unfunded effort provision and establishing appropriate support and promotion criteria for CEnR-engaged faculty. Thus, enabling CEnR good practices can improve future HIV-related implementation research and EHE goal achievement.

Integrating cardiovascular implementation science research within healthcare systems

Only 1 in 5 evidence-based interventions make it to routine clinical practice and the evidence generated from clinical research may take 17 years to be implemented. This represents a lost opportunity to improve clinical care in healthcare systems. Implementation science refers to the study of methods to promote the adoption and integration of evidence-based practices, interventions, and policies into real-world clinical settings to positively impact population health. Therefore, implementation roadmaps can be crucial for learning healthcare systems (LHS) to bridge the research-to-practice gap, particularly for cardiovascular disease which remains the leading cause of death in the United States. Implementation models exist, all of which require a thorough understanding of the key phases of implementation for effective healthcare system incorporation and optimization (pre-implementation, implementation, monitoring the implementation, evaluation, sustaining, and scaling-up or de-implementation). This review serves as a call-to-action for involvement of large-scale LHS for cardiovascular implementation science, and provides a roadmap by summarizing various implementation science models, highlighting key implementation phases and discussing successful initiatives to improve the process. We also assess challenges associated with implementation science and provide possible solutions to improve translation of evidence in real-world clinical settings.

Implementation Science Approaches to Addressing the Social and Structural Determinants of Health of Criminal-Legal Involved People Living With HIV to Improve HIV Care Outcomes

BACKGROUND

People living with HIV in the United States are overrepresented in the criminal-legal system and experience unique barriers to engagement in HIV care postincarceration. Individuals who are criminal-legal involved (CLI) experience worse HIV care outcomes compared to the general population. Interventions aiming to improve engagement and retention in HIV care for CLI populations are urgently needed. This study aims to highlight an array of NIH-funded research projects across the United States leveraging implementation science to investigate and design interventions aimed at addressing social determinants of health and improving HIV care outcomes among CLI populations in the United States.

SETTING

United States.

METHODS

In September 2023, the National Institutes of Health funded 47 new implementation research projects as part of the Ending the HIV Epidemic initiative, including 10 projects focused on addressing HIV among CLI populations. This paper highlights several projects that are addressing the social determinants of health affecting CLI populations living with HIV in the United States.

PROJECT OVERVIEW

The funded projects use innovative, community-engaged approaches to investigate and design interventions to address social determinants of health among CLI populations living with HIV including health care access, legal needs, social support, and holistic needs.

CONCLUSIONS

We believe these projects will substantially contribute to the evidence base to aid the development of guidelines and the implementation of programs that can be adopted and adapted by a wide range of settings working toward improving the health and wellness of CLI people living with HIV.

Generating Evidence for Effective HIV Implementation at Scale: The Value and Feasibility of a Network for Implementation Science in HIV

ABSTRACT

The Network for Implementation Science in HIV (NISH) was established to conduct multisite research to study real-world implementation of evidence-based HIV interventions across US contexts, and to generate generalizable knowledge around implementation strategies to support the achievement of Ending the HIV Epidemic goals. NISH sites represent diverse Ending the HIV Epidemic priority jurisdictions and include participation of multiple units within those sites (eg, multiple clinics and community-based organizations) and bring together research teams from multiple backgrounds within implementation science and the HIV service sector. We argue and provide examples of how NISH studies have and can contribute to the context versus generalizability debate, generate power in numbers, and synthesize, develop, and test implementation strategies that advance both effectiveness and equity. To date, the network has conducted observational studies exploring ongoing implementation and determinants across contexts, and the identification and codesign of strategies to be leveraged in future work. The next stage of network evolution is to leverage this infrastructure to test implementation strategies through nimble study designs built for fast-changing evidence and implementation environments. We argue that the initial successes of NISH warrant future investment to efficiently capitalize on developed infrastructure and optimize science that can effectively be scaled up to address our most critical questions to end the HIV epidemic and support communities most affected.

The Strategies Timeline and Activities Reporting Tables: Improving HIV Care by Improving the Reporting of Implementation Strategies

BACKGROUND

The United States has made significant progress toward achieving the goals of its Ending the HIV Epidemic initiative. However, systematic reviews on HIV implementation research have identified problems regarding strategy specification that limit the research's transparency and replicability, and in turn limit improvements regarding HIV care in real-world practice.

METHODS

The strategies timeline, activities, and resources (STAResources) Table, developed as part of the substance abuse treatment to HIV Care II Project, was completed for it and 3 other HIV implementation research projects funded by the National Institute of Health. Each evaluated it in terms of the extent to which it addressed prior recommendations on strategy specification; issues related to rigor and reproducibility; and the extent to which it seemed pragmatic, simple, adaptable, relevant, helpful, useful, acceptable, appropriate, suitable, applicable, and fitting. Each was rated on a 4-point scale (0 = not at all; 1 = a little; 2 = moderately, and 3 = very much).

RESULTS

Overall, the STAResources Table was rated favorably. It received a mean of 3.0 (SD = 0) in terms of being pragmatic, relevant, helpful, acceptable, appropriate, and applicable. The Strategies Timeline, Activities, and Rationale (STARationale) Table emerged during the process and was also rated favorably.

CONCLUSIONS

To help the Ending the HIV Epidemic initiative achieve its goals, there is a critical need for transparent and replicable implementation research on identifying the most effective strategies for equitably implementing evidence-based practices within real-world settings. Addressing this need, the Strategies Timeline and Activities Reporting (STAReporting)Tables are pragmatic tools for helping improve the transparency and replicability of implementation strategy research.

Strengthening the US Health Workforce to End the HIV Epidemic: Lessons Learned From 11 Ending the HIV Epidemic Jurisdictions

BACKGROUND

Supplements were awarded under the National Institutes of Health, ending the HIV epidemic (EHE) initiative to foster implementation science through community-engaged research. The objective of this study was to synthesize lessons learned, identify areas of research sufficiently studied, and present an agenda for future research on HIV health workforce development from a collaboration across 9 EHE projects in 11 jurisdictions in the United States.

METHODS

EHE supplement recipients completed a semistructured questionnaire to identify shared lessons learned about common themes of workforce development using the Consolidated Framework for Implementation Research and Expert Recommendation for Implementing Change frameworks. Data were synthesized to identify shared lessons learned, topic areas no longer in need of research, and next steps.

RESULTS

Project teams emphasized several strategies including clarifying roles and responsibilities, the need for dynamic training, and stigma mitigation as strategies to enhance the implementation of HIV prevention and treatment services. Strengthening organizational support through supportive supervision structures, ensuring sustainable funding, preventing turnover, addressing salary constraints, and establishing clear promotion and educational pathways were identified as useful workplace development strategies. Supplements identified lessons learned about deploying community engagement strategies to ensure communities were aware of HIV prevention and treatment services. Several areas sufficiently studied that can be deprioritized were identified and discussed.

CONCLUSION

A research agenda for workplace development moving forward is discussed with several recommendations to improve the implementation of HIV prevention and treatment programs.

Understanding implementation determinants of universal school meals through an equity-driven mixed methods approach

BACKGROUND

Policies, such as Universal School Meals (USM), are essential for preventing inequities in chronic disease risk among socially and economically marginalized populations. Implementing USM reduces food insecurity and obesity risk, among other academic/health outcomes; unfortunately, across the nation student participation (i.e., reach) is lower than expected, limiting its public health impact. Grounded in implementation science and health equity frameworks, this study aimed to: 1) investigate the determinants of implementing USM in a large, urban school district and 2) assess key challenges and supports across schools with varying levels of participation in USM.

METHODS

A needs and assets assessment was undertaken in the 2023-2024 academic year with the School District of Philadelphia to address implementation-related challenges for USM as part of a broader Implementation Mapping process. Overall, 8 schools (6 middle; 2 high) participated in a convergent mixed methods study comprising qualitative interviews, surveys, and mealtime observations. Data collection was grounded in the Consolidated Framework for Implementation Research (CFIR) and Health Equity Measurement Framework. Interviews were deductively coded through the CFIR; barriers were coded negatively (either -1 or -2), supports coded positively (+ 1 or + 2), and neutral determinants coded as 0. Schools were grouped into low, moderate, and high meal participation for disaggregated analysis and comparison of determinants across reach.

RESULTS

193 participants included teachers (29%), parents (26%), students (middle 14%; high school 10%), administrators (13.5%), and food service personnel (11%). Participants identified as Black/African American (43%), White (26%), Hispanic/Latino (20%), Asian (5%), Middle Eastern (1.8%), and other (3.8%). The strongest facilitators of USM implementation were Mid-level Leaders (i.e., climate leaders; M = 1.29[-1,2]) and High-level Leaders (i.e., administrators; M = 0.96[-1,2]); strongest negative USM determinants were Market Pressure (i.e., competitive foods; M = -1.35[-2,0]), and Relative Priority (M = -1.17[-2,-1]). Emerging differences between low and moderate/high participation groups were found in Culture, Assessing Needs of Recipients, Access to Knowledge/Information, Human Equality-Centeredness, and Implementation Leads. Overall, higher participation schools reported less stigma, more equitable implementation procedures, and more involvement from food service managers than lower participation schools.

CONCLUSIONS

Equity-focused strategies targeting key issues within and outside the school setting are needed to reduce stigma and increase capacity for implementation.

Progress and Priorities to End the HIV Epidemic by 2030: Combined Lessons From 120 US Implementation Research Projects

ABSTRACT

Five years into the US national Ending the HIV Epidemic (EHE) plan, it is a critical time to examine what has been learned and what still needs to be studied to achieve its 2030 goals of reducing new HIV infections by 90%. While much has already been gained from the 250+ individual National Institutes of Health-funded implementation research projects and the capacity building provided by the Implementation Science Coordination Initiative (ISCI) and 9 regional consultation hubs (RCHs), identifying generalizable implementation science lessons requires the synthesis of findings across multiple sites, studies, and/or contexts. This supplemental issue of JAIDS emphasizes collaborative papers that summarize shared HIV implementation knowledge from multiple EHE-funded research projects. The 24 papers herein represent work from 111 EHE supplement projects and 7 R01s happening in 40 EHE priority jurisdictions, as well as from ISCI, all RCHs, and federal partners. We identified the following 4 overarching themes: infrastructure for HIV implementation research, methods for conducting HIV implementation research with specific communities, implementation strategies to help deliver HIV-related interventions, and training in implementation science for the HIV workforce. Insights shared in this issue provide a clear pathway for the next phase of EHE, in which research infrastructure must remain robust, workforce investments must prioritize sustainability, and partnerships must continue to bridge local innovation with systemic change.

Policymaker Perspectives on Implementation Determinants of Rapid ART and Same-Day PrEP in Seven Priority Jurisdictions for Ending the HIV Epidemic: A Multisite Qualitative Study

BACKGROUND

Although rapid antiretroviral therapy (ART) and same-day pre-exposure prophylaxis models (henceforth "rapid START") are feasible, acceptable, and cost-effective in various contexts, significant barriers have hindered their broader implementation and scalability in the United States. Ryan White-funded clinics are cornerstones for HIV services, yet strategies are urgently needed to facilitate equitable rapid START adoption across contexts. This study aimed to identify common factors influencing rapid START to inform strategies applicable throughout jurisdictional settings.

METHODS

The Network for Implementation Science in HIV examined the current implementation of rapid START among diverse Ryan White Part A-D-funded organizations across seven Ending the HIV Epidemic jurisdictions across the United States. Semistructured interviews (n = 13) were administered from March 2023 to August 2024, with HIV leadership across jurisdictions to identify rapid START implementation determinants and strategies to catalyze rapid START delivery. Data were deductively analyzed using the Consolidated Framework for Implementation Research.

RESULTS

Prominent barriers to rapid ART implementation across settings included provider/patient hesitancy and awareness gaps, siloed care systems, and funding complexities. Prominent implementation facilitators included learning collaboratives, technology integration, and clear contracting language. Key constraints to same-day pre-exposure prophylaxis implementation included funding inequities and suboptimal client/patient awareness, whereas enablers included integrated care models, availability of starter packs, and medication-assistance programs.

CONCLUSIONS

Several consistent key barriers and facilitators spanned multiple Ending the HIV Epidemic jurisdictions despite contextual differences (eg, Medicaid expansion). Collaborative efforts between system leaders and service providers were universally characterized as essential for equitable adoption and penetration of rapid START models.

Development of the Applied Coaching Tool for Pediatric Rehabilitation Therapists: A Practice Support Tool for Therapists Coaching Parents of Young Children

AIM

Describes the development and implementation of the Applied Coaching Tool (ACT), and training protocol, to build coaching competency in therapists supporting parents of young children.

METHODS

The ACT was developed using literature review, draft tool creation, expert review and refinement. A training protocol for therapists to learn how to coach was developed using principles of adult learning, coaching and instructional design to increase learner competence and confidence.

RESULTS

The ACT framework includes five coaching events to support therapists to implement coaching practices including self-directed goals, learner-focused interventions with meaningful reflection, practice and feedback. Within the ACT, behaviors associated with coaching events were defined as overt therapist actions and elaborations - examples of interactional behaviors. The training plan for therapists consisted of a workshop, intentional practice with coaching feedback over a period of five months, and assessment of competence. Pilot implementation demonstrated evidence of acceptability, appropriateness, adoption and fidelity of the ACT.

CONCLUSION

Use of the ACT, and the training plan, provides practical clinical behaviors for therapists to coach families to be active participants in rehabilitation which may contribute to improvements in self-efficacy and motivation in therapy. Furthermore, it provides a reliable standard amongst therapists coaching in pediatric rehabilitation.

"The problem is not detection, it is treatment": exploring why women needing pre-cervical cancer care are lost to follow-up at the hospital in Iquitos, Peru

BACKGROUND

The objective of this study was to explore the barriers to follow-up - as well as potential ways to reduce these - of women with cervical lesions suspicious for cancer who were ineligible for primary-level treatment and needed, but did not receive, hospital-level follow-up in Iquitos, Peru.

METHODS

In-depth, semi-structured interviews were conducted with 18 HPV-positive women requiring hospital-level follow-up but for whom there was no documentation of completion regarding their experienced barriers to follow-up and suggestions to reduce these barriers. After thematically analyzing these patient interviews, interview findings about these topics were presented to seven doctors and five nurse-midwives at both the hospital and primary care levels. Finally, 19 health authorities and professionals discussed all findings and identified action steps for systems-level changes at a group model building workshop.

RESULTS

Patient-identified barriers to hospital care were mainly: (1) a limited patient understanding of follow-up or treatment steps (both prior to and after the hospital visit), and (2) administrative challenges to obtaining appointments or follow-up care at the hospital. Patients identified the utility of a patient navigator for this process to reduce these barriers. The healthcare professionals concurred with the barriers identified by the patients and the suggestion of a patient navigator, but further elucidated suggestions for change, including (1) differentiating referral for those with suspicion for cancer to prioritize those patients when referred to the hospital, (2) increasing information flow between the different levels of care through an integrated patient registry, and (3) improving provider education regarding HPV and the standard of care. The group model building workshop served as a space to discuss findings and action items that could potentially make these changes possible to ultimately improve the continuum of care.

CONCLUSIONS

Despite an overall increase in follow-up for HPV-positive women since the implementation of the new HPV-based screen-and-treat program, women suspicious for cervical cancer are still being lost to follow-up after being referred to the hospital. Systems-level improvements should focus on improving information about patient flow across the continuum of care for health providers and hospital staff (who make appointments), strengthening referral systems between primary and tertiary level providers through an integrated patient registry, improving health education on HPV and screening for patients, and establishing a patient navigation system.

Assessing the time required for qualitative analysis: A comparative methodological study of coding interview data in health services research

A reliable estimation of required resources is essential for sound research. So far, there have only been a few studies on researchers' time investment in qualitative studies. The aim of this study, therefore, was to provide an empirical account of the estimation of timescales of qualitative analysis.In this methodological study, time expenditure was documented and compared for the focused coding of transcripts of semi-structured interviews within five qualitative studies in health services research. Data were analyzed descriptively by means of absolute frequencies.Across studies, focused coding was assessed in 94 interviews with a total interview duration of 52 hours and 44 minutes. The number of interviews per study ranged from n=11 to n=27, with a mean duration of 36 minutes. Total coding time amounted to 76 hours, with a mean of 32 min per interview. Coding time per interview time ratio ranged from 0.75 to 1.52 minutes. On average, the time spent on focused coding roughly corresponds to the duration of the interviews. Focused coding tended to get quicker over time, though variation among studies was high.The results of this study provide a reference for estimating timescales of qualitative analysis and highlights the importance of considering factors such as composition of data and researchers' experience and involvement. In a specific research project, this effort must be balanced against the objective of the analysis, including the desired accuracy, detail and depth. Further research is needed to specify how specific parameters (i. e. nature of the study population, method of data analysis and use of concepts and theories) affect coding in qualitative analysis.

Impact of soil-transmitted helminths infections on anemia burden: a global analysis of children under five and reproductive-age women

BACKGROUND

Soil-transmitted Helminths (STH) infections and anemia are significant global health threats, particularly affecting children under five and reproductive-age women. The World Health Organization (WHO) has established a roadmap to eliminate Neglected tropical diseases (NTDs) and achieve Sustainable Development Goals (SDGs) by 2030. This study analyzes the impact of STH infections on the anemia burden in these populations across 187 countries from 2015 to 2019.

METHODS

Following the Systemic Rapid Assessment (SYSRA) framework, this ecological study examines the relationship between STH infections and anemia in children under five and reproductive-age women. Factors considered include Universal Health Coverage (UHC) Index, Water and Sanitation Indicators (SDG 6.1 and 6.2), Government Effectiveness, and Human Development Index (HDI). Paired t-tests assess annual changes in STH infection and anemia prevalence, while Chi-Square and logistic regression tests identify factors associated with anemia prevalence.

RESULTS

From 2015 to 2019, STH infection prevalence decreased significantly, while anemia prevalence fluctuated. STH infections were significantly associated with anemia in children under 5. However, STH infections did not significantly impact anemia prevalence in children under 5 or reproductive-age women. HDI influenced anemia prevalence in children under 5 (OR = 14.17, p < 0.05), while Safe Drinking Water infrastructure (OR = 3.98, p < 0.05) and UHC coverage (OR = 4.09, p < 0.05) influenced anemia prevalence in reproductive-age women.

CONCLUSION

This study enhances our understanding of the link between STH infections and anemia burden in children under 5 and reproductive-aged women. Findings align with existing literature on reducing disparities in STH infection and anemia prevalence based on socioeconomic factors, specifically for children under 5. Inconsistencies compared to previous studies highlight the need for comprehensive interventions involving health, social, economic, and cultural aspects to address NTDs effectively.

Does notifying clinicians about poor sleep quality influence patient-perceived empathy? Results from a randomized controlled trial

BACKGROUND

Evidence suggests that greater levels of comfort and capability are associated with lower levels of distress (feelings of anxiety or depression) and lower levels unhelpful thinking (common misconceptions) about bodily sensations. Given the social stigma associated with mental health, patients and clinicians may be hesitant to talk about thoughts and emotions in the setting of musculoskeletal specialty care. Given the relationship between sleep quality and mental health, an alternative may be discussion of sleep quality. Among people presenting for musculoskeletal specialty care, we enrolled people with sleep disturbance, and asked: 1) Is clinician awareness of a patient's poor sleep quality associated with patient perceived clinician empathy? 2) What factors are associated with worse sleep quality? And 3) Is clinician awareness of a sleep disturbance related to discussion of sleep quality interventions?

METHODS

In a randomized controlled trial, we enrolled 114 patients seeking musculoskeletal specialty care with a score of 3 or higher on the Pittsburg Sleep Quality Index (PSQI) questionnaire and randomized whether to inform their clinician of their sleep score or not. At the end of the visit, patients completed a demographic survey, the Jefferson Scale of Patient's Perception of Physician Empathy (JSPPPE), and indicated whether or not their clinician discussed sleep quality. Factors associated with perceived empathy, sleep quality, and discussion of sleep intervention were sought in multivariable analysis.

RESULTS

Accounting for potential confounders including misconceptions about symptoms, lower perceived clinician empathy was associated with the clinician being informed of the patient's sleep quality (Regression Coefficient [RC] = -0.14 95 % Confidence Interval [95 %CI] = -0.24 to -0.03l; p = 0.011) and greater misinterpretation of symptoms (RC = -0.14 95 %CI = -0.24 to -0.03; p = 0.04). Worse sleep quality was associated with distress regarding symptoms (RC = 0.048 95 %CI = 0.024 to 0.072; p < 0.001). Clinician discussion of sleep intervention was not associated with clinician awareness of sleep quality or any other factors.

CONCLUSIONS

The finding that clinician awareness of poor sleep quality was associated with modestly lower perceived clinician empathy whether or not the clinician discussed sleep quality, suggests that addressing sleep may not be more acceptable than addressing mental health. Clinicians can choose to address sleep or mental health as part of fostering a more comprehensive and effective biopsychosocial approach to musculoskeletal illness.

LEVEL OF EVIDENCE

Level I Prognostic Study.

How Personality and Affective Responses Are Associated with Skepticism Towards Virtual Reality in Medical Training-A Pre-Post Intervention Study

Virtual reality (VR) offers a safe, immersive environment for medical training, but some users remain skeptical about a broader implementation. Our study aims to explore how personality traits, affective responses, and task-related perceptions correlate with attitudes towards VR-based medical emergency training. Forty-seven medical students participated in a 30-minute VR emergency training. Personality traits were assessed using the short version of the Big Five Inventory beforehand, while affective responses (using the Positive and Negative Affect Schedule, PANAS), stress, and motivation were measured before and after the training. Participants also rated the sessions' difficulty, cognitive challenge, and technical maturity of the VR program and their acceptance of VR for training and examination purposes. Cluster analysis identified three groups: Cluster 1, characterized by low technical affinity, limited prior VR experience, and high extraversion, demonstrated the greatest increase in negative affective responses and the lowest VR acceptance. In contrast, cluster 3, with high technical affinity and neuroticism, experienced more positive affective responses and increased motivation, expressing high acceptance of VR for training purposes but some reservation regarding its use in examinations. Cluster 2 displayed balanced affective responses and strong support for VR use in both settings. Thematic analysis identified perceived lack of control due to insufficient medical knowledge, technical issues, and simulation sickness as sources of negative affective responses. In conclusion, personality and affective responses may play a significant role in shaping the attitude towards VR training applications. Uncovering emotional barriers to VR adoption among skeptical users and understanding their underlying reasons may inform future strategies for overcoming them. Given the relatively small sample size, results of this preliminary study should be expanded through further examination of diverse populations and a broader range of VR applications.

Provider Perspectives on Implementing an Enhanced Digital Screening for Adolescent Depression and Suicidality: Qualitative Study

Background

With a growing adolescent mental health crisis, pediatric societies are increasingly recommending that primary care providers (PCPs) engage in mental health screening. While symptom-level screens identify symptoms, novel technology interventions can assist PCPs with providing additional point-of-care guidance to increase uptake for behavioral health services.

Objective

In this study, we sought community PCP feedback on a web-based, digitally enhanced mental health screening tool for adolescents in primary care previously only evaluated in research studies to inform implementation in community settings.

Methods

A total of 10 adolescent providers were recruited to trial the new screening tool and participate in structured interviews based on the Consolidated Framework for Implementation Research domains. Interviews were audio recorded, transcribed, and coded according to a prespecified codebook using a template analysis approach.

Results

Providers identified improving mental health screening and treatment in pediatric primary care as a priority and agreed that a web-based digitally enhanced screening tool could help facilitate identification of and management of adolescent depression. Salient barriers identified were lack of electronic health record integration, time to administer screening, implications on clinic workflow, accessibility, and lack of transparency within health care organizations about the process of approving new technologies for clinical use. Providers made multiple suggestions to enhance implementation in community settings, such as incorporating customization options.

Conclusions

Technology interventions can help address the need for improved behavioral health support in primary care settings. However, numerous barriers exist, complicating implementation of new technologies in real-world settings.

Cross-Sectional associations between inner setting determinants of self-efficacy and intent to deliver a healthy eating and activity curriculum embedded in a community setting

BACKGROUND

Healthy Eating and Active Living Taught at Home (HEALTH) embeds healthy eating and activity content within Parents as Teachers (PAT), a national home visiting program. HEALTH is evidence based to prevent weight gain among mothers of young children. This secondary analysis aims to understand the factors associated with intention and self-efficacy to deliver HEALTH among parent educators (home vising providers).

METHODS

This is a cross-sectional, secondary analysis of data from a trial evaluating the effectiveness of HEALTH when delivered by parent educators as part of usual practice. Parent educators completed surveys following training in the HEALTH intervention; demographic characteristics (including self-reported body mass index) were collected in a baseline survey (pre-training). Surveys were based on two implementation science frameworks: Consolidated Framework for Implementation Research (CFIR, implementation context) and Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM, implementation outcomes). Associations between intent to deliver HEALTH (intent) and self-efficacy (SE) to deliver HEALTH, implementation context constructs and demographic characteristics were explored using Pearson correlations (continuous variables) and t-tests (binary variable). Relationships were considered significant if the p-value was < 0.05.

RESULTS

Among the 149 parent educators who completed the survey, just over half identified as white/non-Hispanic (53%), while just over a third identified as Hispanic. Participants reported having worked at their site for a mean of 4.7 years (standard deviation, SD = 5.85), and the mean body mass index was 30.43 kg/m2 (SD = 7.35). There was a significant correlation between intent and SE, r = 0.46 (< 0.0001). Most demographic characteristics (e.g., body mass index, age) were not significantly correlated with either variable, however, intent and SE were both significantly lower among white non-Hispanic parent educators than among those identifying as another race/ethnicity. Several other implementation context constructs such as evidence strength and quality, mission alignment, appeal, openness, and relative advantage were positively correlated with both intent and SE; complexity was negatively correlated.

CONCLUSIONS

When implementing healthy eating and activity content within community settings, it is important to consider what factors may be related to provider intent and provider self-efficacy to deliver the content. Specifically, mission alignment, complexity, evidence strength and quality, and relative advantage may be important.

TRIAL REGISTRATION

NCT03758638 ( https://clinicaltrials.gov/study/NCT03758638 ), registered Nov 29, 2018.

Experiences and Needs of Leaders Supporting Multilingual ABA Staff: A Qualitative Exploration

Heritage-language-speaking caregivers of autistic children in the United States (U.S.) have encountered barriers when attempting to access multilingual support for their children. Multilingual autism providers, such as professionals in Applied Behavior Analysis (ABA), have also reported challenges in providing multilingual care, such as a lack of training opportunities. Little is known about the experiences and needs of leaders in ABA who support multilingual direct care staff. Therefore, the current study aimed to answer the research question: What are the experiences and needs of ABA leaders in autism care related to supporting multilingual ABA staff who work with multilingual autistic children and their families? This exploratory qualitative study used semi-structured focus groups and interviews with monolingual and multilingual behavior analysts who had experience supporting multilingual ABA staff. Transcripts were analyzed using reflexive thematic analysis. The 14 participants were a diverse sample of U.S.-based monolingual, multilingual, autistic, and non-autistic leaders in ABA with experience supervising multilingual ABA staff. Two major themes were generated from the data set: (1) Diverse Experiences: Organizational Policies and Actions Impacting Multilingual Staff, and (2) Building Community and Creating Solutions. Participants shared experiences and challenges supervising multilingual ABA staff. Implications highlight the need to closely examine organizational policies to prevent discrimination and spotlight the need for more research to be conducted in this area.

Time required to implement a computerized patient decision aid for lupus in outpatient visits

BACKGROUND

Patient decision aids have the potential to lower decision conflict for patients and to improve patient-physician communication. However, uptake of decision aids has been poor, in part because the time required to incorporate these into clinical practice is not well understood.

OBJECTIVE

To estimate the time required for a rheumatology clinic to implement a validated decision aid for patients with lupus.

METHODS

Using a cohort of eight implementation sites, study investigators identified the activities required to administer a decision aid. Site coordinators embedded within the clinics timed the duration of each activity. To estimate the effect of viewing the decision aid on the length of the physician-patient interaction, patient visits were timed and the length of visits for patients who viewed the decision aid were compared with visit lengths for three groups of control patients.

RESULTS

Estimates of the effect of the decision aid on patient visit lengths ranged from a reduction of 3 min per visit to an increase of 3.88 min per visit, with five out of six estimates suggesting the decision aid is associated with shorter patient visits. Introducing the decision aid to patients took a mean of 4.12 min (median of 2 min). Identifying patients eligible for the decision aid was a weekly or bi-weekly process for most clinics and took an average of 41.43 min.

CONCLUSION

The time required for a rheumatology clinic to implement the decision aid for patients with lupus is low. Our results raise questions about why decision aid take up is low among clinical practices, given the benefits the lupus decision aid offers to patients (reduced decisional conflict and better-informed choice of immunosuppressive medications used for the treatment of lupus kidney disease). More research is needed to identify barriers to decision aid adoption.

Barriers and facilitators in implementing evidence-based practice: a parallel cross-sectional mixed methods study among nursing administrators

BACKGROUND

Evidence-based practice (EBP) is a cornerstone of quality healthcare, yet a significant gap persists between nursing administrators' advocacy for EBP and its clinical adoption, particularly in resource-constrained settings.

AIM

This study investigates barriers and facilitators to EBP adoption as perceived by nursing administrators in Saudi Arabian hospitals to inform tailored interventions.

DESIGN

A parallel mixed-method, cross-sectional design was employed.

METHODS

A total of 385 nursing administrators from 12 stratified hospital types in the Northern Region of Saudi Arabia completed structured surveys assessing EBP barriers and facilitators. Semi-structured interviews with 40 purposively sampled participants provided qualitative insights. Data were analyzed using descriptive, correlational, and thematic approaches.

RESULTS

Key barriers included insufficient staffing and time resources, particularly in private and specialized hospitals (mean = 4.05, SD = 1.46, p < 0.05). Supportive organizational policies (p = 0.015) and leadership experience significantly influenced EBP adoption. Barriers, such as resource constraints, were negatively correlated with willingness to adopt EBP (r = -0.17 to -0.35), while multifaceted strategies explained 27% of the variance in implementation intentions. Qualitative findings highlighted that 92% prioritized patient care quality, while 80% emphasized cost-benefit trade-offs.

CONCLUSION

This study highlights the critical role of organizational support, leadership advocacy, and tailored interventions in overcoming EBP barriers. Gender diversity among administrators and the influence of hierarchical dynamics in Saudi Arabian healthcare settings provide novel insights for improving EBP adoption.

IMPLICATIONS FOR THE PROFESSION

The findings provide actionable strategies for policymakers and nursing leaders to enhance EBP adoption, fostering improved healthcare outcomes and leadership effectiveness.

CLINICAL TRIAL NUMBER

Not applicable.

Exploring the role of virtual reality in preparing emergency responders for mass casualty incidents

BACKGROUND

The increasing complexity of mass casualty incidents (MCIs) necessitates highly effective training for emergency responders. Traditional training methods, while effective in teaching core skills, often fail to replicate the dynamic, high-pressure environments responders face in real-world crises. Virtual reality (VR) offers a novel approach to emergency training, providing an immersive, controlled setting that can simulate real-life scenarios. This study explores the effectiveness of VR in training paramedic students for MCIs and compares the outcomes to those from conventional training methods.

METHODS

A comparative study was conducted with 37 paramedic students who underwent either VR-based training or conventional training using mannequins and real-world equipment. The VR application simulated a mass casualty car accident, focusing on triage and patient management. Both groups were assessed based on their performance in key areas, including the accuracy of situational reporting (METHANE), patient triage, heart rate monitoring, and perceived demand using the NASA Task Load Index (NASA-TLX).

RESULTS

The VR group demonstrated significantly lower mental demand (p < 0.001) and frustration levels (p = 0.021) compared to traditional training. However, task completion times were slower in the VR setting (p < 0.001), likely due to the interface's unfamiliarity. Accuracy in situational reporting was higher in VR (p = 0.002), while heart rate monitoring did not reveal a significant difference between the groups (p = 0.516). Although VR did not reduce temporal demand (p = 0.057), it showed potential for improving focus and precision in training. Error rates in triage were similar across both training methods (p = 0.882), indicating comparable performance levels in patient classification.

CONCLUSIONS

VR presents a promising tool for training emergency responders, particularly in situations that require rapid upskilling, such as crises or wars. The ability to simulate realistic, high-pressure scenarios in a controlled environment can enhance both cognitive and emotional preparedness. Further research is necessary to optimize VR systems and interfaces, making them more efficient for real-time decision-making. As VR technology advances, it holds potential as a key component in future emergency preparedness strategies.

Exploring factors influencing the consistent adoption of a post-stroke upper extremity outcome measure using Normalisation Process Theory

BACKGROUND

Stroke rehabilitation guidelines recommend using outcome measures like the Fugl-Meyer Assessment for Upper Extremity (FMA-UE) to assess post-stroke upper extremity function. However, integrating such outcome measures into routine clinical practice remains challenging, highlighting the need to understand factors affecting their implementation in evolving healthcare models.

OBJECTIVE

Our study aimed to identify the barriers and facilitators to sustain the routine use of the FMA-UE among hospital-based occupational therapists (OTs) using a theory-driven approach.

METHODS

Employing a mixed-method sequential exploratory study design rooted in Normalisation Process Theory (NPT), we gathered quantitative data through a validated survey followed by qualitative insights analysed with directed content analysis from focus group discussions involving occupational therapists from four hospitals.

RESULTS

Survey findings (n = 34) revealed barriers primarily associated with NPT constructs of collective action and coherence. Facilitators were linked to the cognitive participation construct. Key barriers identified in focus groups included insufficient coaching, competing priorities, and perceived limited value of the FMA-UE. Facilitators included legitimation of therapists' role in outcome measurements and an open learning culture.

CONCLUSIONS

Through a theory-based approach, we identified barriers and facilitators to sustain the routine of the FMA-UE. Our findings offer insights for designing implementation strategies to embed the FMA-UE into routine practice, supporting its sustained use in stroke rehabilitation.

Impact evaluation of the modified adverse inpatient medication event (AIME-Frail) model in hospitalised adults

AIMS

To assess whether the AIME-Frail tool assists in medication management prioritisation and reduces inpatient medication harm events, evaluate tool implementation challenges and enablers, and identify predictive risk factors for medication harm.

METHODS

General and geriatric medicine patients at a tertiary hospital in Queensland, Australia were enrolled in a controlled study. Medication harm was identified through electronic medical record (EMR) reviews, a trigger tool, and discussions with treating teams. In the intervention group, pharmacists used the AIME-Frail tool for risk-based prioritisation of medication reviews, while the control group received usual care. Incidence and types of medication harm were compared between groups. Reflexive journaling was used to document insights on tool use by pharmacists, identifying barriers and enablers for implementation. Predictive risk factors were identified using regression models.

RESULTS

A total of 279 patients participated. Medication harm occurred in 51 patients (18.3%). The most common type was gastrointestinal harm, with opioids and antibacterials causing constipation and nausea/vomiting, while anticoagulants caused bleeding and bruising. There was no difference between intervention and control groups in incidence of medication harm 23/142 (16.2%) versus 28/137 (20.4%) respectively (P = 0.44). Key implementation challenges included lack of integration into the EMR and suboptimal compliance with tool use by pharmacists. Predictive risk factors for medication harm included renal impairment, dementia, depression, and longer hospital stay (P ≤ 0.05).

CONCLUSION

While the AIME-Frail tool identified high-risk patients, it did not significantly reduce medication harm, possibly due to implementation challenges. Future studies should aim to update the model using predictive risk factors and optimise the usability of the tool for pharmacists.

How do we leverage implementation science to support and accelerate uptake of clinical practice guidelines in transfusion medicine

BACKGROUND

Developing and disseminating clinical practice guidelines is a common strategy used to inform practice and address evidence-to-practice gaps that are prominent in transfusion medicine. Despite a highly systematic method for synthesizing evidence into guideline recommendations, comparatively little attention is paid to the real-world implementation of the recommendations in routine practice. A more scientific approach drawing on learnings from the field of implementation science is therefore warranted.

STUDY DESIGN AND METHODS

In this article, we propose a methodological roadmap to embed implementation science principles, frameworks, and methods to facilitate the development and uptake of transfusion medicine guidelines. We draw upon research undertaken in partnership with the International Collaboration of Transfusion Medicine Guidelines (ICTMG) to illustrate the roadmap in action.

RESULTS

The methodological roadmap constitutes five steps which have been matched to existing processes for developing and implementing clinical practice guidelines: (1) environmental scan; (2) detailing who needs to do what differently, per guideline recommendation; (3) barriers and enablers assessment; (4) tailoring implementation strategies to identified barriers and enablers; and (5) implementation and evaluation of implementation strategies. For each step, we define the key concepts and methods involved, and share examples from work done with ICTMG to support transfusion medicine guideline implementation.

DISCUSSION

We intend this methodological roadmap for clinicians, researchers, and organizations involved in supporting clinical practice guideline use. Informed by principles, frameworks, and methods from implementation science, the roadmap can provide a more structured, transparent, and replicable approach to improve the implementation of guideline recommendations in transfusion medicine.

Digital Decision Support for Perioperative Care of Patients With Type 2 Diabetes: A Call to Action

Unlabelled

Type 2 diabetes mellitus affects over 500 million people globally, with 10%-20% requiring surgery. Patients with diabetes are at increased risk for perioperative complications, including prolonged hospital stays and higher mortality, primarily due to perioperative hyperglycemia. Managing blood glucose during the perioperative period is challenging, and conventional monitoring is often inadequate to detect rapid fluctuations. Clinical decision support systems (CDSS) are emerging tools to improve perioperative diabetes management by providing real-time glucose data and medication recommendations. This viewpoint examines the role of CDSS in perioperative diabetes care, highlighting their benefits and limitations. CDSS can help manage blood glucose more effectively, preventing both hyperglycemia and hypoglycemia. However, technical and integration challenges, along with clinician acceptance, remain significant barriers.

A qualitative analysis on the implementation of a nudge intervention to reduce post-surgical opioid prescribing

BACKGROUND

Reducing above-guideline opioid prescribing is one approach to reducing the availability of unused opioids. We describe contextual factors affecting the implementation and outcomes of a successful email 'nudge' aimed at reducing post-operative opioid prescribing, with the goal of informing future implementation and dissemination efforts.

METHODS

Between October 2021-September 2022, we sent email nudges to general, orthopedic, and obstetrics/gynecology surgeons at 19 hospitals in a large integrated healthcare system in California whose patients had post-operative opioid prescriptions that exceeded guideline-recommended quantities. We then interviewed 36 surgeons between September 2022-January 2023 and coded and themed transcripts and implementation process documents from the study. We used the Consolidated Framework for Implementation Research (CFIR) to understand the contextual factors impacting nudge design, implementation, and effectiveness.

RESULTS

Factors across all five CFIR domains were found to be important in understanding the acceptability, feasibility, and sustainability of the intervention. In the Innovation Domain, key factors included the method of nudge delivery, the validity of comparators, and the design and layout of the nudge itself. The interaction between the nudges and existing state regulations (Outer Setting Domain) caused confusion, while the size, structure, and centralization of hospitals (Inner Setting Domain) influenced communication and leadership engagement, underscoring the need for local champions (Individuals Domain). In the Implementation Process Domain, workflow considerations emerged, e.g., the fact that the surgeon performing the procedure was at times not the discharge prescriber, the need for pre-intervention education, and the importance of ensuring surgeons have a clear process to access additional information when questions arise about nudge content.

CONCLUSIONS

Contextual factors related to how the nudges were implemented influenced their acceptability among surgeons. Future dissemination efforts of similar interventions to curb opioid overprescribing should take these design considerations into account, including how to account for variations in prescribing workflows, the amount of information provided in the nudge, how information is construed, and how the rest of the hospital system can adjust to encourage guideline-supported opioid prescribing at the point of post-surgical discharge. These types of considerations may also apply to other clinician-directed, nudge-based interventions beyond the subject of opioid prescribing.

TRIAL REGISTRATION

Clinicaltrials.gov, Identifier: NCT05070338, Registration Date: October 19, 2021.

Deimplementation of ineffective and harmful medical practices: a data-driven commentary

Deimplementation is the discontinuation or abandonment of medical practices that are ineffective or of unclear effectiveness, ranging from simply unhelpful to harmful. With epidemiology expanding to include more translational sciences, epidemiologists can contribute to deimplementation by defining evidence, establishing causality, and advising on study design. An estimated 10%-30% of health care practices have minimal to no benefit to patients and should be targeted for deimplementation. The steps in deimplementation are (1) identify low-value clinical practices, (2) facilitate the deimplementation process, (3) evaluate deimplementation outcomes, and (4) sustain deimplementation, each of which is a complex project. Deimplementation science involves researchers, health care and clinical stakeholders, and patient and community partners affected by the medical practice. Increasing collaboration between epidemiologists and implementation scientists is important to optimizing health care delivery.