Printed educational materials: effects on professional practice and healthcare outcomes

Supporting health and social care professionals in serious illness conversations: Development, validation, and preliminary evaluation of an educational booklet

Serious illness conversations aim to align the care process with the goals and preferences of adult patients suffering from any advanced disease. They represent a challenge for healthcare professionals and require specific skills. Conversation guides consistent with task-centered instructional strategies may be particularly helpful to improve the quality of communication. This study aims to develop, validate, and preliminarily evaluate an educational booklet to support Italian social and healthcare professionals in serious illness conversations. A three-step approach, including development, validation, and evaluation, was followed. A co-creation process with meaningful stakeholders led to the development of the booklet, validated by 15 experts on clarity, completeness, coherence, and relevance. It underwent testing on readability (Gulpease index, 0 = lowest-100 = maximum) and design (Baker Able Leaflet Design criteria, 0 = worst to 32 = best). Twenty-two professionals with different scope of practice and care settings evaluated acceptability (acceptable if score ≥30), usefulness, feasibility to use (1 = not at all to 10 = extremely), and perceived acquired knowledge (1 = not at all to 5 = extremely). After four rounds of adjustments, the booklet scored 97% for relevance, 60 for readability, and 25/32 for design. In all, 18 (81.8%), 19 (86.4%) and 17 (77.3%) professionals deemed the booklet acceptable, moderate to highly useful, and feasible to use, respectively; 18/22 perceived gain in knowledge and all would recommend it to colleagues. The booklet has good readability, excellent design, high content validity, and a high degree of perceived usefulness and acquired knowledge. The booklet is tailored to users' priorities, mirrors their most frequent daily practice challenges, and offers 1-minute, 2-minute and 5-minute solutions for each scenario. The co-creation process ensured the development of an educational resource that could be useful regardless of the scope of practice and the care setting to support professionals in serious illness conversations.

Effectiveness of a classification-based approach to low back pain in primary care - a benchmarking controlled trial

OBJECTIVE

The aim of this study was to assess the effectiveness of classification-based approach for low back pain care in Finnish primary care.

DESIGN

A benchmarking controlled trial design was used.

SUBJECTS/PATIENTS

Three primary healthcare areas and 654 low back pain patients with or without sciatica.

METHODS

Classification-based care (using the STarT Back Tool) was implemented using organizational-, healthcare professional-, and patient-level interventions. The primary outcome was change in Patient-Reported Outcomes Measurement Information System, Physical Function (PROMIS PF-20) from baseline to 12 months.

RESULTS

No difference was found between the intervention and control in change in PROMIS PF-20 over the 12-month follow-up (mean difference 0.33 confidence interval -2.27 to 2.9, p = 0.473). Low back pain-related healthcare use, imaging, and sick leave days were significantly lower in the intervention group. Reduction in intensity of low back pain appeared to be already achieved at the 3-month follow-up (mean difference -1.3, confidence interval -2.1 to -0.5) in the intervention group, while in the control group the same level of reduction was observed at 12 months (mean difference 0.7, confidence interval -0.2 to 1.5, treatment*time p = 0.003).  Conclusion: Although classification-based care did not appear to influence physical functioning, more rapid reductions in pain intensity and reductions in healthcare use and sick leave days were observed in the intervention group.

The Birth of the Contextual Health Education Readability Score in an Examination of Online Influenza Patient Education Materials

Introduction Influenza is a major global health concern, with its rapid spread and mutation rate posing significant challenges in public health education and communication. Effective patient education materials (PEMs) are crucial for informed decision-making and improved health outcomes. This study evaluates the efficacy of online influenza PEMs using traditional readability tools and introduces the Contextual Health Education Readability Score (CHERS) to address the limitations of existing methods that do not capture the diverse array of visual and thematic means displayed. Materials and methods A comprehensive search was conducted to select relevant online influenza PEMs. This involved looking through Google's first two pages of results sorted by relevance, for a total of 20 results. These materials were evaluated using established readability tools (e.g., Flesch Reading Ease, Flesch-Kincaid Grade Level) and the Patient Education Materials Assessment Tool (PEMAT) for understandability and actionability. The study also involved the creation of CHERS, integrating factors such as semantic complexity, cultural relevance, and visual aid effectiveness. The development of CHERS included weighting each component based on its impact on readability and comprehension. Results The traditional readability tools demonstrated significant variability in the readability of the selected materials. The PEMAT analysis revealed general trends toward clarity in purpose and use of everyday language but indicated a need for improvement in summaries and visual aids. The CHERS formula was calculated as follows: CHERS = (0.4 × Average Sentence Length) + (0.3 × Average Syllables per Word) + (0.15 × Semantic Complexity Score) + (0.1 × Cultural Relevance Score) + (0.05 × Visual Aid Effectiveness Score), integrating multiple dimensions beyond traditional readability metrics. Discussion The study highlighted the limitations of traditional readability tools in assessing the complexity and cultural relevance of health information. The introduction of CHERS addressed these gaps by incorporating additional dimensions crucial for understanding in a healthcare context. The recommendations provided for creating effective influenza PEMs focused on language simplicity, cultural sensitivity, and actionability. This may enable further research into evaluating current PEMs and clarifying means of creating more effective content in the future. Conclusions The study underscores the need for comprehensive readability assessments in PEMs. The creation of CHERS marks a significant advancement in this field, providing a more holistic approach to evaluating health literacy materials. Its application could lead to the development of more inclusive and effective educational content, thereby improving public health outcomes and reducing the global burden of influenza. Future research should focus on further validating CHERS and exploring its applicability to other health conditions.

A Virtual Hospital Model of Care for Low Back Pain, Back@Home: Protocol for a Hybrid Effectiveness-Implementation Type-I Study

BACKGROUND

Low back pain (LBP) was the fifth most common reason for an emergency department (ED) visit in 2020-2021 in Australia, with >145,000 presentations. A total of one-third of these patients were subsequently admitted to the hospital. The admitted patient care accounts for half of the total health care expenditure on LBP in Australia.

OBJECTIVE

The primary aim of the Back@Home study is to assess the effectiveness of a virtual hospital model of care to reduce the length of admission in people presenting to ED with musculoskeletal LBP. A secondary aim is to evaluate the acceptability and feasibility of the virtual hospital and our implementation strategy. We will also investigate rates of traditional hospital admission from the ED, representations and readmissions to the traditional hospital, demonstrate noninferiority of patient-reported outcomes, and assess cost-effectiveness of the new model.

METHODS

This is a hybrid effectiveness-implementation type-I study. To evaluate effectiveness, we plan to conduct an interrupted time-series study at 3 metropolitan hospitals in Sydney, New South Wales, Australia. Eligible patients will include those aged 16 years or older with a primary diagnosis of musculoskeletal LBP presenting to the ED. The implementation strategy includes clinician education using multimedia resources, staff champions, and an "audit and feedback" process. The implementation of "Back@Home" will be evaluated over 12 months and compared to a 48-month preimplementation period using monthly time-series trends in the average length of hospital stay as the primary outcome. We will construct a plot of the observed and expected lines of trend based on the preimplementation period. Linear segmented regression will identify changes in the level and slope of fitted lines, indicating immediate effects of the intervention, as well as effects over time. The data will be fully anonymized, with informed consent collected for patient-reported outcomes.

RESULTS

As of December 6, 2023, a total of 108 patients have been cared for through Back@Home. A total of 6 patients have completed semistructured interviews regarding their experience of virtual hospital care for nonserious back pain. All outcomes will be evaluated at 6 months (August 2023) and 12 months post implementation (February 2024).

CONCLUSIONS

This study will serve to inform ongoing care delivery and implementation strategies of a novel model of care. If found to be effective, it may be adopted by other health districts, adapting the model to their unique local contexts.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/50146.

N-of-1 Trials of Antimicrobial Stewardship Interventions to Optimize Antibiotic Prescribing for Upper Respiratory Tract Infection in Emergency Departments: Protocol for a Quasi-Experimental Study

BACKGROUND

Antimicrobial stewardship programs attempting to optimize antibiotic therapy and clinical outcomes mainly focus on inpatient and outpatient settings. The lack of antimicrobial stewardship program studies in the emergency department (ED) represents a gap in tackling the problem of antimicrobial resistance as EDs treat a substantial number of upper respiratory tract infection cases throughout the year.

OBJECTIVE

We intend to implement two evidence-based interventions: (1) patient education and (2) providing physician feedback on their prescribing rates. We will incorporate evidence from a literature review and contextualizing the interventions based on findings from a local qualitative study.

METHODS

Our study uses a quasi-experimental design to evaluate the effects of interventions over time in the EDs of 4 public hospitals in Singapore. We will include an initial control period of 18 months. In the next 6 months, we will randomize 2 EDs to receive 1 intervention (ie, patient education) and the other 2 EDs to receive the alternative intervention (ie, physician feedback). All EDs will receive the second intervention in the subsequent 6 months on top of the ongoing intervention. Data will be collected for another 6 months to assess the persistence of the intervention effects. The information leaflets will be handed to patients at the EDs before they consult with the physician, while feedback to individual physicians by senior doctors is in the form of electronic text messages. The feedback will contain the physicians' antibiotic prescribing rate compared with the departments' overall antibiotic prescribing rate and a bite-size message on good antibiotic prescribing practices.

RESULTS

We will analyze the data using segmented regression with difference-in-difference estimation to account for concurrent cluster comparisons.

CONCLUSIONS

Our proposed study assesses the effectiveness of evidence-based, context-specific interventions to optimize antibiotic prescribing in EDs. These interventions are aligned with Singapore's national effort to tackle antimicrobial resistance and can be scaled up if successful.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05451863; https://clinicaltrials.gov/study/NCT05451836.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/50417.

Using implementation science to promote the use of the fascia iliaca blocks in hip fracture care

PURPOSE

There is variable and suboptimal use of fascia iliaca compartment nerve blocks (FICBs) in hip fracture care. Our objective was to use an evidence-based and theory-informed implementation science approach to analyze barriers and facilitators to timely administration of FICB and select evidence-based interventions to enhance uptake.

METHODS

We conducted a qualitative study at a single centre using semistructured interviews and site observations. We interviewed 35 stakeholders including health care providers, managers, patients, and caregivers. We mapped barriers and facilitators to the Theoretical Domains Framework (TDF) and Consolidated Framework for Implementation Research (CFIR). We compared the rate and timeliness of FICB administration before and after evidence-based implementation strategies were applied.

RESULTS

The study identified 18 barriers and 11 facilitators within seven themes of influences of FICB use: interpersonal relationships between health care professionals; clinician knowledge and skills related to FICB; roles, responsibilities, and processes for delivering FICB; perceptions on using FICB for pain; patient and caregiver perceptions on using FICB for pain; communication of hip fracture care between departments; and resources for delivering FICBs. We mapped the behaviour change domains to eight implementation strategies: restructure the environment, create and distribute educational materials, prepare patients to be active participants, perform audits and give feedback, use local opinion leaders, use champions, train staff on FICB procedures, and mandate change. We observed an increase in the rates of FICBs administered (48% vs 65%) and a decrease in the median time to administration (1.63 vs 0.81 days).

CONCLUSION

Our study explains why FICBs are underused and shows that the TDF and CFIR provide a framework to identify barriers and facilitators to FICB implementation. The mapped implementation strategies can guide institutions to improve use of FICB in hip fracture care.

Health professionals' perceptions of patient safety competencies: psychometric properties of the French version of the H-PEPSS in France and Switzerland

BACKGROUND

Several initiatives have been implemented to develop, manage, and assess patient safety (PS) competencies, which are considered as a serious public health issue across the world. The Health Professional Education in Patient Safety Survey (H-PEPSS) is widely used as a psychometric scale for evaluating perceived PS competencies but has not been validated in French. The purpose of the study was to investigate the main psychometric properties of the French version of the H-PEPSS.

METHODS

A total of 449 students enrolled in nursing and physiotherapy schools in France and French-speaking Switzerland completed a self-administered questionnaire. The 38 items of the H-PEPSS were translated into French following a committee approach. The scale's construct validity was assessed using confirmatory factor analysis. Reliability of the six factors of the H-PEPSS was evaluated using Cronbach α and McDonald's ω. Measurement invariance across countries and academic majors as well as discriminant validity were also investigated.

RESULTS

After we removed one item, the H-PEPSS 6-factor model demonstrated adequate goodness-of-fit statistics (χ2[194] = 316.633, χ2/df = 1.632, p < 0.001, CFI = 0.934, TLI = 0.922, RMSEA = 0.041 [0.033, 0.049], SRMR = 0.044). The total score can be also used as an overall measure of PS competence (χ2[203] = 342.251, χ2/df = 1.686, p < 0.001, CFI = 0.925, TLI = 0.915, RMSEA = 0.043 [0.035, 0.051], SRMR = 0.047). One item was removed because of its high multicollinearity with other items. The reliability was deemed satisfactory (Cronbach α ≥ 0.60), except for the "Understanding human and environmental factors" subscale. Consistently, this subscale was often reported with the lowest reliability in previous studies. We confirmed scalar invariance between countries and partial scalar invariance between majors (ΔCFI ≤ 0.01). The heterotrait-monotrait ratio of correlations ranged from 0.63 to 0.91. In our results, country, academic year, and academic satisfaction were frequently the main predictors of self-reported PS competencies.

CONCLUSION

Perceived PS competencies can be assessed and fairly compared across France and Switzerland and across nursing and physiotherapy students. We discuss the relevance of the introduction of the H-PEPSS in the training pathway of health professions degree courses and the fallout in clinical contexts.

Evaluation of an implementation support package to increase community mental health clinicians' routine delivery of preventive care for multiple health behaviours: a non-randomised controlled trial

BACKGROUND

People with a mental health condition are more likely to engage in risk behaviours compared to people without. Delivery of preventive care to improve such behaviours is recommended for community mental health services, but inadequately implemented. This study assessed the effectiveness of an implementation support package on clinicians' delivery of preventive care (assessment, advice, referral) for four risk behaviours (tobacco smoking, harmful alcohol consumption, physical inactivity, inadequate fruit and vegetable intake) compared to no implementation support. The participatory approach to developing the support package, and fidelity of the implementation strategies, are also described.

METHODS

A non-randomised controlled trial was undertaken in 2019-2020 with two community mental health services (control and target) in one health district in New South Wales, Australia. A 4-month support package consisting of multiple implementation strategies was delivered to one site following a two-phase participatory design process. Five implementation strategies were proposed to service managers by researchers. After consultation with managers and clinicians, the final implementation support package included four strategies: training and education materials, enabling resources and prompts, client activation material, and audit and feedback. Client-reported receipt of the three elements of preventive care for the four risk behaviours was collected from a cross-sectional sample of clients who had recently attended the service at baseline (6 months) and follow-up (5 months). Logistic regression models examined change in receipt of preventive care to assess effectiveness.

RESULTS

A total of 860 client surveys were completed (control baseline n = 168; target baseline n = 261; control follow-up n = 164; and target follow-up n = 267). Analyses revealed no significant differential changes in preventive care receipt between the target and control sites from baseline to follow-up, including across the four primary outcomes: assessed for all behaviours (OR = 1.19; 95% CI 0.55, 2.57; p = 0.65); advised for all relevant risk behaviours (OR = 1.18; 95% CI 0.39, 3.61; p = 0.77); referred for any relevant risk behaviour (OR = 0.80; 95% CI 0.40, 1.63; p = 0.55); and complete care (OR = 3.11; 95% CI 0.62, 15.63; p = 0.17). Fidelity of the implementation strategies was limited as one of the four strategies (audit and feedback) was not delivered, components of two strategies (enabling resources and prompts, and client activation material) were not delivered as intended, and one strategy (education and training) was delivered as intended although some components were offered late in the implementation period.

CONCLUSIONS

The implementation support package was ineffective at increasing preventive care delivery. Further investigation is required to determine optimal participatory design methods to develop effective implementation strategies, including those that support delivery of care in community mental health settings within the ongoing context of uncertain environmental challenges.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12619001379101.

Systematic development of a set of implementation strategies for transitional care innovations in long-term care

BACKGROUND

Numerous transitional care innovations (TCIs) are being developed and implemented to optimize care continuity for older persons when transferring between multiple care settings, help meet their care needs, and ultimately improve their quality of life. Although the implementation of TCIs is influenced by contextual factors, the use of effective implementation strategies is largely lacking. Thus, to improve the implementation of TCIs targeting older persons receiving long-term care services, we systematically developed a set of viable strategies selected to address the influencing factors.

METHODS

As part of the TRANS-SENIOR research network, a stepwise approach following Implementation Mapping (steps 1 to 3) was applied to select implementation strategies. Building on the findings of previous studies, existing TCIs and factors influencing their implementation were identified. A combination of four taxonomies and overviews of change methods as well as relevant evidence on their effectiveness were used to select the implementation strategies targeting each of the relevant factors. Subsequently, individual consultations with scientific experts were performed for further validation of the process of mapping strategies to implementation factors and for capturing alternative ideas on relevant implementation strategies.

RESULTS

Twenty TCIs were identified and 12 influencing factors (mapped to the Consolidated Framework for Implementation Research) were designated as priority factors to be addressed with implementation strategies. A total of 40 strategies were selected. The majority of these target factors at the organizational level, e.g., by using structural redesign, public commitment, changing staffing models, conducting local consensus discussions, and organizational diagnosis and feedback. Strategies at the level of individuals included active learning, belief selection, and guided practice. Each strategy was operationalized into practical applications.

CONCLUSIONS

This project developed a set of theory and evidence-based implementation strategies to address the influencing factors, along further tailoring for each context, and enhance the implementation of TCIs in daily practice settings. Such work is critical to advance the use of implementation science methods to implement innovations in long-term care successfully.

Professional medical education approaches: mobilizing evidence for clinicians

Rapidly proliferating high-quality evidence supports daily decision-making in clinical practice. Continuing professional medical education links this evidence to practicing clinicians who are strongly motivated to improve the quality of their care by using the latest information. Approaches to professional education vary, and their effects depend on specific scenarios. This narrative review summarizes the main approaches for professional medical education that facilitate the mobilization of evidence for clinicians. It includes traditional learning (passive and active dissemination of educational materials, lectures, and mass media dissemination), constructivist learning (engaging in local consensus processes and education outreach visits, interfacing with local opinion leaders, conducting patient-mediated interventions, employing audit and feedback processes, and utilizing clinical decision-supporting systems), and blended learning approaches (the integration of in-person or online passive learning with active and creative learning by the learners). An optimized selection from these approaches is challenging but critical to clinicians and healthcare systems.

The impact of an e-newsletter or animated video to disseminate outdoor free-play information in relation to COVID-19 guidelines in New South Wales early childhood education and care services: a randomised controlled trial

BACKGROUND

State-based Guidelines were issued for Early Childhood Education and Care (ECEC) services (caring for children 0-6 years) recommending greater time outdoors and inclusion of indoor-outdoor programs to facilitate social distancing to reduce spread of COVID-19. The aim of this 3-arm randomised controlled trial (RCT) was to examine the impact of different dissemination strategies on increasing ECEC service intentions to adopt recommendations from the Guidelines.

METHODS

This was a post-intervention only RCT. A sample of eligible ECEC services in New South Wales (n = 1026) were randomly allocated to one of three groups; (i) e-newsletter resource; (ii) animated video resource; or (iii) control (standard email). The intervention was designed to address key determinants of guideline adoption including awareness and knowledge. Following delivery of the intervention in September 2021, services were invited to participate in an online or telephone survey from October-December 2021. The primary trial outcome was the proportion of services intending to adopt the Guidelines, defined as intention to; (i) offer an indoor-outdoor program for the full day; or (ii) offer more outdoor play time. Secondary outcomes included awareness, reach, knowledge and implementation of the Guidelines. Barriers to Guideline implementation, cost of the dissemination strategies and analytic data to measure fidelity of intervention delivery were also captured.

RESULTS

Of the 154 services that provided post-intervention data, 58 received the e-newsletter (37.7%), 50 received the animated video (32.5%), and 46 received the control (29.9%). Services who received the animated video had nearly five times the odds (OR: 4.91 [1.03, 23.34] p = 0.046) than those in the control group, to report having intentions to adopt the Guidelines. There were no statistically significant differences in awareness or knowledge of the Guidelines between either intervention or control services. Development costs were greatest for the animated video. The extent to which the dissemination strategy was viewed in full, were similar for both the e-newsletter and animated video.

CONCLUSION

This study found potential for the inclusion of interactive strategies to disseminate policy and guideline information within the ECEC setting, in the context of the need for rapid communication. Further research should explore the added benefits of embedding such strategies within a multi-strategy intervention.

TRIAL REGISTRATION

Retrospectively registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) on the 23/02/2023 (ACTRN 12,623,000,198,628).

Sharing voice during deliberative engagement to improve guideline adherence in dental clinics: findings from a qualitative evaluation of an online deliberative forum discussion

OBJECTIVES

Selecting effective implementation strategies to support guideline-concordant dental care is a complex process. For this research project, an online deliberative forum brought together staff from dental clinics to discuss the strengths and weaknesses of implementation strategies and barriers to implementation of a component of a dental (pit-and-fissure) guideline. The goal was to determine whether deliberative engagement enabled participants' sharing of promotive and prohibitive voice about implementation strategies to promote guideline-concordant care.

DESIGN

Qualitative analysis of online chat transcripts of facilitated deliberations from 31 small group sessions.

SETTING

Kaiser Permanente Dental (KP Dental) in the USA.

PARTICIPANTS

All staff from 16 dental offices.

RESULTS

The directed content analysis revealed that participants shared prohibitive and promotive voice when offering critique of the barriers and the implementation strategies suggested by the researchers. The analysis also revealed that the focus of the deliberations often was not on the aspect of the pit-and-fissure guideline intended by the research team for deliberation.

CONCLUSIONS

The deliberative forum discussions were a productive venue to ask staff in dental clinics to share their perspectives on strategies to promote guideline-concordant care as well as barriers. Participants demonstrated prohibitive voice and engaged critically with the materials the research team had put together. An important limitation of the deliberation was that the discussion often centred around an aspect of the pit-and-fissure guideline that already was implemented well. To ensure a deliberation oriented towards resolving challenging aspects of the pit-and-fissure guideline, greater familiarity with the guideline would have been important, as well as more intimate knowledge of the current discrepancies in guideline-concordant care.

TRIAL REGISTRATION NUMBER

This project is registered at ClinicalTrials.gov with ID NCT04682730. The trial was first registered on 18 December 2020. https://clinicaltrials.gov/ct2/show/NCT04682730.

Efficacy of a multidimensional self-management intervention on low-education women with metabolic syndrome: a cluster randomized controlled trial

Low-education women, a substantially older population, are subject to increased risks of metabolic syndrome and consequent cardiometabolic diseases; early detection and effective management were urgently needed. Ninety-nine women with metabolic syndrome, age 61 and education ≤ 6 years, from four community units were randomly assigned to either a self-management intervention (n = 51) or a control arm (n = 48). The intervention consisted of five dimensions, physical activity and diet modifications (daily exercise classes and two nutrition courses), goal setting, coaching and peer support, problem-solving, and self-monitoring. The control arm received an education leaflet. Assessments were performed at baseline, six months, and 18 months. Compared with the control, the intervention participants improved the overall rate of meeting the recommended servings for six health foods, including vegetables, dairy products, and nuts (except whole grains, fruits, and protein); the rate of meeting regular leisure-time physical activity; and criteria biomarkers-waist circumference, fasting blood glucose, high-density lipoprotein cholesterol (except blood pressure and triglycerides); as well as body weight and body mass index; consequently decreased the number of risk factors and rate of metabolic syndrome. In conclusion, the multidimensional self-management intervention improved physical activity, healthy eating, and metabolic syndrome risks among low-education women with metabolic syndrome.

Characteristics and impact of interventions to support healthcare providers' compliance with guideline recommendations for breast cancer: a systematic literature review

BACKGROUND

Breast cancer clinical practice guidelines (CPGs) offer evidence-based recommendations to improve quality of healthcare for patients. Suboptimal compliance with breast cancer guideline recommendations remains frequent, and has been associated with a decreased survival. The aim of this systematic review was to characterize and determine the impact of available interventions to support healthcare providers' compliance with CPGs recommendations in breast cancer healthcare.

METHODS

We searched for systematic reviews and primary studies in PubMed and Embase (from inception to May 2021). We included experimental and observational studies reporting on the use of interventions to support compliance with breast cancer CPGs. Eligibility assessment, data extraction and critical appraisal was conducted by one reviewer, and cross-checked by a second reviewer. Using the same approach, we synthesized the characteristics and the effects of the interventions by type of intervention (according to the EPOC taxonomy), and applied the GRADE framework to assess the certainty of evidence.

RESULTS

We identified 35 primary studies reporting on 24 different interventions. Most frequently described interventions consisted in computerized decision support systems (12 studies); educational interventions (seven), audit and feedback (two), and multifaceted interventions (nine). There is low quality evidence that educational interventions targeted to healthcare professionals may improve compliance with recommendations concerning breast cancer screening, diagnosis and treatment. There is moderate quality evidence that reminder systems for healthcare professionals improve compliance with recommendations concerning breast cancer screening. There is low quality evidence that multifaceted interventions may improve compliance with recommendations concerning breast cancer screening. The effectiveness of the remaining types of interventions identified have not been evaluated with appropriate study designs for such purpose. There is very limited data on the costs of implementing these interventions.

CONCLUSIONS

Different types of interventions to support compliance with breast cancer CPGs recommendations are available, and most of them show positive effects. More robust trials are needed to strengthen the available evidence base concerning their efficacy. Gathering data on the costs of implementing the proposed interventions is needed to inform decisions about their widespread implementation.

TRIAL REGISTRATION

CRD42018092884 (PROSPERO).

Osteoporosis management by primary care physicians in Singapore: a survey on osteoporosis guidelines utilisation and barriers to care

This study seeks to understand the knowledge/utilisation of osteoporosis guidelines among PCPs in Singapore, their confidence in and barriers to osteoporosis management. Knowledge and usage of guidelines was associated with confidence in management. Effective guideline adoption is therefore crucial. PCPs also need systemic support to overcome barriers to osteoporosis care.

PURPOSE

Primary care physicians (PCPs) are at the forefront of offering osteoporosis screening and treatment. However, osteoporosis remains under-treated in primary care, despite the existence of osteoporosis clinical practice guidelines for PCPs. This study aims to determine the self-reported knowledge and utilisation of local osteoporosis guidelines and associated sociodemographic factors and to determine the confidence and barriers to osteoporosis screening and management among PCPs in Singapore.

METHODS

An anonymous web-based survey was conducted. PCPs in public and private practice were invited to participate in the self-administered survey via e-mail and messaging platforms. Chi-square test was performed for bivariate analysis; multivariable logistic regression models were used for factors with p value < 0.2.

RESULTS

Three hundred thirty-four complete survey datasets were processed for analysis. Two hundred fifty-one PCPs (75.1%) had read the osteoporosis guidelines. 70.5% self-reported good knowledge, and 74.9% use the guidelines. PCPs who self-reported good guideline knowledge (OR = 5.84; 2.96-11.49) and utilisation (OR = 4.54; 2.21-9.34) were more likely to perceive confidence in osteoporosis management. PCPs' perception that patients had other medical priorities during the consultation (79.3%) was the commonest barrier to screening. Limited anti-osteoporosis medication (54.1%) in the practice was a hindrance to management. Polyclinic-based PCPs frequently cited the lack of consultation time as a barrier; more systemic barriers were faced by PCPs in private practices.

CONCLUSION

Most PCPs know and use the local osteoporosis guidelines. Knowledge and usage of guidelines was associated with confidence in management. Strategies to address the prevalent barriers to osteoporosis screening and management faced by PCPs are needed.

Applying the behavioural change wheel to guide the implementation of a biopsychosocial approach to musculoskeletal pain care

Achieving high value, biopsychosocial pain care can be complex, involving multiple stakeholders working synergistically to support the implementation of quality care. In order to empower healthcare professionals to assess, identify and analyse biopsychosocial factors contributing to musculoskeletal pain, and describe what changes are needed in the whole-of-system to navigate this complexity, we aimed to: (1) map established barriers and enablers influencing healthcare professionals' adoption of a biopsychosocial approach to musculoskeletal pain against behaviour change frameworks; and (2) identify behaviour change techniques to facilitate and support the adoption and improve pain education. A five-step process informed by the Behaviour Change Wheel (BCW) was undertaken: (i) from a recently published qualitative evidence synthesis, barriers and enablers were mapped onto the Capability Opportunity Motivation-Behaviour (COM-B) model and Theoretical Domains Framework (TDF) using "best fit" framework synthesis; (ii) relevant stakeholder groups involved in the whole-of-health were identified as audiences for potential interventions; (iii) possible intervention functions were considered based on the Affordability, Practicability, Effectiveness and Cost-effectiveness, Acceptability, Side-effects/safety, Equity criteria; (iv) a conceptual model was synthesised to understand the behavioural determinants underpinning biopsychosocial pain care; (v) behaviour change techniques (BCTs) to improve adoption were identified. Barriers and enablers mapped onto 5/6 components of the COM-B model and 12/15 domains on the TDF. Multi-stakeholder groups including healthcare professionals, educators, workplace managers, guideline developers and policymakers were identified as target audiences for behavioural interventions, specifically education, training, environmental restructuring, modelling and enablement. A framework was derived with six BCTs identified from the Behaviour Change Technique Taxonomy (version 1). Adoption of a biopsychosocial approach to musculoskeletal pain involves a complex set of behavioural determinants, relevant across multiple audiences, reflecting the importance of a whole-of-system approach to musculoskeletal health. We proposed a worked example on how to operationalise the framework and apply the BCTs. Evidence-informed strategies are recommended to empower healthcare professionals to assess, identify and analyse biopsychosocial factors, as well as targeted interventions relevant to various stakeholders. These strategies can help to strengthen a whole-of-system adoption of a biopsychosocial approach to pain care.

Virtual Oral Health across Canada: A Critical Comparative Analysis of Clinical Practice Guidances during the COVID-19 Pandemic

During the COVID-19 pandemic, teledentistry was suggested as a cost-effective and promising approach to improve access to oral health care. In response, Canadian provincial and territorial dental regulatory authorities (DRAs) published teledentistry-related clinical practice guidances (TCPGs). However, an in-depth comparison between them is needed to understand their gaps and commonalities so as to inform research, practice, and policy. This review aimed to provide a comprehensive analysis of TCPGs published by Canadian DRAs during the pandemic. A critical comparative analysis of these TCPGs published between March 2020 and September 2022 was conducted. Two members of the review team screened the official websites of dental regulatory authorities (DRAs) to identify TCPGs and performed data extraction. Among Canada's 13 provinces and territories, only four TCPGs were published during the relevant time period. There were some similarities and differences in these TCPGs, and we identified gaps pertaining to communication tools and platforms, and measures to safeguard patients' privacy and confidentiality. The insights from this critical comparative analysis and the unified workflow on teledentistry can aid DRAs in their development of new or an improvement to existing TCPGs or the development of nationwide TCP guidelines on teledentistry.

A Web-Based Reporting System for Reviewing Local Practice Patterns of Anesthesiologists Derived from the Electronic Medical Record

After completion of training, anesthesiologists may have fewer opportunities to see how colleagues practice, and their breadth of case experiences may also diminish due to specialization. We created a web-based reporting system based on data extracted from electronic anesthesia records that allows practitioners to see how other clinicians practice in similar cases. One year after implementation, the system continues to be utilized by clinicians.

Clinical research coordinators' role in knowledge translation activities in rehabilitation: a mixed methods study

BACKGROUND

Clinical research coordinators (CRCs) facilitate the interaction between researchers and knowledge users in rehabilitation centres to promote and sustain evidence-informed practices. Despite their presence in rehabilitation settings in Quebec for over 20 years, little is known about their profiles and knowledge translation (KT) activities nor how they can best enact their role. This study explored CRCs' roles and perspectives on the barriers, enablers, and strategies for improving KT activities in rehabilitation settings.

METHODS

We conducted a multi-centre, participatory sequential mixed methods study. In the descriptive quantitative phase, we collected data via an online survey to determine CRCs' role in research and KT. In the subsequent qualitative phase, we conducted an in-person focus group to elicit CRCs' perspectives regarding factors influencing their work in KT, and potential solutions for overcoming these challenges. We used a descriptive and an inductive content analysis approach for the data analysis. The data synthesis was inspired by the Promoting Action on Research Implementation in Health Services framework.

RESULTS

All nine CRCs from five partner health regions of a large rehabilitation research centre agreed to participate in the study. The data suggest that CRCs are like knowledge brokers and boundary spanners. As information managers, linkage agents and facilitators, CRCs play a pivot role in diffusion, dissemination, synthesis and tailoring of knowledge to improve evidence informed practices and quality of care in rehabilitation. The factors influencing CRCs' KT activities are mostly linked to the context such as the receptivity of the organization as well as the lack of time and resources, and limited understanding of their roles by stakeholders. Two main suggestions made to enhance CRCs' contribution to KT activities include the harmonisation of expectations between the large research centre and their partner health regions, and better promotion of their role to clinical and research teams.

CONCLUSIONS

This study provides valuable insights into the scope of CRCs' role. The results shed light on the challenges that they face and potential solutions to overcome them. The knowledge generated in this study can be used to implement this role with similar duties in rehabilitation settings or other health care domains.

Developing spinal cord injury physiotherapy clinical practice guidelines: a qualitative study to determine how physiotherapists and people living with spinal cord injury use evidence

STUDY DESIGN

Generic qualitative design.

OBJECTIVES

Australian and New Zealand SCI physiotherapists are developing clinical practice guidelines for the physiotherapy management of people living with spinal cord injury. To guide the development of the guidelines it was important to understand how physiotherapists and people living with spinal cord injury use evidence to choose interventions and the potential barriers and facilitators to the uptake of the clinical practice guidelines.

SETTING

Spinal Cord Injury Centres in Sydney, Australia and New Zealand.

METHODS

Focus groups and interviews with physiotherapists and people living with spinal cord injury were recorded, transcribed, and subjected to thematic analysis.

RESULTS

A total of 75 participants took part in the study, 45 physiotherapists and 30 people living with spinal cord injury. Three main themes were identified from the data: (1) Types and sources of evidence that influence treatment choices, (2) the many factors determining treatment choices, and (3) ways in which clinical practice guidelines could influence treatment.

CONCLUSIONS

Clinical practice guidelines have the potential to reduce the barriers identified by physiotherapists in accessing and interpreting research evidence on interventions for people living with spinal cord injury. Supported implementation of guidelines is required to demonstrate their benefit and encourage physiotherapists to factor in evidence when balancing the multiple factors influencing choice of physiotherapy intervention.

A Community-Based Participatory Framework to Co-Develop Patient Education Materials (PEMs) for Rare Diseases: A Model Transferable across Diseases

At least 50% of chronic disease patients don't follow their care plans, leading to lower health outcomes and higher medical costs. Providing Patient Education Materials (PEMs) to individuals living with a disease can help to overcome these problems. PEMs are especially beneficial for people suffering from multisystemic and underrecognized diseases, such as rare diseases. Congenital disorders of glycosylation (CDG) are ultra-rare diseases, where a need was identified for PEMs in plain language that can clearly explain complex information. Community involvement in the design of PEMs is extremely important for diseases whose needs are underserved, such as rare diseases; however, attempts to involve lay and professional stakeholders are lacking. This paper presents a community-based participatory framework to co-create PEMs for CDG, that is transferable to other diseases. A literature review and questionnaire were performed, and only four articles describing the development of PEMS for rare diseases have been found, which demonstrates a lack of standardized approaches. The framework and PEMs were co-developed with CDG families and will be crucial in increasing health literacy and empowering families. We will close a gap in the creation of PEMs for CDG by delivering these resources in lay language in several languages.

Clinical practice guideline adherence in oncology: A qualitative study of insights from clinicians in Australia

BACKGROUND

The burden of cancer is large in Australia, and rates of cancer Clinical Practice Guideline (CPG) adherence is suboptimal across various cancers.

METHODS

The objective of this study is to characterise clinician-perceived barriers and facilitators to cancer CPG adherence in Australia. Semi-structured interviews were conducted to collect data from 33 oncology-focused clinicians (surgeons, radiation oncologists, medical oncologists and haematologists). Clinicians were recruited in 2019 and 2020 through purposive and snowball sampling from 7 hospitals across Sydney, Australia, and interviewed either face-to-face in hospitals or by phone. Audio recordings were transcribed verbatim, and qualitative thematic analysis of the interview data was undertaken. Human research ethics committee approval and governance approval was granted (2019/ETH11722, #52019568810127).

RESULTS

Five broad themes and subthemes of key barriers and facilitators to cancer treatment CPG adherence were identified: Theme 1: CPG content; Theme 2: Individual clinician and patient factors; Theme 3: Access to, awareness of and availability of CPGs; Theme 4: Organisational and cultural factors; and Theme 5: Development and implementation factors. The most frequently reported barriers to adherence were CPGs not catering for patient complexities, being slow to be updated, patient treatment preferences, geographical challenges for patients who travel large distances to access cancer services and limited funding of CPG recommended drugs. The most frequently reported facilitators to adherence were easy accessibility, peer review, multidisciplinary engagement or MDT attendance, and transparent CPG development by trusted, multidisciplinary experts. CPGs provide a reassuring framework for clinicians to check their treatment plans against. Clinicians want cancer CPGs to be frequently updated utilising a wiki-like process, and easily accessible online via a comprehensive database, coordinated by a well-trusted development body.

CONCLUSION

Future implementation strategies of cancer CPGs in Australia should be tailored to consider these context-specific barriers and facilitators, taking into account both the content of CPGs and the communication of that content. The establishment of a centralised, comprehensive, online database, with living wiki-style cancer CPGs, coordinated by a well-funded development body, along with incorporation of recommendations into point-of-care decision support would potentially address many of the issues identified.

Audit and feedback in cardio- and cerebrovascular setting: Toward a path of high reliability in Italian healthcare

Adopting audit and feedback (A&F) strategies could be a suitable healthcare intervention to fulfill the challenge of monitoring and improving clinical guidelines in evidence-based medicine. Indeed, A&F is used to encourage professionals to better adhere to standard guidelines to improve healthcare performance. Briefly, an audit is an inspection of professional practice in comparison to professional standards or targets whose results are subsequently communicated to professionals in a structured manner. Although A&F strategies have been adopted in several time-dependent settings, such as for acute myocardial infarction (AMI) and stroke, interest of audits in rehabilitation care is also emerging. Recently, the Italian Ministry of Health has funded a national network project called EASY-NET, whose main objective is to evaluate the effectiveness of A&F strategies to improve healthcare practice and equity in various clinical and organizational settings in seven Italian regions. Last but not the least of these regions is the Sicily, represented within the project by the IRCCS Centro Neurolesi Bonino-Pulejo of Messina as the work package 7 (WP7). The EASY-NET WP7 is focused on the effectiveness of A&F strategies in both AMI and ischemic stroke setting, from acute to rehabilitation process of care. In this study, we described the study protocol, including the study design and methodology, providing a detailed description of the new model of A&F based on telemedicine, and discussing the possible challenges of this project.

Adaptation, implementation, and mixed methods evaluation of an interprofessional modular clinical practice guideline for delirium management on an inpatient palliative care unit

BACKGROUND

Using delirium clinical guidelines may align interprofessional clinical practice and improve the care of delirious patients and their families. The aim of this project was to adapt, implement and evaluate an interprofessional modular delirium clinical practice guideline for an inpatient palliative care unit.

METHODS

The setting was a 31-bed adult inpatient palliative care unit within a university-affiliated teaching hospital. Participants for the evaluation were interprofessional team members. Using integration of guideline adaptation and an education initiative, an interprofessional guideline adaptation group developed a face-to-face 'starter kit' module and four online self-learning modules. The mixed methods evaluation comprised pre-and post-implementation review of electronic patient records, an online survey, and analysis of focus groups/ interviews using an iterative, inductive thematic analysis approach.

RESULTS

Guideline implementation took 12 months. All palliative care unit staff attended a 'starter kit' session. Overall completion rate of the four e-Learning modules was 80.4%. After guideline implementation, nursing documentation of non-pharmacological interventions occurring before medication administration was observed. There was 60% less scheduled antipsychotic use and an increase in 'as needed' midazolam use. The online survey response rate was 32% (25/77). Most participants viewed the guideline's implementation favourably. Six key themes emerged from the qualitative analysis of interviews and focus groups with ten participants: prior delirium knowledge or experiences, challenges of facilitating change, impacts on practice, collaborative effort of change, importance of standardized guidelines, and utility of guideline elements.

CONCLUSIONS

Guideline implementation warrants concerted effort, time, and management support. Interprofessional team support facilitates the modular approach of guideline adaptation and implementation, leading to a change in clinical practice.

A randomised controlled trial of an implementation strategy delivered at scale to increase outdoor free play opportunities in early childhood education and care (ECEC) services: a study protocol for the get outside get active (GOGA) trial

BACKGROUND

Increased outdoor play time in young children is associated with many health and developmental benefits. This study aims to evaluate the impact of a multi-strategy implementation strategy delivered at scale, to increase opportunities for outdoor free play in Early Childhood Education and Care (ECEC) services.

METHODS

The study will employ a parallel-group randomised controlled trial design. One hundred ECEC services in the Hunter New England region of New South Wales, Australia, will be recruited and randomised to receive either a 6-month implementation strategy or usual care. The trial will seek to increase the implementation of an indoor-outdoor routine (whereby children are allowed to move freely between indoor and outdoor spaces during periods of free play), to increase their opportunity to engage in outdoor free play. Development of the strategy was informed by the Behaviour Change Wheel to address determinants identified in the Theoretical Domains Framework. ECEC services allocated to the control group will receive 'usual' implementation support delivered as part of state-wide obesity prevention programs. The primary trial outcome is the mean minutes/day (calculated across 5 consecutive days) of outdoor free play opportunities provided in ECEC services measured at baseline, 6-months (primary end point) and 18-months post baseline. Analyses will be performed using an intention-to-treat approach with ECEC services as the unit of analysis, using a linear mixed effects regression model to assess between-group differences. A sensitivity analysis will be undertaken, adjusting for service characteristics that appear imbalanced between groups at baseline, and a subgroup analysis examining potential intervention effect among services with the lowest baseline outdoor free play opportunities.

DISCUSSION

Identifying effective strategies to support the implementation of indoor-outdoor routines in the ECEC setting at scale is essential to improve child population health.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ( ACTRN12621000987864 ). Prospectively registered 27th July 2021, ANZCTR - Registration.

"She'll Be Right, Mate": A Mixed Methods Analysis of Skin Cancer Prevention Practices among Australian Farmers-An At-Risk Group

This study examined Australian farmers’ engagement with skin cancer prevention behaviours and explored what made it hard for them to be ‘SunSmart’ (barriers), and what could be done to make prevention easier (facilitators). In total, 498 farmers (83.1% male, 22–89 years, 50.8% grain, sheep, or cattle farmers) participated. The least frequently performed SunSmart behaviours (reported as never practiced during summer) were using SPF 30+ sunscreen (16.6%), wearing protective sunglasses (10.5%), and wearing protective clothing (8.6%). Greater engagement (i.e., higher scores on scale from Never to Always) with SunSmart behaviours was explained by gender (female), educational attainment (trade or technical college certificate vs. high school), personal skin cancer history, and skin sun sensitivity. Barriers reported by farmers related to personal preferences (e.g., short-sleeved rather than long-sleeved clothing), comfort, and perceived impracticality of sun protection. Farmers’ solutions included making protective clothing and sunscreen more appropriate for farm work (e.g., by making clothing more breathable). A personal health scare was the most reported motivation for skin cancer prevention. Findings highlight the need for increased access to sun-protective clothing and sunscreen that is suitable for wearing when working on farms, complemented by culturally appropriate health education messaging, to encourage more farmers to perform SunSmart behaviours.

Sources of Information on Medicinal Products Among Physicians - A Survey Conducted Among Primary Care Physicians in Poland

Introduction: Primary care physicians need to have access to up-to-date knowledge in various fields of medicine and high-quality information sources, but little is known about the use and credibility of sources of information on medicinal products among Polish doctors. The main goal of this study was to analyze the sources of information on medicinal products among primary care physicians in Poland.

Methods: A survey was conducted among 316 primary care physicians in Poland. The following information was collected: demographic data of participants, type and frequency of using data sources on medicinal products, barriers to access credible information, assessment of the credibility of the sources used, impact of a given source and other factors on prescription decisions.

Results: The most frequently mentioned sources of information were medical representatives (79%), medical journals (78%) and congresses, conventions, conferences, and training (76%). The greatest difficulty in finding the latest information about medicinal products was the lack of time. The surveyed doctors considered clinical guidelines to be the most credible source of information, and this source also had the greatest impact on the choice of prescribed medicinal products.

Conclusion: The study showed that clinicians consider clinical guidelines as the most credible source of information with the greatest impact on prescribing medicinal products. However, it is not the source most often mentioned by doctors for obtaining knowledge about medicinal products. There is a need to develop strategies and tools to provide physicians with credible sources of information.

Cochrane Pflegeforum

Gedruckte Schulungsmaterialien zur Verbesserung von beruflichem/professionellem Handeln im Gesundheitswesen und der Gesundheit von Patienten

Printed educational materials directed at Ontario family physicians do not improve adherence to guideline recommendations for diabetes management: a pragmatic, factorial, cluster randomized controlled trial [ISRCTN72772651]

Background

Printed educational materials (PEMs) have long been used to inform clinicians on evidence-based practices. However, the evidence for their effects on patient care and outcomes is unclear. In Ontario, despite widely available clinical practice guidelines recommending antihypertensives and cholesterol-lowering agents for patients with diabetes, prescriptions remain low. We aimed to determine whether PEMs can influence physicians to intensify prescribing of these medications.

Methods

A pragmatic, 2 × 2 factorial, cluster randomized controlled trial was designed to ascertain the effect of two PEM formats on physician prescribing: a postcard-sized message (“outsert”) or a longer narrative article (“insert”). Ontario family physician practices (clusters) were randomly allocated to receive the insert, outsert, both or neither. Physicians were eligible if they were in active practice and their patients were included if they were over 65 years with a diabetes diagnosis; both were unaware of the trial. Administrative databases at ICES (formerly the Institute for Clinical Evaluative Sciences) were used to link patients to their physician and to analyse prescribing patterns at baseline and 1 year following PEM mailout. The primary outcome was intensification defined as the addition of a new antihypertensive or cholesterol-lowering agent, or dose increase of a current drug, measured at the patient level. Analyses were by intention-to-treat and accounted for the clustering of patients to physicians.

Results

We randomly assigned 4231 practices (39% of Ontario family physicians) with a total population of 185,526 patients (20% of patients with diabetes in Ontario primary care) to receive the insert, outsert, both, and neither; among these, 4118 practices were analysed (n = 1025, n = 1037, n = 1031, n = 1025, respectively). No significant treatment effect was found for the outsert (odds ratio (OR) 1.01, 95% confidence interval (CI) 0.98 to 1.04) or the insert (OR 0.99, 95% CI 0.96 to 1.02). Percent of intensification in the four arms was similar (approximately 46%). Adjustment for physician characteristics (e.g., age, sex, practice location) had no impact on these findings.

Conclusions

PEMs have no effect on physician’s adherence to recommendations for the management of diabetes-related complications in Ontario. Further research should investigate the effect of other strategies to narrow this evidence-to-practice gap.

Trial registration

ISRCTN72772651. Retrospectively registered 21 July 2005.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01592-9.

Design and pilot evaluation of an evidence-based worksheet and clinician guide to facilitate nutrition counselling for patients with severe mental illness

BACKGROUND

Schizophrenia spectrum disorders (SSD) are severe, persistent mental illnesses resulting in considerable disability and premature mortality. Emerging evidence suggests that diet may be a modifiable risk factor in mental illness; however, use of nutritional counselling as a component of psychiatric clinical practice is limited. The objective of this project is the design and evaluate a worksheet and clinician guide for use in facilitating nutritional counseling in the context of existing mental health care.

METHODS

The worksheet and clinician guide were developed based on the results of a recent scoping review on the relationship between diet and mental health symptoms among individuals with SSD. A feedback process involved a focus group with psychiatrists and interviews with individuals with lived experience with psychosis. Participants were asked a series of structured and open-ended questions. Interviews were transcribed and data units were allocated to categories from an existing framework. The comments were used to guide modifications to the worksheet and clinician guide. A brief interview with all participants was completed to gather feedback on the final version.

RESULTS

Five psychiatrist participants and six participants with lived experience completed interviews. Participants provided positive comments related to the worksheet design, complexity and inclusion of interactive components. A novel theme emerged relating to the lack of nutritional counselling in psychiatric training and clinical practice. Many constructive comments were provided which resulted in meaningful revisions and improvements to the worksheet and clinician guide design and content. All participants were satisfied with the final versions.

CONCLUSIONS

A worksheet and clinician guide designed to facilitate nutritional counselling with individuals with SSD was found to be acceptable to all participants following a process of feedback and revision. Further research and dissemination efforts aimed at increasing the use of nutritional counselling in psychiatric practice are warranted.

Barriers, Enablers, and Consumer Design Ideas for Health Literacy Responsive Hospital Waiting Areas: A Framework Method Analysis

AIM

The study aim was to (1) investigate the barriers and enablers experienced by consumers to accessing and engaging with health tools in hospital waiting areas and (2) evaluate consumers' ideas for designing a health literacy responsive waiting area.

BACKGROUND

Health information, resources, and supports ("health tools") in waiting areas should be responsive to the health literacy needs of consumers. However, consumers' experiences of using health tools and their ideas for improving them are not known.

METHODS

Multicenter study was set in hospital waiting areas of outpatient rehabilitation services. Semistructured in-person interviews were conducted with 33 adult consumers attending appointments for various health conditions. Seven stages of the Framework Method were used to analyze data.

RESULTS

Six themes were identified which explained barriers and enablers from the perspective of consumers. The barriers were accessibility issues; personal factors-physical condition, emotional state, and preferences; and poorly presented and outdated resources. The enablers were design suits consumer needs and preferences; usable in available time or portable; and compatible environment for engaging and sharing. Consumers shared design ideas which fit within four typologies.

CONCLUSIONS

A range of barriers and enablers exist which have an impact on consumers' ability to engage with available health information, resources, and supports in hospital outpatient waiting areas. Practical insights from the perspective of consumers can be applied to future health service design. Consumer's design ideas suggest that partnerships with consumers should be formed to design health literacy responsive waiting areas.

Implementing work-related Mental health guidelines in general PRacticE (IMPRovE): a protocol for a hybrid III parallel cluster randomised controlled trial

BACKGROUND

The Clinical Guideline for the Diagnosis and Management of Work-related Mental Health Conditions in General Practice (the Guideline) was published in 2019. The objective of this trial is to implement the Guideline in general practice.

TRIAL DESIGN

Implementing work-related Mental health conditions in general PRacticE is a hybrid III, parallel cluster randomised controlled trial undertaken in Australia. Its primary aim is to assess the effectiveness of a complex intervention on the implementation of the Guideline in general practice. Secondary aims are to assess patient health and work outcomes, to evaluate the cost-effectiveness of the trial, and to develop a plan for sustainability.

METHODS

A total of 86 GP clusters will be randomly allocated either to the intervention arm, where they will receive a complex intervention comprising academic detailing, enrolment in a community of practice and resources, or to the control arm, where they will not receive the intervention. GP guideline concordance will be assessed at baseline and 9 months using virtual simulated patient scenarios. Patients who meet the eligibility criteria (>18years, employed, and receiving care from a participating GP for a suspected or confirmed work-related mental health condition) will be invited to complete surveys about their health and work participation and provide access to their health service use data. Data on health service use and work participation compensation claim data will be combined with measures of guideline concordance and patient outcomes to inform an economic evaluation. A realist evaluation will be conducted to inform the development of a plan for sustainability.

RESULTS

We anticipate that GPs who receive the intervention will have higher guideline concordance than GPs in the control group. We also anticipate that higher concordance will translate to better health and return-to-work outcomes for patients, as well as cost-savings to society.

CONCLUSIONS

The trial builds on a body of work defining the role of GPs in compensable injury, exploring their concerns, and developing evidence-based guidelines to address them. Implementation of these guidelines has the potential to deliver improvements in GP care, patient health, and return-to-work outcomes.

TRIAL REGISTRATION

ACTRN12620001163998 , November 2020.

A Health eLearning Ontology and Procedural Reasoning Approach for Developing Personalized Courses to Teach Patients about Their Medical Condition and Treatment

We propose a methodological framework to support the development of personalized courses that improve patients' understanding of their condition and prescribed treatment. Inspired by Intelligent Tutoring Systems (ITSs), the framework uses an eLearning ontology to express domain and learner models and to create a course. We combine the ontology with a procedural reasoning approach and precompiled plans to operationalize a design across disease conditions. The resulting courses generated by the framework are personalized across four patient axes-condition and treatment, comprehension level, learning style based on the VARK (Visual, Aural, Read/write, Kinesthetic) presentation model, and the level of understanding of specific course content according to Bloom's taxonomy. Customizing educational materials along these learning axes stimulates and sustains patients' attention when learning about their conditions or treatment options. Our proposed framework creates a personalized course that prepares patients for their meetings with specialists and educates them about their prescribed treatment. We posit that the improvement in patients' understanding of prescribed care will result in better outcomes and we validate that the constructs of our framework are appropriate for representing content and deriving personalized courses for two use cases: anticoagulation treatment of an atrial fibrillation patient and lower back pain management to treat a lumbar degenerative disc condition. We conduct a mostly qualitative study supported by a quantitative questionnaire to investigate the acceptability of the framework among the target patient population and medical practitioners.

Baby Steps: Using Intervention Mapping to Develop a Sustainable Perinatal Physical Activity Healthcare Intervention

While the benefits of physical activity (PA) during and after pregnancy have been established, many women do not reach the recommended PA levels during this time. A major barrier found in the literature is a lack of counselling by healthcare providers (HCPs), which is partly caused by the limited knowledge on the topic. The aim of this study was to develop an intervention to improve the promotion of PA by HCPs. We used Intervention Mapping (IM), a theory-based framework to develop an intervention, called "Baby steps", in a high-income (Austria) and a low-to-middle-income country (South Africa). We applied the following IM steps: (1) A needs assessment to determine the barriers and enablers of PA promotion by HCPs, including a scoping literature review and community needs assessments (qualitative interviews, questionnaires, and focus groups with midwives, obstetricians, and community health workers) to determine the desired outcomes of the intervention. (2) Performance and change objectives were formulated, describing the behaviors that need to change for the intervention to succeed. (3) Based on these objectives, theory-based behavior change techniques were selected, and practical applications were developed. (4) The applications were combined into two evidence-based interventions tailored to each country's needs. Step (5) and (6) consist of an implementation and evaluation plan, respectively. The intervention is aimed at HCPs, such as midwives and community health workers, consisting of a two-day training course, including practical resources. Combining didactic and interactive education, it addresses both PA knowledge and the skills needed to transfer knowledge and facilitate behavior change. In the future, the intervention's effect on women's activity levels during and after pregnancy needs to be studied.

Clinician perspectives on a culturally adapted patient decision aid concerning maintenance therapy for asthma

BACKGROUND AND OBJECTIVE

Patients with persistent asthma often show poor adherence to inhaled corticosteroids (ICS). Shared decision-making can improve adherence rates in this population. Patient decision aids (PDAs) are tools to facilitate shared decision-making. To date, only one PDA, developed in a Canadian French-speaking population, exists for patients considering ICS maintenance therapy. This PDA has been culturally adapted in this study to contextualize to the needs of multi-ethnic Asian patients in Singapore. This study explored the views of local clinicians on the content, design and implementation of this newly-adapted PDA.

METHODS

24 clinicians, who were purposively sampled from polyclinics and a tertiary institution, were interviewed on the content, design and implementation of the PDA. The interviews were audio-recorded, transcribed and analyzed via thematic analysis.

RESULTS

Clinicians generally accepted the design of the PDA. They suggested for the target users to be patients on Step 2 of GINA guidelines and the number of options to be reduced from four to two (do nothing or start inhaled corticosteroids). Moreover, they supported including a list of values for patients to select from given that Asian patients often do not articulate their values readily. The addition of more visual aids, the production of multilingual Asian editions and the involvement of nurses to administer the PDA was also suggested.

CONCLUSION

The PDA was culturally-adapted with local clinicians' perspectives to target multi-ethnic Asian patients with persistent asthma (Step 2 GINA guidelines). The main changes include a list of values and addition of visual aids.

Stakeholder selected strategies for obesity prevention in childcare: results from a small-scale cluster randomized hybrid type III trial

BACKGROUND

Together, We Inspire Smart Eating (WISE) is an intervention for the early care and education setting to support children's exposure to and intake of fruits and vegetables. WISE emphasizes 4 evidence-based practices (EBPs): (1) use of a mascot; (2) educators' role modeling; (3) positive feeding practices; and (4) hands-on exposures. The current study reports on a small-scale implementation trial aimed at improving the use of WISE EBPs by teachers.

METHODS

A Hybrid Type III Cluster Randomized Design compared a Basic and Enhanced implementation strategy. The Basic Strategy included training and reminders only; the Enhanced strategy was a multi-faceted package of stakeholder-selected strategies including a leadership commitment, an implementation blueprint, a local champion, an environmental reminder of the EBPs, facilitation, and tailored educational resources and incentives. All study sites were Head Starts. Sites were randomized using a balancing technique that considered site characteristics; 4 sites (20 classrooms, 39 educators, 305 children) received Enhanced support; 5 sites (18 classrooms, 36 educators, 316 children) received Basic support. RE-AIM guided the evaluation, and implementation fidelity was the primary outcome. Strategies were assessed using examination of data distributions and unadjusted comparisons (t tests) as well as general linear and mixed effects models controlling for covariates.

RESULTS

For the primary outcome of fidelity, the Enhanced group had significantly higher means for 3 of 4 EBPs. Multivariate models explained a significant portion of variance for both mascot use and hands-on exposure with a significant positive effect observed for treatment condition. The Enhanced group also had higher rates of Appropriateness and Organizational Readiness for Implementing Change (as indicators of implementation and adoption, respectively). There was no significant difference between groups for indicators of Reach, Effectiveness or Maintenance. Formative interviews indicated key targets for iteration and potential mechanisms. Key events were catalogued to provide context for interpretation (e.g., 61% of classrooms with turnover).

CONCLUSIONS

Findings were mixed but suggested promise for the Enhanced strategy, especially considering key events of the study. Implementation fidelity improvements occurred mainly in the last 3 months of the school year; additional time may be needed to translate to improvements in child outcomes.

TRIAL REGISTRATION

NCT03075085 Registered 20 February 2017.

Strategies for facilitating the delivery of cluster randomized trials in hospitals: A study informed by the CFIR-ERIC matching tool

BACKGROUND

Recruitment and engagement of clusters in a cluster randomized controlled trial can sometimes prove challenging. Identification of successful or unsuccessful strategies may be beneficial in guiding future researchers in conducting their cluster randomized controlled trial. This study aimed to identify strategies that could be used to facilitate the delivery of cluster randomized controlled trials in hospitals.

METHODS

The study employed the Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change matching tool. The barriers and enablers to cluster randomized controlled trial conduct identified in our previously conducted studies served as a means of determinant identification for the conduct of cluster randomized controlled trials. These determinants were mapped to Consolidated Framework for Implementation Research constructs and then matched to Expert Recommendations for Implementing Change compilation strategies using the Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change matching tool.

RESULTS

The Expert Recommendations for Implementing Change strategies matched to at least one determinant Consolidated Framework for Implementation Research construct were as follows: (1) 'Identify and prepare champions', (2) 'Conduct local needs assessment', (3) 'Conduct educational meetings', (4) 'Inform local opinion leaders', (5) 'Build a coalition', (6) 'Promote adaptability', (7) 'Develop a formal implementation blueprint', (8) 'Involve patients/consumers and family members', (9) 'Obtain and use patients/consumers and family feedback', (10) 'Develop educational materials', (11) 'Promote network weaving', (12) 'Distribute educational materials', (13) 'Access new funding' and (14) 'Develop academic partnerships'.

CONCLUSION

This study was intended as a step in the research agenda aimed at facilitating cluster randomized controlled trial delivery in hospitals and can act as a resource for future researchers when planning their cluster randomized controlled trial, with the expectation that the strategies identified here will be tailored to each context.