Healthcare professional behaviour: health impact, prevalence of evidence-based behaviours, correlates and interventions

Using an intersectionality lens to explore barriers and enablers to hepatitis C point-of-care testing: a qualitative study among people who inject drugs and service providers

BACKGROUND

Hepatitis C virus (HCV) infection is a significant global health burden, particularly among people who inject drugs. Rapid point-of-care HCV testing has emerged as a promising approach to improve HCV detection and linkage to care in harm reduction organizations such as needle and syringe programs. The objective of this study was to use an intersectionality lens to explore the barriers and enablers to point-of-care HCV testing in a needle and syringe program.

METHODS

A qualitative study was conducted using semi-structured interviews with clients (people who inject drugs) and service providers in a large community organization focused on the prevention of sexually transmitted and blood borne infections and harm reduction in Montreal, Canada. An intersectionality lens was used alongside the Theoretical Domains Framework to guide the formulation of research questions as well as data collection, analysis, and interpretation.

RESULTS

We interviewed 27 participants (15 clients, 12 providers). For clients, four themes emerged: (1) understanding and perceptions of HCV testing, (2) the role of an accessible and inclusive environment, (3) the interplay of emotions and motivations in decision-making, and (4) the impact of intersectional stigma related to HCV, behaviors, and identities. For providers, five themes emerged: (1) knowledge, skills, and confidence for HCV testing, (2) professional roles and their intersection with identity and lived experience, (3) resources and integration of services, (4) social and emotional factors, and (5) behavioral regulation and incentives for HCV testing. Intersectional stigma amplified access, emotional and informational barriers to HCV care for clients. In contrast, identity and lived experience acted as powerful enablers for providers in the provision of HCV care.

CONCLUSION

The application of an intersectionality lens provides a nuanced understanding of multilevel barriers and enablers to point-of-care HCV testing. Findings underscore the need for tailored strategies that address stigma, improve provider roles and communication, and foster an inclusive environment for equitable HCV care. Using an intersectionality lens in implementation research can offer valuable insights, guiding the design of equity-focused implementation strategies.

Barriers and enablers to the implementation of patient-reported outcome and experience measures (PROMs/PREMs): protocol for an umbrella review

BACKGROUND

Patient-reported outcome and experience measures (PROMs and PREMs, respectively) are evidence-based, standardized questionnaires that can be used to capture patients' perspectives of their health and health care. While substantial investments have been made in the implementation of PROMs and PREMs, their use remains fragmented and limited in many settings. Analysis of multi-level barriers and enablers to the implementation of PROMs and PREMs has been hampered by the lack of use of state-of-the-art implementation science frameworks. This umbrella review aims to consolidate available evidence from existing quantitative, qualitative, and mixed-methods systematic and scoping reviews covering factors that influence the implementation of PROMs and PREMs in healthcare settings.

METHODS

An umbrella review of systematic and scoping reviews will be conducted following the guidelines of the Joanna Briggs Institute (JBI). Qualitative, quantitative, and mixed methods reviews of studies focusing on the implementation of PROMs and/or PREMs in all healthcare settings will be considered for inclusion. Eight bibliographical databases will be searched. All review steps will be conducted by two reviewers independently. Included reviews will be appraised and data will be extracted in four steps: (1) assessing the methodological quality of reviews using the JBI Critical Appraisal Checklist; (2) extracting data from included reviews; (3) theory-based coding of barriers and enablers using the Consolidated Framework for Implementation Research (CFIR) 2.0; and (4) identifying the barriers and enablers best supported by reviews using the Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) approach. Findings will be presented in diagrammatic and tabular forms in a manner that aligns with the objective and scope of this umbrella review, along with a narrative summary.

DISCUSSION

This umbrella review of quantitative, qualitative, and mixed-methods systematic and scoping reviews will inform policymakers, researchers, managers, and clinicians regarding which factors hamper or enable the adoption and sustained use of PROMs and PREMs in healthcare settings, and the level of confidence in the evidence supporting these factors. Findings will orient the selection and adaptation of implementation strategies tailored to the factors identified.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023421845.

Aligning organisational priorities and implementation science for cancer research

BACKGROUND

The challenge of implementing evidence into routine clinical practice is well recognised and implementation science offers theories, models and frameworks to promote investigation into delivery of evidence-based care. Embedding implementation researchers into health systems is a novel approach to ensuring research is situated in day-to-day practice dilemmas. To optimise the value of embedded implementation researchers and resources, the aim of this study was to investigate stakeholders' views on opportunities for implementation science research in a cancer setting that holds potential to impact on care. The research objectives were to: 1) Establish stakeholder and theory informed organisation-level implementation science priorities and 2) Identify and prioritise a test case pilot implementation research project.

METHODS

We undertook a qualitative study using semi-structured interviews. Participants held either a formal leadership role, were research active or a consumer advocate and affiliated with either a specialist cancer hospital or a cancer alliance of ten hospitals. Interview data were summarised and shared with participants prior to undertaking both thematic analysis, to identify priority areas for implementation research, and content analysis, to identify potential pilot implementation research projects. The selected pilot Implementation research project was prioritised using a synthesis of an organisational and implementation prioritisation framework - the organisational priority setting framework and APEASE framework.

RESULTS

Thirty-one people participated between August 2022 and February 2023. Four themes were identified: 1) Integration of services to address organisational priorities e.g., tackling fragmented services; 2) Application of digital health interventions e.g., identifying the potential benefits of digital health interventions; 3) Identification of potential for implementation research, including deimplementation i.e., discontinuing ineffective or low value care and; 4) Focusing on direct patient engagement e.g., wider consumer awareness of the challenges in delivering cancer care. Six potential pilot implementation research projects were identified and the EMBED project, to support clinicians to refer appropriate patients with cancer for genetic testing, was selected using the synthesised prioritisation framework.

CONCLUSIONS

Using a theory informed and structured approach the alignment between strategic organisational priorities and implementation research priorities can be identified. As a result, the implementation research focus can be placed on activities with the highest potential impact.

Care partners experience of an oral health intervention for individuals with mild cognitive impairment and mild dementia using behavior change technique: A qualitative study

Oral health declines in older adults with cognitive impairment. We aimed to improve oral hygiene outcomes for individuals with mild cognitive impairment (MCI) or mild dementia (MD) by fostering behavior changes among carepartners assisting them. We used qualitative data of verbatim transcripts of coaching sessions with carepartners (n = 17 dyads:10 dyads for MCI, 7 dyads for MD). Directed and emergent coding were used to understand behavior change techniques (BCTs). BCTs were compared with carepartners of participants with MCI and MD. Most frequently used BCTs in both groups: prompts and cues, instruction on how to perform the behavior, review behavioral goal, and problem solving. Different BCTs emerged in study: social support-unspecified of the MCI group and credible source for MD group. Findings clarified active intervention components, common BCTs used by carepartners, and different BCT approaches for both participants. Findings help to elucidate the mechanisms of changes in individuals' behaviors in these interventions.

Identifying behaviour change techniques in 287 randomized controlled trials of audit and feedback interventions targeting practice change among healthcare professionals

BACKGROUND

Audit and feedback (A&F) is among the most widely used implementation strategies, providing healthcare professionals with summaries of their practice performance to prompt behaviour change and optimize care. Wide variability in effectiveness of A&F has spurred efforts to explore why some A&F interventions are more effective than others. Unpacking the variability of the content of A&F interventions in terms of their component behaviours change techniques (BCTs) may help advance our understanding of how A&F works best. This study aimed to systematically specify BCTs in A&F interventions targeting healthcare professional practice change.

METHODS

We conducted a directed content analysis of intervention descriptions in 287 randomized trials included in an ongoing Cochrane systematic review update of A&F interventions (searched up to June 2020). Three trained researchers identified and categorized BCTs in all trial arms (treatment & control/comparator) using the 93-item BCT Taxonomy version 1. The original BCT definitions and examples in the taxonomy were adapted to include A&F-specific decision rules and examples. Two additional BCTs ('Education (unspecified)' and 'Feedback (unspecified)') were added, such that 95 BCTs were considered for coding.

RESULTS

In total, 47/95 BCTs (49%) were identified across 360 treatment arms at least once (median = 5.0, IQR = 2.3, range = 129 per arm). The most common BCTs were 'Feedback on behaviour' (present 89% of the time; e.g. feedback on drug prescribing), 'Instruction on how to perform the behaviour' (71%; e.g. issuing a clinical guideline), 'Social comparison' (52%; e.g. feedback on performance of peers), 'Credible source' (41%; e.g. endorsements from respected professional body), and 'Education (unspecified)' (31%; e.g. giving a lecture to staff). A total of 130/287 (45%) control/comparator arms contained at least one BCT (median = 2.0, IQR = 3.0, range = 0-15 per arm), of which the most common were identical to those identified in treatment arms.

CONCLUSIONS

A&F interventions to improve healthcare professional practice include a moderate range of BCTs, focusing predominantly on providing behavioural feedback, sharing guidelines, peer comparison data, education, and leveraging credible sources. We encourage the use of our A&F-specific list of BCTs to improve knowledge of what is being delivered in A&F interventions. Our study provides a basis for exploring which BCTs are associated with intervention effectiveness.

TRIAL REGISTRATIONS

N/A.

Three-year COVID-19 and flu vaccinations among medical residents in a tertiary hospital in Italy: The threat of acceptance decline in seasonal campaigns

The COVID-19 vaccination campaign in Italy started in December 2020, and, due to the Omicron variant's emergence, a second booster dose was recommended for high-risk individuals and healthcare workers from July 2022. The aim of the study was to evaluate the vaccination coverages for the COVID-19 second booster dose and to identify predictors of its acceptance within the population of medical residents (MRs) of the Fondazione Policlinico Universitario "A. Gemelli" IRCCS (FPG) University Hospital. The study was conducted at FPG from October 4th to December 21st, 2022, and COVID-19 second booster dose and influenza vaccines were administered. The study analyzed collected data and conducted multivariate logistic regressions to explore potential predictors of vaccination adherence. The analyses performed were compared with the sample enrolled in FPG residency programs at the start of the COVID-19 vaccination campaign. 1968 MRs were involved in the 2022-2023 vaccination campaign (mean age 28.97, SD 3.44), and the second booster dose of COVID-19 vaccination coverage was low (18.80%). Almost all participants opted for co-administration of COVID-19 and influenza vaccinations, leading to a similar rate of influenza vaccination coverage (16.26%). Being a frontline resident, meaning a direct involvement in managing COVID-19 patients and vaccination campaigns, was the main predictor of vaccination adherence (OR 1.72, 95% CI 1.25-2.17). The dropping in influenza vaccination coverage in 2022-2023 and the low adherence to COVID-19 second booster dose among young physicians is concerning, calling for tailored vaccination campaigns and interventions.

Behavior change training for pregnant women's communication during birth: A randomized controlled trial

Applying health psychological theories can improve communication interventions to empower pregnant women and ensure safe births. The aim was to test a short digital communication intervention based on the health action process approach. A randomized-controlled trial was conducted with pregnant women at two German university hospitals. The intervention group (NT1  = 225; NT2  = 142) received a 2.5 h online training focusing on communication planning, self-efficacy and communicating personal needs and preferences under difficult circumstances. This group was compared with a passive control group (NT1  = 199; NT2  = 144). Data from the N = 286 women with complete datasets were used for multilevel analyses. Data from all recruited N = 424 women were used for intention-to-treat analyses with multiple imputation. Both groups improved regarding communication behavior, quality of birth, action planning, coping planning and coping self-efficacy after birth, which was more pronounced in the intervention group. The intention-to-treat analyses confirmed the higher improvement for communication behavior, perceived quality of birth and coping planning. The intervention was related to improvements in pregnant women's communication behavior and quality of birth. Hence, future research and practice should apply and evaluate health psychological theories when targeting communication and empowerment.

Exercise Promotion Practices among Mental Health Professionals: A Scoping Review

Mental health professionals (MHPs) have a unique opportunity to integrate PA and exercise promotion into clinical care. This scoping review employed the information-motivation-behavioral Skills (IMB) model to examine the exercise promotion practices of MHP. An electronic search of four major databases from 2007 to August 2020 was conducted and results were reported using PRISMA. Seventeen studies were included where the variables of interest were knowledge, attitudes, and beliefs regarding exercise promotion. MHP expressed a need for additional training and the integration of exercise specialists to care for the physical health of patients. Practitioners need additional education to understand the guidelines for exercise prescription for individuals with SMI and the role exercise could have in improving the quality of life for their patients. Findings were conceptualized utilizing the IMB model to inform future quantitative measures and health behavior interventions.

Protocol for a randomised pilot study of a novel Parent-Child Interaction Therapy (PCIT) 're-implementation' intervention

BACKGROUND

Despite a number of clinicians having been trained in Parent-Child Interaction Therapy (PCIT) in Aotearoa/New Zealand, few are regularly delivering the treatment, with barriers to use including a lack of suitable equipment and lack of professional support. This pragmatic, parallel-arm, randomised, controlled pilot trial includes PCIT-trained clinicians who are not delivering, or only rarely utilising, this effective treatment. The study aims to assess the feasibility, acceptability and cultural responsivity of study methods and intervention components and to collect variance data on the proposed future primary outcome variable, in preparation for a future, larger trial.

METHODS

The trial will compare a novel 're-implementation' intervention with a refresher training and problem-solving control. Intervention components have been systematically developed to address barriers and facilitators to clinician use of PCIT using implementation theory, and a draft logic model with hypothesised mechanisms of action, derived from a series of preliminary studies. The intervention includes complimentary access to necessary equipment for PCIT implementation (audio-visual equipment, a 'pop-up' time-out space, toys), a mobile senior PCIT co-worker and an optional weekly PCIT consultation group, for a 6-month period. Outcomes will include the feasibility of recruitment and trial procedures; acceptability of the intervention package and data collection methods to clinicians; and clinician adoption of PCIT.

DISCUSSION

Relatively little research attention has been directed at interventions to resurrect stalled implementation efforts. Results from this pragmatic pilot RCT will refine and shape knowledge relating to what it might take to embed the ongoing delivery of PCIT in community settings, providing more children and families with access to this effective treatment.

TRIAL REGISTRATION

ANZCTR, ACTRN12622001022752, registered on July 21, 2022.

Determinants of Patient-Perceived Primary Healthcare Quality in Lithuania

Patient-centered care is considered to be one of the essential pillars of a modern healthcare system. Thus, quality assessment based on patients' perceptions, views and experiences in their journey through the healthcare system is recognized as one of the key principles for quality improvement initiatives. Measuring patient satisfaction can be confounded by expectations and prior experiences, which can be at least partly overcome by evaluating patient-perceived healthcare quality (PPHQ). Understanding the principal constituents of PPHQ may aid healthcare professionals and decision makers in the healthcare management process and help in creating instruments to meaningfully measure patient feedback. Herein, we aimed to analyze the primary determinants of PPHQ and their interactions, with a focus on patient experiences and healthcare accessibility, using the example of Lithuanian primary healthcare. For this purpose, we conducted a cross-sectional representative telephone survey that included a total of 1033 respondents (48% male) who had encountered primary healthcare during last 3 years. Survey questions consisted of sociodemographic characteristics, patient perceptions of healthcare service provision, patient experiences, self-reported health status and overall PPHQ ranked with a 5-point Likert scale as the primary outcome. The classification-regression tree (CRT) technique was used to analyze the relationship between different explanatory variables and PPHQ, as well as their relative importance and interactions. The majority of respondents (89%) evaluated PPHQ as acceptable or good. CRT analysis identified staff behavior, organizational accessibility and financial accessibility as the most important factors affecting PPHQ. Importantly, the latter factors surpassed the effect of other known PPHQ determinants, such as sociodemographic characteristics or health status. Further analysis has revealed that the relative importance of staff behavior, including understanding, attention and empathy, increased when more problems with organizational accessibility were encountered. In conclusion, our study suggests that PPHQ in primary healthcare may primarily be determined by organizational and financial accessibility and staff behavior, which may also act as an important mediating factor.

Understanding how primary care practitioners can be supported to recognise, screen and initially diagnose oropharyngeal dysphagia: protocol for a behavioural science realist review

INTRODUCTION

Oropharyngeal dysphagia (OD) affects around 15% of older people; however, it is often unrecognised and underdiagnosed until patients are hospitalised. Screening is an important process which aims to facilitate proactive assessment, diagnosis and management of health conditions. Healthcare systems do not routinely screen for OD in older people, and healthcare professionals (HCPs) are largely unaware of the need to screen. This realist review aims to identify relevant literature and develop programme theories to understand what works, for whom, under what circumstances and how, to facilitate primary care HCPs to recognise, screen and initially diagnose OD.

METHODS AND ANALYSIS

We will follow five steps for undertaking a realist review: (1) clarify the scope, (2) literature search, (3) appraise and extract data, (4) evidence synthesis and (5) evaluation. Initial programme theories (IPTs) will be constructed after the preliminary literature search, informed by the Theoretical Domains Framework and with input from a stakeholder group. We will search Medline, Google Scholar, PubMed, EMBASE, CINAHL, AMED, Scopus and PsycINFO databases. We will obtain additional evidence through grey literature, snowball sampling, lateral searching and consulting the stakeholder group. Literature will be screened, evaluated and synthesised in Covidence. Evidence will be assessed for quality by evaluating its relevance and rigour. Data will be extracted and synthesised according to their relation to IPTs. We will follow the Realist and Meta-narrative Evidence Syntheses: Evolving Standards quality and publication standards to report study results.

ETHICS AND DISSEMINATION

Formal ethical approval is not required for this review. We will disseminate this research through publication in a peer-reviewed journal, written pieces targeted to diverse groups of HCPs on selected online platforms and public engagement events.

PROSPERO REGISTRATION NUMBER

CRD42022320327.

Machine Learning Modeling of Disease Treatment Default: A Comparative Analysis of Classification Models

Generally, treatment default of diseases by patients is regarded as the biggest threat to favourable disease treatment outcomes. It is seen as the reason for the resurgence of infectious diseases including tuberculosis in some developing countries. Sadly, its occurrence in chronic disease management is associated with high morbidity and mortality rates. Many reasons have been adduced for this phenomenon. Exploration of treatment default using biographic and behavioral metrics collected from patients and healthcare providers remains a challenge. The focus on contextual nonbiomedical measurements using a supervised machine learning modeling technique is aimed at creating an understanding of the reasons why treatment default occurs, including identifying important contextual parameters that contribute to treatment default. The predicted accuracy scores of four supervised machine learning algorithms, namely, gradient boosting, logistic regression, random forest, and support vector machine were 0.87, 0.90, 0.81, and 0.77, respectively. Additionally, performance indicators such as the positive predicted value score for the four models ranged between 98.72%–98.87%, and the negative predicted values of gradient boosting, logistic regression, random forest, and support vector machine were 50%, 75%, 22.22%, and 50%, respectively. Logistic regression appears to have the highest negative-predicted value score of 75%, with the smallest error margin of 25% and the highest accuracy score of 0.90, and the random forest had the lowest negative predicted value score of 22.22%, registering the highest error margin of 77.78%. By performing a chi-square correlation statistic test of variable independence, this study suggests that age, presence of comorbidities, concern for long queuing/waiting time at treatment facilities, availability of qualified clinicians, and the patient’s nutritional state whether on a controlled diet or not are likely to affect their adherence to disease treatment and could result in an increased risk of default.

Ivers N. Surfacing the causal assumptions and active ingredients of healthcare quality improvement interventions: An application to primary care opioid prescribing

Background

Efforts to maximize the impact of healthcare improvement interventions are hampered when intervention components are not well defined or described, precluding the ability to understand how and why interventions are expected to work.

Method

We partnered with two organizations delivering province-wide quality improvement interventions to establish how they envisaged their interventions lead to change (their underlying causal assumptions) and to identify active ingredients (behavior change techniques [BCTs]). The interventions assessed were an audit and feedback report and an academic detailing program. Both focused on supporting safer opioid prescribing in primary care in Ontario, Canada. Data collection involved semi-structured interviews with intervention developers (n = 8) and a content analysis of intervention documents. Analyses unpacked and articulated how the interventions were intended to achieve change and how this was operationalized.

Results

Developers anticipated that the feedback report would provide physicians with a clear understanding of their own prescribing patterns in comparison to others. In the feedback report, we found an emphasis on BCTs consistent with that assumption (feedback on behavior; social comparison). The detailing was designed to provide tailored support to enable physicians to overcome barriers to change and to gradually enact specific practice changes for patients based on improved communication. In the detailing materials, we found an emphasis on instructions on how to perform the behavior, for a range of behaviors (e.g., tapering opioids, treating opioid use disorder). The materials were supplemented by detailer-enacted BCTs (e.g., social support [practical]; goal setting [behavior]; review behavioral goal[s]).

Conclusions

The interventions included a small range of BCTs addressing various clinical behaviors. This work provides a methodological example of how to apply a behavioral lens to surface the active ingredients, target clinical behaviors, and causal assumptions of existing large-scale improvement interventions that could be applied in other contexts to optimize effectiveness and facilitate scale and spread.