Using action research and a community-academic partnership to understand clinical trial participation: a patient-centered perspective

BACKGROUND

Clinical trials that are patient-centered appear to be more successful (e.g., clinical outcomes, improved communication, mutual empowerment, changed attitudes), thus, action research may be a field of importance. The current study explores the Formation and Execution of Activities phases of a community-academic partnership (CAP).

METHODS

Members consisted of industry stakeholders, a healthcare/academic institution, and patients/families with lived experiences as cancer survivors and/or caregivers. Retrospectively, CAP members described the facilitating and/or hindering factors present in the partnership development. A document review process was used. Field notes from three CAP meetings, which focused on understanding clinical trial participation, were analyzed using a thematic approach.

RESULTS

Seven facilitating and three hindering factors were present. Interpersonal (vs. operational) processes were referenced as influential facilitating factors more often. Themes that emerged included 'trials as a treatment option', 'leaving a legacy', and 'timing is critical.'

CONCLUSION

This study provides a patient-centered perspective on barriers/challenges of clinical trial participation and how to improve future perceptions.

NICU Parent and Staff Advocacy to Address Parental Mental Health

Parents of infants requiring neonatal intensive care unit (NICU) hospitalization often experience increased rates of distress, trauma, and perinatal mood disorders. Untreated parental mental health conditions have short- and long-term effects for infants and families. While some NICUs provide varying degrees of mental health supports for NICU families, these services are not universally or systematically integrated in US NICUs. Multiple factors contribute to this gap in care, including mental health stigma, funding constraints, and lack of staff training and capacity. In an effort to address this gap, we used a participatory action research approach, guided by a Patient and Stakeholder Engagement model, to partner with graduate NICU parents and patient-facing NICU staff to identify parental mental health needs and ideas to address them. Through efforts to mitigate power differentials and engage parents as research and program development partners, our work shaped NICU practices, programming, and subsequent research.

Record, reflect and refine: using video review as an initiative to improve neonatal care

BACKGROUND

The goal of every medical team is to provide optimal care for their patients. We aimed to use video review (VR) sessions to identify and address areas for improvement in neonatal care.

METHODS

For nine months, neonatal procedures (stabilization at birth, intubations and sterile line insertions) were video recorded and reviewed with the neonatal care providers. Action research was used to identify and address areas for improvement which were categorized as (1) protocol/equipment adjustments, (2) input for research, (3) aspects of variety, or (4) development of educational material or training programs.

RESULTS

Eighteen VR sessions were organized with a mean(SD) of 17(5) staff members participating. In total, 120 areas for improvement were identified and addressed, of which 84/120 (70%) were categorized as aspects of variety, 20/120 (17%) as development of educational material or training programs, 10/120 (8%) as protocol/equipment adjustments, and 6/120 (5%) as input for research. The areas for improvement were grouped in themes per category, including sterility, technique, equipment, communication, teamwork, parents' perspective and ventilation.

CONCLUSION

Our study showed that regularly organized VR empowered healthcare providers to identify and address a large variety of areas for improvement, contributing to continuous learning and improvement processes.

IMPACT

Video review empowered healthcare providers to identify areas for improvement in neonatal care Video review gave providers the opportunity to address identified areas for improvement, either by enhancing the application of external evidence (i.e. guidelines), learning from individual clinical expertise or strengthening resilience and teamwork Embedding regularly organized video review sessions allowed for continuous monitoring of care by providers, which can be beneficial for creating ongoing learning and improvement processes The structured pathways, supporting implementation of changes that were proposed based on the video review sessions, could help other centers make use of the potential video review has to offer.

Oral health education for systemic sclerosis patients: A booklet report

Purpose/objectives

Systemic sclerosis (SSc) is a rare chronic autoimmune disease characterized by vascular abnormalities and connective tissue disorders. In 2021, the multidisciplinary team of the university hospital recognized a demand for oral health information among SSc patients. This study aims to describe the development of an SSc oral health booklet and its validation by people with SSc.

Methods

For the development of the booklet, the project creators employed the action research methodology involving ten stages. SSc patients evaluated the material by filling out a digital form.

Results

One hundred and thirty-one people with SSc evaluated the booklet. It received an average score of 9.73 (SD: 0.80) in relevance, 9.82 (SD: 0.47) in explicitness, and 9.49 (SD: 0.93) in aesthetics. The final version was emailed to the participants and posted on social media.

Innovation

This is the first booklet that deeply addresses these issues in Portuguese and constitutes a soft technology to instruct and assist patients with SSc.

Conclusion

The production of high-quality educational materials on oral health for patients with SSc is necessary. The online distribution increased its reach and had great importance in the context of the COVID-19 pandemic.

A study protocol to develop and test an e-health intervention in follow-up service for intensive care survivors' relatives

BACKGROUND

The negative impact on long-term health-related outcomes among relatives of critically ill patients in the intensive care unit (ICU) has been well described. High-quality ICU specialized follow-up care, which is easily accessible with digital innovation and which is designed by and with relevant stakeholders (i.e., ICU patients' relatives and nurses), should be considered to reduce these impairments in the psychological and social domains.

AIM

The programme's aim is to develop and test an e-health intervention in a follow-up service to support ICU patients' relatives. Here, the protocol for the overall study programme will be described.

STUDY DESIGN

The overall study comprises a mixed-methods, multicentre research design with qualitative and quantitative study parts. The study population is ICU patients' adult relatives and ICU nurses. The main outcomes are the experiences of these stakeholders with the newly developed e-health intervention. There will be no predefined selection based on age, gender, and level of education to maximize diversity throughout the study programme. After the participants provide informed consent, data will be gathered through focus groups (n = 5) among relatives and individual interviews (n = 20) among nurses exploring the needs and priorities of a digital follow-up service. The findings will be explored further for priority considerations among members of the patient/relative organization (aiming n = 150), which will serve as a basis for digital prototypes of the e-health intervention. Assessment of the intervention will be followed during an iterative process with investigator-developed questionnaires. Finally, symptoms of anxiety and depression will be measured with the 14-item Dutch version of the 'Hospital Anxiety and Depression Scale', and symptoms of posttraumatic stress will be measured with the 21-item Dutch version of the 'Impact of Events Scale-Revised' to indicate the effectiveness of digital support among ICU patients' relatives.

RELEVANCE TO CLINICAL PRACTICE

The e-health intervention to be developed during this research programme can possibly bridge the gap in integrated ICU follow-up care by providing relevant information, self-monitoring and stimulating self-care among ICU patients' relatives.

Development of a physical activity counseling intervention for people with chronic respiratory disease based on the health action process approach

BACKGROUND

Physical activity (PA) counseling holds promise for increasing PA levels in people with chronic respiratory disease, though little long-term change has been shown to date. Here, we describe the development of a Health Action Process Approach-based PA counseling intervention that aims to promote PA and exercise in people with chronic respiratory disease who are enrolled in pulmonary rehabilitation.

METHODS

To collaborate in defining and refining the intervention, we convened a varied team of authors that included a panel of five stakeholder partners: three patients, one clinician, and one health behavior change researcher. We completed three steps in the intervention development process: (1) initial intervention creation, (2) iterative intervention refinement, and (3) assessment of intervention acceptability. In step 1, we created an initial draft of the PA counseling intervention based on the HAPA theoretical framework, previous evidence in people with chronic respiratory disease, and clinical experience. In step 2, we used qualitative methods of focus groups and interviews to further develop and refine the intervention. Fifteen meetings occurred with the five-member stakeholder partner panel (six focus groups with the three patient partners, four interviews with the clinician partner, and five interviews with the researcher partner) over 5 months to systematically elicit input and incorporate it into the intervention. In step 3, we measured the intervention acceptability using five-point Likert scale ratings.

RESULTS

Intervention materials included the eligibility screen, participant workbook, and leader guide. We identified key themes in the input from the stakeholder partners and incorporated this input into the intervention content and methods. Ratings of the intervention by the stakeholder partners (n=5) were high with mean ratings ranging 4.0-5.0 on a five-point scale.

CONCLUSIONS

This development process successfully engaged an intervention development team with diverse perspectives and resulted in a PA counseling intervention for people with chronic respiratory disease. The intervention's strong theoretical underpinning, person-centeredness, and the contributions from varied perspectives during intervention development position it well for future evaluations of feasibility, efficacy, and effectiveness.

Development of a practical guideline for person centred goal setting in geriatric rehabilitation: a participatory action research

PURPOSE

To improve goal setting in Geriatric Rehabilitation (GR), by developing an evidence-based practical guideline for patient-centred goal setting.

METHODS

Participatory action research (PAR) in a cyclical process, with GR professionals as co-researchers. Each cycle consisted of five phases: problem analysis, literature review, development, practical experience, feedback & evaluation. The evaluation was based on video recordings of goal setting conversations, and on oral and written feedback of the GR professionals who tested the guideline.

RESULTS

In two PAR-cycles the guideline was developed, consisting of eight recommendations for setting and using goals, and of practical advices elaborating three of the recommendations, concerning conversational skills specific for goal setting conversations. After the second cycle the research team concluded that the guideline was feasible in daily practice and effective when used consciously.

CONCLUSION

In this study, a practical guideline for setting and using goals in GR was developed. GR teams can improve their patient centred working with goals by discussing the recommendations in their team and choosing the recommendations to work on. This can be supported by the development of an interdisciplinary training. The effect on quality of care should be subject to further investigation.

SWOT analysis to reduce surgical center idleness and increase revenue in a hospital

OBJECTIVE

To reduce surgical center idleness by analyzing the competitive structure of the surgical center in a hospital, and thereby generate value in operations and increase hospital revenue.

METHODS

The study used qualitative and quantitative methods and an action research approach involving the surgical center leadership of a small private specialized hospital in southeastern Brazil. We used the Strengths, Weaknesses, Opportunities, and Threats or SWOT tool to analyze the competitive structure of the surgical center and then implemented interventions as proposed by the science of improvement method proposed by the Institute of Healthcare Improvement.

RESULTS

By applying the SWOT tool, we identified a concentration of surgeries in the specialty of Otolaryngology and the need to establish a health management system to reduce the idleness of the operating rooms. Based on subsequent intervention, procedures from other specialties were inserted that increased surgical production by 2.62X, reduced idleness by 67.84%, and increased revenue by over US$ 276,609.87 in 2018 compared to the previous year 2017.

CONCLUSION

Investing in quality, surgical schedule management, and inducting new surgeons to the clinical staff resulted in decreased surgical idleness, increased production, better uniformity in scheduling, and increased revenue, while costs remained below the linear trend, allowing for increased profits.

Uptake of pharmacist recommendations by patients after discharge: Implementation study of a patient-centered medicines review service

BACKGROUND

Polypharmacy and potentially inappropriate medicine use is common in older people, resulting in harm increased by lack of patient-centred care. Hospital clinical pharmacy services may reduce such harm, particularly prevalent at transitions of care. An implementation program to achieve such services can be a complex long-term process.

OBJECTIVES

To describe an implementation program and discuss its application in the development of a patient-centred discharge medicine review service; to assess service impact on older patients and their caregivers.

METHOD

An implementation program was begun in 2006. To assess program effectiveness, 100 patients were recruited for follow-up after discharge from a private hospital between July 2019 and March 2020. There were no exclusion criteria other than age less than 65 years. Medicine review and education were provided for each patient/caregiver by a clinical pharmacist, including recommendations for future management, written in lay language. Patients were asked to consult their general practitioner to discuss those recommendations important to them. Patients were followed-up after discharge.

RESULTS

Of 368 recommendations made, 351 (95%) were actioned by patients, resulting in 284 (77% of those actioned) being implemented, and 206 regularly taken medicines (19.7 % of all regular medicines) deprescribed.

CONCLUSION

Implementation of a patient-centred medicine review discharge service resulted in patient-reported reduction in potentially inappropriate medicine use and hospital funding of this service. This study was registered retrospectively on 12^th July 2022 with the ISRCTN registry, ISRCTN21156862, https://www.isrctn.com/ISRCTN21156862 .

Improving the Management of Children with Fevers by Healers in Native Rural Areas in the South of Ecuador

BACKGROUND

Indigenous populations are represented among the poor and disadvantaged in rural areas. High rates of infectious diseases are observed in indigenous child populations, and fever as a general symptom is common.

OBJECTIVE

We aim to improve the skills of healers in rural indigenous areas in the South of Ecuador for managing children with fevers.

METHOD

We performed participatory action research (PAR) for this study with 65 healers.

RESULTS

The PAR focused on the following four phases: (1) 'observation,' eight focus groups were used. (2) 'planning' phase was developed, and with culturally reflective peer group sessions, a culturally adapted flowchart was constructed titled "Management of children with fever." In phase (3): 'action', the healers were trained to manage children with fever. Phase (4): 'evaluation', 50% of the healers used the flowchart.

CONCLUSIONS

Explicit recognition of the need for traditional healers and health professionals in indigenous communities to work together to improve health indicators such as infant mortality exists. Additionally, strengthening the transfer system in rural areas is based on knowledge and cooperation between the community and the biomedical system.

Digital Health Literacy and Person-Centred Care: Co-Creation of a Massive Open Online Course for Women with Breast Cancer

The diagnosis of breast cancer (BC) can make the affected person vulnerable to suffering the possible consequences of the use of low-quality health information. Massive open online courses (MOOCs) may be a useful and efficient resource to improve digital health literacy and person-centred care in this population. The aim of this study is to co-create a MOOC for women with BC, using a modified design approach based on patients' experience. Co-creation was divided into three sequential phases: exploratory, development and evaluation. Seventeen women in any stage of BC and two healthcare professionals participated. In the exploratory phase, a patient journey map was carried out and empowerment needs related to emotional management strategies and self-care guidelines were identified, as well as information needs related to understanding medical terminology. In the development phase, participants designed the structure and contents of the MOOC through a Moodle platform. A MOOC with five units was developed. In the evaluation phase, participants strongly agreed that their participation was useful for the MOOC's development and participating in the co-creation process made the content more relevant to them (experience in the co-creation); most of the participants positively evaluated the content or interface of the MOOC (acceptability pilot). Educational interventions designed by women with BC is a viable strategy to generate higher-quality, useful resources for this population.

Towards a Checklist for Improving Action Research Quality in Healthcare Contexts

Published accounts of action research studies in healthcare frequently underreport the quality of the action research. These studies often lack the specificity and details needed to demonstrate the rationale for the selection of an action research approach and how the authors perceive the respective study to have met action research quality criteria. This lack contributes to a perception among academics, research funding agencies, clinicians and policy makers, that action research is ‘second class’ research. This article addresses the challenge of this perception by offering a bespoke checklist called a Quality Action Research Checklist (QuARC) for reporting action research studies and is based on a quality framework first published in this journal. This checklist, comprising four factors - context, quality of relationships, quality of the action research process itself and the dual outcomes, aims to encourage researchers to provide complete and transparent reporting and indirectly improve the rigor and quality of action research. In addition, the benefit of using a checklist and the challenges inherent in such application are also discussed.

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.

Development, implementation and evaluation of the digital transformation of renal services in Wales: the journey from local to national

BACKGROUND

Treatment for people with kidney disease is often associated with complicated combinations of medicines. Logistical challenges with traditiona paper-based prescribing means that these patients are particularly susceptible to medication-relation errors and harm.

AIM

To improve the quality of care that people with kidney disease receive across Wales through a Value-Based digital transformation programme.

SETTING

Renal units within the National Welsh Renal Clinical Network (WRCN).

DEVELOPMENT

A novel Electronic Prescribing & Medicines Administration (EPMA) system, integrated into a patient care record and linked to a patient portal was developed in South West Wales (SWW) region of the WRCN, enabled by the Welsh Government (WG) Efficiency Through Technology Fund. National upscale was enabled through the WG Transformation Fund.

IMPLEMENTATION

EPMA was designed and rolled out initially in SWW region of the WRCN (2018). A dedicated delivery team used the blueprint to finalise and implement a strategy for successful national roll-out eventually across all Wales (completed 2021).

EVALUATION

A multi-factorial approach was employed, as both the technology itself and the healthcare system within which it would be introduced, were complex. Continuous cycles of action research involving informal and formal qualitative interviews with service-users ensured that EPMA was accessible and optimally engaging to all target stakeholders (patients and staff). Results confirmed that EPMA was successful in improving the quality of care that people with kidney disease receive across Wales, contributed to Value-Based outcomes, and put people who deliver and access care at the heart of transformation.

CONCLUSION

Key findings of this study align directly with the national design principles to drive change and transformation, put forward by the WG in their plan for Health and Social Care: prevention and early intervention; safety; independence; voice; seamless care.

Workplace Health Promotion Among Ethnically Diverse Women in Midlife With a Low Socioeconomic Position

Workplace health promotion (WHP) may be an appropriate way to support women with a low socioeconomic position (SEP) during midlife. Little is known about reaching and engaging women in WHP, particularly not at the intersection of midlife, low SEP, and ethnicity. We initiated the ProudWoman project, in which we implemented a WHP intervention aimed at supporting midlife women as a pilot in an academic hospital. We qualitatively evaluated the implementation using the RE-AIM framework. The pilot comprised multiple steps: tailoring the intervention to the needs of ethnically diverse group of midlife women with a low SEP, developing an implementation protocol, implementing the tailored intervention, and evaluating the implementation process. The main findings of our study are: (1) due to a wide range of recruitment activities that were actively deployed, we were able to reach an ethnically diverse group of midlife women with a low SEP; (2) regarding adoption, awareness of the relevance of this topic as an occupational health challenge was not self-evident at the organizational level; (3) according to our participants, various facilitators and barriers should be taken into account in the implementation of the work-life program; and (4) our focus group discussion revealed as maintenance is relevant to these levels in different ways, awareness of midlife and menopause as an occupational health challenge should be raised at four professional levels. We conclude that elements, such as an active and personal recruitment approach, are important in the implementation of WHP for ethnically diverse midlife women with an SEP.

A health promotion intervention to address youth violence among students in a technical college in Sri Lanka guided by the participatory action research approach: a study protocol

BACKGROUND

Youth violence is a global public health issue and the highest rates are reported in Low and Middle-Income Countries (LMICs). Higher rates of youth violence are reported in Sri Lanka as well. Students who fail to continue higher studies in schools or enter the universities in Sri Lanka, enroll in technical colleges and are associated with a higher number of risk factors of violence. This study aims to empower youth (15-29 years old) of a technical college in Matale district, Sri Lanka, to carry out activities among themselves to improve their knowledge, change perceptions, and violence-related behaviours.

METHODS

The Participatory Action Research (PAR) approach will be used. The study participants will be eighty students in a technical college in Matale district, Sri Lanka. The study period will be three years. Study participants will also be collaborators and they will involve actively in all stages of the study. A health promotion intervention will be implemented to identify determinants of youth violence and to design and implement actions while monitoring the changes. The data will be collected mainly through focus group discussions and key informant interviews both before and after the health promotion intervention. Additionally, a self-administered questionnaire will be used and the principal investigator will maintain a reflective diary. The qualitative data will be analysed thematically whereas quantitative data will be analysed using descriptive statistics. Data will be triangulated to increase the rigour of the study.

DISCUSSION

According to literature, PAR is not widely used in health promotion. The enabling and empowerment goals of health promotion are fulfilled in PAR. Thus, this will be a novel experience for researchers and this will stimulate discussion on the combination of PAR and health promotion. This study design itself promotes active participant involvement and it may generate effective youth-led, culturally appropriate actions to address youth violence. The findings will describe what works and why it works and will help Sri Lanka and similar LMICs to create safe environments for youth in educational institutes or training colleges.

A Novel Interprofessional Education and Supervision Student Placement Model: Student and Clinical Educator Perspectives and Experiences

Interprofessional student placements can not only cater to the added pressures on student placement numbers but can also enhance the work readiness of new graduates. For rural areas, there is a potential for interprofessional student placements to attract the future healthcare workforce. However, tried and tested models of interprofessional placements in rural areas backed up by rigorous evaluation, remain scarce. The Rural Interprofessional Education and Supervision (RIPES) model was developed, implemented, and evaluated across four rural health services in Queensland to address this gap. Students from two or more professions undertook concurrent placements at RIPES sites, with a placement overlap period of at least five weeks. Eleven focus groups (n = 58) with clinical educators (CEs) and students were conducted to explore student and clinical educator experiences and perspectives. Content analysis of focus group data resulted in the development of the following categories: value of the RIPES placement model, unintended benefits to CEs, work units and rural areas, tension between uni-professional and IPE components, and sustainability considerations. Students and CEs alike valued the learning which arose from participation in the model and the positive flow-on effects to both patient care and work units. This unique study was undertaken in response to previous calls to address a gap in interprofessional education models in rural areas. It involved students from multiple professions and universities, explored perspectives and experiences from multiple stakeholders, and followed international best practice interprofessional education research recommendations. Findings can inform the future use and sustainability of the RIPES model.

Incorporating value-based healthcare projects in residency training: a mixed-methods study on the impact of participation on understanding and competency development

OBJECTIVES

Stimulating the active participation of residents in projects with societally relevant healthcare themes, such as value-based healthcare (VBHC), can be a strategy to enhance competency development. Canadian Medical Education Directions for Specialists (CanMEDS) competencies such as leader and scholar are important skills for all doctors. In this study, we hypothesise that when residents conduct a VBHC project, CanMEDS competencies are developed. There is the added value of gaining knowledge about VBHC.

DESIGN

An explorative mixed-methods study assessing residents' self-perceived learning effects of conducting VBHC projects according to three main components: (1) CanMEDS competency development, (2) recognition of VBHC dilemmas in clinical practice, and (3) potential facilitators for and barriers to implementing a VBHC project. We triangulated data resulting from qualitative analyses of: (a) text-based summaries of VBHC projects by residents and (b) semistructured interviews with residents who conducted these projects.

SETTING

Academic and non-academic hospitals in the Netherlands.

PARTICIPANTS

Out of 63 text-based summaries from residents, 56 were selected; and out of 19 eligible residents, 11 were selected for semistructured interviews and were included in the final analysis.

RESULTS

Regarding CanMEDS competency development, the competencies 'leader', 'communicator' and 'collaborator' scored the highest. Opportunities to recognise VBHC dilemmas in practice were mainly stimulated by analysing healthcare practices from different perspectives, and by learning how to define costs and relate them to outcomes. Finally, implementation of VBHC projects is facilitated by a thorough investigation of a VBHC dilemma combined with an in-depth stakeholder analysis.

CONCLUSION

In medical residency training programmes, competency development through active participation in projects with societally relevant healthcare themes-such as VBHC-was found to be a promising strategy. From a resident's perspective, combining a thorough investigation of the VBHC dilemma with an in-depth stakeholder analysis is key to the successful implementation of a VBHC project.

Improving public health sector service delivery in the Free State, South Africa: development of a provincial intervention model

Background

Public health sector service delivery challenges leading to poor population health outcomes have been observed in the Free State province of South Africa for the past decade. A multi-method situation appraisal of the different functional domains revealed serious health system deficiencies and operational defects, notably fragmentation of healthcare programmes and frontline services, as well as challenges related to governance, accountability and human resources for health. It was therefore necessary to develop a system-wide intervention to comprehensively address defects in the operation of the public health system and its major components.

Methods

This study describes the development of the ‘Health Systems Governance & Accountability’ (HSGA) intervention model by the Free State Department of Health (FSDoH) in collaboration with the community and other stakeholders following a participatory action approach. Documented information collected during routine management processes were reviewed for this paper. Starting in March 2013, the development of the HSGA intervention model and the concomitant application of Kaplan and Norton’s (1992) Balanced Scorecard performance measurement tool was informed by the World Health Organization’s (2007) conceptual framework for health system strengthening and reform comprised of six health system ‘building blocks.’ The multiple and overlapping processes and actions to develop the intervention are described according to the four steps in Kaplan et al.’s (2013) systems approach to health systems strengthening: (i) problem identification, (ii) description, (iii) alteration and (iv) implementation.

Results

The finalisation of the HSGA intervention model before end-2013 was a prelude to the development of the FSDoH’s Strategic Transformation Plan 2015–2030. The HSGA intervention model was used as a tool to implement and integrate the Plan’s programmes moving forward with a consistent focus on the six building blocks for health systems strengthening and the all-important linkages between them.

Conclusion

The model was developed to address fragmentation and improve public health service delivery by the provincial health department. In January 2016, the intervention model became an official departmental policy, meaning that it was approved for implementation, compliance, monitoring and reporting, and became the guiding framework for health systems strengthening and transform in the Free State.

Best Practices and Lessons Learned for Action Research in eHealth Design and Implementation: Literature Review

BACKGROUND

Action research (AR) is an established research framework to introduce change in a community following a cyclical approach and involving stakeholders as coresearchers in the process. In recent years, it has also been used for eHealth development. However, little is known about the best practices and lessons learned from using AR for eHealth development.

OBJECTIVE

This literature review aims to provide more knowledge on the best practices and lessons learned from eHealth AR studies. Additionally, an overview of the context in which AR eHealth studies take place is given.

METHODS

A semisystematic review of 44 papers reporting on 40 different AR projects was conducted to identify the best practices and lessons learned in the research studies while accounting for the particular contextual setting and used AR approach.

RESULTS

Recommendations include paying attention to the training of stakeholders' academic skills, as well as the various roles and tasks of action researchers. The studies also highlight the need for constant reflection and accessible dissemination suiting the target group.

CONCLUSIONS

This literature review identified room for improvements regarding communicating and specifying the particular AR definition and applied approach.

Long-term effectiveness evaluation of an action-research intervention to improve hand hygiene in an intensive care unit

OBJECTIVES

To evaluate the long-term effectiveness of an action research intervention aimed at improving hand hygiene in an intensive care unit of a public hospital in Italy.

METHODS

An observational, prospective before-after study was carried out.Compliance with hand hygiene was estimated by measuring the utilization of hand hygiene products before the intervention and four years after the end of the project. Products used were the following: detergent liquid soap, antiseptic liquid soap and alcohol-based hand gel. Endpoints were quantity consumed (in grams) for each product category. Quantitative consumptions per workshift were compared.

RESULTS

In 2017 the median consumption of antiseptic liquid soap and alcohol-based hand gel per workshift was significantly higher than in 2012 (111.5 g vs 72.5 g, p = 0.014, and 18.0 g vs 5.0 g, p < 0.001). Odds in favour of a higher value in 2017 were 1.99:1 (CI95%: 1.19:1 to 3.73:1) for antiseptic solution, and 5.39:1 (CI95%: 3.09:1 to 13.61:1) for antiseptic gel. Covariates were not associated with consumption of products, and this made it possible to compare the measurements in the two data collections.

CONCLUSIONS

Results of this study support the long-term effectiveness of the action research intervention to improve practices of hand hygiene in an intensive care setting.

Exploring the Intersection Between Health Professionals' Learning and eHealth Data: Protocol for a Comprehensive Research Program in Practice Analytics in Health Care

Background

There is an increasing amount of electronic data sitting within the health system. These data have untapped potential to improve clinical practice if extracted efficiently and harnessed to change the behavior of health professionals. Furthermore, there is an increasing expectation from the government and peak bodies that both individual health professionals and health care organizations will use electronic data for a range of applications, including improving health service delivery and informing clinical practice and professional accreditation.

Objective

The aim of this research program is to make eHealth data captured within tertiary health care organizations more actionable to health professionals for use in practice reflection, professional development, and other quality improvement activities.

Methods

A multidisciplinary approach was used to connect academic experts from core disciplines of health and medicine, education and learning sciences, and engineering and information communication technology with government and health service partners to identify key problems preventing the health care industry from using electronic data to support health professional learning. This multidisciplinary approach was used to design a large-scale research program to solve the problem of making eHealth data more accessible to health professionals for practice reflection. The program will be delivered over 5 years by doctoral candidates undertaking research projects with discrete aims that run in parallel to achieving this program’s objectives.

Results

The process used to develop the research program identified 7 doctoral research projects to answer the program objectives, split across 3 streams.

Conclusions

This research program has the potential to successfully unpack electronic data siloed within clinical sites and enable health professionals to use them to reflect on their practice and deliver informed and improved care. The program will contribute to current practices by fostering stronger connections between industry and academia, interlinking doctoral research projects to solve complex problems, and creating new knowledge for clinical sites on how data can be used to understand and improve performance. Furthermore, the program aims to affect policy by developing insights on how professional development programs may be strengthened to enhance their alignment with clinical practice. The key contributions of this paper include the introduction of a new conceptualized research program, Practice Analytics in Health care, by describing the foundational academic disciplines that the program is formed of and presenting scientific methods for its design and development.

International Registered Report Identifier (IRRID)

PRR1-10.2196/27984

Implementing Electronic Health Records in Primary Care Using the Theory of Change: A Nigerian Case Study (Preprint)

Background

Objective

Methods

Results

Conclusions

Developing a Web-Based Shared Decision-Making Tool for Fertility Preservation Among Reproductive-Age Women With Breast Cancer: An Action Research Approach

Background

The pregnancy rate after cancer treatment for female survivors is lower than that of the general population. Future infertility is a significant concern for patients with breast cancer and is associated with a poor quality of life. Reproductive-age patients with breast cancer have safe options when choosing a type of fertility preservation method to be applied. Better information and support resources aimed at women to support their decision making are needed.

Objective

The objective of this study was to develop a web-based shared decision-making tool for helping patients with breast cancer make decisions on fertility preservation.

Methods

We used the action research cycle of observing, reflecting, planning, and acting to develop a web-based shared decision-making tool. The following four phrases were applied: (1) observe and reflect—collect and analyze the decision-making experiences of patients and health care providers; (2) reflect and plan—apply the initial results to create a paper design and modify the content; (3) plan and act—brainstorm about the web pages and modify the content; (4) act and observe—evaluate the effectiveness and refine the website’s shared decision-making tool. Interviews, group meetings, and constant dialogue were conducted between the various participants at each step. Effectiveness was evaluated using the Preparation for Decision-Making scale.

Results

Five major parts were developed with the use of the action research approach. The Introduction (part 1) describes the severity of cancer treatment and infertility. Options (part 2) provides the knowledge of fertility preservation. The shared decision-making tool was designed as a step-by-step process (part 3) that involves the comparison of options, patient values, and preferences; their knowledge regarding infertility and options; and reaching a collective decision. Resources (part 4) provides information on the hospitals that provide such services, and References (part 5) lists all the literature cited in the website. The results show the web-based shared decision-making meets both patients’ and health providers’ needs and helps reproductive-age patients with breast cancer make decisions about fertility preservation.

Conclusions

We have created the first web-based shared decision-making tool for making fertility preservation decisions in Taiwan. We believe female patients of reproductive age will find the tool useful and its use will become widespread, which should increase patient autonomy and improve communication about fertility preservation with clinicians.

Trial Registration

Clinicaltrials.gov NCT04602910; https://clinicaltrials.gov/ct2/show/NCT04602910

An Initiative to Increase Resident Performance of Operative Vaginal Deliveries

The objective of this single-centre, action research study was to increase resident experience performing operative vaginal deliveries. The secondary objective was to assess the incidence of maternal and neonatal complications. The rate of forceps deliveries increased in the post-training period (1.8%-4.0%; P < 0.001) but the overall rate of operative vaginal delivery did not change. The composite maternal complications rate following forceps delivery was lower in the post- training period (P = 0.006). There were no significant differences in maternal or neonatal complications with vacuum delivery between the periods before and after the initiative. Experiential training of residents may be a viable alternative to simulation training as it does not require expensive state-of-the-art simulation technology.

Improving Physical Activity in Adults Admitted to a Hospital With Interventions Developed and Implemented Through Cocreation: Protocol for a Pre-Post Embedded Mixed Methods Study

Background

Admission to a hospital is often related with hospital-associated disabilities. Improving physical activity during hospitalization is considered effective to counteract hospital-associated disabilities, whereas many studies report on very low physical activity levels. Gradually developing and implementing interventions in cocreation with patients and health care professionals rather than implementing predefined interventions may be more effective in creating sustainable changes in everyday clinical practice. However, no studies have reported on the use of cocreation in the development and implementation of interventions aimed at improving physical activity.

Objective

This protocol presents a study that aims to investigate if interventions, which will be developed and implemented in cocreation, improve physical activity among patients in surgery, internal medicine, and cardiology hospital wards. The secondary aims are to investigate effectiveness in terms of the reduction in the time patients spend in bed, the length of hospital stay, and the proportion of patients going home after discharge.

Methods

The Better By Moving study takes place for 12 months at the following five different wards of a university hospital: two gastrointestinal and oncology surgery wards, one internal medicine hematology ward, one internal medicine infectious diseases ward, and one cardiology ward. The step-by-step implementation model of Grol and Wensing is used, and all interventions are developed and implemented in cocreation with health care professionals and patients. Outcome evaluation is performed across the different hospital wards and for each hospital ward individually. The primary outcome is the amount of physical activity in minutes assessed with the Physical Activity Monitor AM400 accelerometer in two individual groups of patients (preimplementation [n=110], and 13 months after the start of the implementation [n=110]). The secondary outcomes are time spent in bed measured using behavioral mapping protocols, and length of stay and discharge destination assessed using organizational data. A process evaluation using semistructured interviews and surveys is adopted to evaluate the implementation, mechanisms of impact, context, and perceived barriers and enablers.

Results

This study is ongoing. The first participant was enrolled in January 2018. The last outcome evaluation and process evaluation are planned for May and June 2020, respectively. Results are expected in April 2021.

Conclusions

This study will provide information about the effectiveness of developing and implementing interventions in cocreation with regard to improving physical activity in different subgroups of hospitalized patients in a university hospital. By following step-by-step implementation and by performing process evaluation, we will identify the barriers and enablers for implementation and describe the effect of new interventions on improving physical activity among hospitalized patients.

Trial Registration

Netherlands Trial Register NL8480; https://www.trialregister.nl/trial/8480

International Registered Report Identifier (IRRID)

DERR1-10.2196/19000

Detection, stratification and treatment of hepatitis C-positive prisoners in the United Kingdom prison estate: Development of a pathway of care to facilitate the elimination of hepatitis C in a London prison

The United Kingdom is committed to eliminating hepatitis C virus (HCV) infection by 2025. The prison estate provides an opportunity to identify and treat HCV-positive individuals in a high-prevalence environment. We designed and implemented a pathway of care within a London prison to diagnose, stratify and link HCV-positive prisoners into care. This study was a two-phase case study of a HCV care pathway. New arrivals to the prison were offered blood-borne virus screening with dried blood spot testing at their secondary health check. Those with active infection completed disease stratification tests and were reviewed at a weekly hospital-based multidisciplinary team meeting to determine management. In Phase-2, the pathway was redesigned to improve testing and the referral of HCV-positive prisoners into treatment. Over the 30-month evaluation period, 12,946 people were received in the prison. During Phase-1, 19.6% of new arrivals completed blood-borne virus testing, with 7.3% identified as HCV-positive. Just 8.3% of HCV-positive individuals were treated or referred for treatment in Phase-1. During Phase-2, 30% of new receptions completed BBV testing and 3.9% were identified as HCV-positive. Linkage into care was improved, with 38.9% treated or referred during the second phase. Poor access to testing and referral to treatment limit the effectiveness of care provision for prisoners with HCV. Elimination of HCV in prisons requires local service configuration to ensure high uptake of testing, with all HCV-positive cases then offered treatment during custody or referral on to treatment after release.

Action research as a catalyst for change: Empowered nurses facilitating patient participation in rehabilitation

Based on action research as a practitioner-involving approach, this article communicates the findings of a two-year study on implementing patient participation as an empowering learning process for both patients and rehabilitation nurses. At a rehabilitation facility for patients who have sustained spinal cord injuries, eight nurses were engaged throughout the process aiming at improving patient participation. The current practice was explored to understand possibilities and obstacles to patient participation. Observations, interviews and logbooks, creative workshops and reflective meetings led to the development and testing of four new rehabilitation initiatives aimed at enhancing patient participation. This study suggests that skills of critical reflection from action research toolbox shed light on both the notion of patient participation and caring in nursing rehabilitation. By actively involving nurses in research, the knowledge development stems from practice and the solutions therefore became practice-oriented. In addition, the personal and professional development experienced by the involved nurses points to a secondary gain in the form of an analytical and reflective approach to complex issues in relation to patient participation, rehabilitation in general and the individual nurses' sense of professional pride.

The SUPPORT-S Protocol Study: A Postvention Program for Professionals After Patient or User Suicide

Background

Exposure to patient or user suicide (PUS) is identified as a challenging occupational hazard for mental health and social work professionals. Professionals exposed to PUS may encounter several ranges of emotional, traumatic or professional impacts in the aftermath. A high proportion of exposed professionals reports a lack of support in the aftermath of PUS. SUPPORT is a postvention program designed to provide a comprehensive, adaptative and effective support to professionals impacted by PUS. The aims of the SUPPORT-S study are to (1) improve the design of the SUPPORT program, (2) evaluate the effectiveness of the program to buffer the emotional, traumatic and professional impacts and to improve the perceived social support for professionals exposed to PUS, and (3) provide more insights into the consequences of PUS on both professionals and organizations.

Method

The SUPPORT-S study is a mixed method collaborative and participatory action research. The simultaneous and complementary collection and analysis of qualitative and quantitative data will offer an in-depth evaluation of the implementation and the effectiveness of the program. The qualitative evaluation includes: (a) an ethnographic observation; (b) 25 semi-directed interviews with randomized participants; (c) an activity analysis with providers of the program; and (d) collaborative sharing of the results with providers and participants. The quantitative evaluation includes pre- and post-measures in participants of: (a) emotional impact (Differential Emotions Scale IV); (b) traumatic impact (Impact of Event Scale-Revised); (c) professional impact (non-validated questionnaire); and (d) perceived social support (Perceived Social Support Scale for Professionals). The action research design will rely on: (a) the cycling process of implementation/evaluation/data sharing/adjustment and (b) the participatory approach through data sharing with providers and participants. Triangulation, saturation, randomization, and participatory design will also reduce the risk of biases and will improve the generalizability of conclusions.

Expected Results

We expect the SUPPORT-S study to evaluate and improve the design of the SUPPORT program to effectively help professionals to cope with PUS.

Conclusion

The results of the study will allow us to disseminate an effective and adaptive postvention program for professionals and institutions encountering PUS.

Capturing the patient voice: implementing patient-reported outcomes across the health system

PURPOSE

Supporting the capture and use of patient-reported outcomes (PROs) at the point-of-care enriches information about important clinical and quality of life outcomes. Yet the ability to scale PROs across healthcare systems has been limited by knowledge gaps around how to manage the diversity of PRO uses and leverage health information technology. In this study, we report learnings and practice insights from UW Medicine's practice transformation efforts to incorporate patient voice into multiple areas of care.

METHODS

Using a participatory, action research approach, we engaged with UW Medicine clinical and administrative stakeholders experienced with PRO implementation to inventory PRO implementations across the health system, characterize common clinical uses for PROs, and develop recommendations for system-wide governance and implementation of PROs.

RESULTS

We identified a wide breadth of PRO implementations (n = 14) in practice and found that nearly half (47%) of employed PRO measures captured shared clinical domains (e.g., depression). We developed three vignettes (use cases) that illustrate how users interact with PROs, characterize common ways PRO implementations support clinical care across the health system (1) Preventive care, (2) Chronic/Specialty care, and (3) Surgical/Interventional care), and elucidate opportunities to enhance efficient PRO implementations through system-level standards and governance.

CONCLUSIONS

Practice transformation efforts increasingly require integration of the patient voice into clinical care, often through the use of PROs. Learnings from our work highlight the importance of proactively considering how PROs will be used across the layers of healthcare organizations to optimize the design and governance of PROs.

Participatory action research to pilot a model of mental health service user involvement in an Ethiopian rural primary healthcare setting: study protocol

BACKGROUND

Involvement of service-users at all levels of the mental health system is a policy imperative in many countries internationally. However, putting policy into practice seems complex; little is known about how best to involve service users and efforts are often criticized for being tokenistic. In low-and-middle income countries, less attention has been given to the roles of service users within mental health systems. The proposed study is part of a larger project intended to develop service-user involvement in mental health system strengthening in Ethiopia. A Theory of Change (ToC) model has already been developed through a participatory approach. This study protocol aims to describe the theoretical background and methods to pilot this model using participatory action research (PAR) and explore participants' experience of involvement.

METHODS

The proposed study will apply a PAR approach situated in critical social theory and conduct a phenomenological case study to find out participants' experience of involvement. This will be conducted in three stages. The focus of Stage 1 will be to(i) establish a Research Advisory Group (RAG), and Research Participant Group (RPG) at district and primary healthcare facility levels, respectively, and (ii) identify and prioritize potential areas of concern for involvement in the domains of advocacy, service planning and development, monitoring and improving service quality. In Stage 2, we will work with the RPG to develop a plan of action for the selected area. Stage 3 will aim to assist the RPG to implement and evaluate the plan of action. Process indicators and observation will be combined with in-depth interviews with participants to elicit their experiences of involvement. Thematic content analysis will be used.

DISCUSSION

The participatory approach to mental health service user involvement in health system strengthening employed by this study will support the implementation of solutions through locally relevant and contextualized actions. Findings from this study will contribute to the body of knowledge towards understanding the complexity of implementation of service user involvement and refine the ToC model for transferability to similar settings.

Igniting intersectoral collaboration in chronic disease management: a participatory action research study on epilepsy care in Ireland

Models of care developed to improve the lives of people with chronic diseases highlight integrated care as essential to meeting their needs and achieving person (patient)-centered care (PCC). Nevertheless, barriers to collaborative practice and siloed work environments persist. To set in motion some groundwork for intersectoral collaboration this study brought two expert groups of epilepsy care practitioners together to engage in participatory action research (PAR). The expert practitioner groups were hospital-based epilepsy specialist nurses (ESNs) and community-based resource officers (CROs). The PAR highlighted, that while the participants share a mutual interest in caring for people with epilepsy, underdeveloped CRO-ESN relationships, arising from unconscious bias and ambiguity can result in missed opportunities for optimal care coordination with consequent potential for unnecessary replication and waste of finite resources. However, through dialogue and critical self-reflection, a growing emotional connection between the disciplines evolved over the course of the PAR. This allowed for buds of collaboration to develop with CROs and ESNs working together to tackle some of the key barriers to their collaboration.