Making psychological theory useful for implementing evidence based practice: a consensus approach

Barriers to implementation of preoperative urostomy site marking in nurse-physician cooperation: A qualitative study based on the Theoretical Domains Framework

Objective

This study aimed to understand the barriers to nurse-physician collaboration in implementing preoperative stoma site marking using qualitative research methods following Theoretical Domain Framework.

Methods

A qualitative descriptive study using semi-structured interviews was conducted from March to June 2023 in the urology departments of nine tertiary hospitals in China. Twelve urologists and eight enterostomal therapists (ETs) were recruited using purposive sampling. Audio recordings were transcribed verbatim and data were analyzed using content analysis.

Results

Five themes were identified in the study: shortage of manpower and stoma care products, lack of standard and regulations, lack of motivation and intention, inconsistency of expectation on consequences, and difficulties in cooperation.

Conclusion

This study indicated that the barriers to implementation of preoperative urostomy localization among urologists and ETs. Institutions, resources, clear career plans, and performance feedback can increase motivation and intention. In addition, the lack of cooperation between urologists and ETs is a key factor for poor urostomy localization implementation, which calls for effective and equal communication between doctors and nurses.

Surviving and Thriving in Medicine: Developing Theory-Based Interventions for Students From Widening Access Backgrounds

The challenges facing students from widening participation (WP) backgrounds do not simply disappear upon entering medicine. Accordingly, it is imperative that in promoting equity in medicine, we understand how WP students may be best supported to thrive in their studies. This research aimed to develop an evidence-based and theory-informed intervention strategy to target student support amongst undergraduate WP students in medicine. Workshops were conducted with staff working in the medical school and students from WP backgrounds. Participants generated potential intervention ideas and critically considered the feasibility of implementation. Data analysis and intervention development were supported by the Theoretical Domains Framework (TDF) and Behaviour Change Wheel (BCW). The TDF and BCW were successfully conceptualised to structure an intervention strategy to enhance student support amongst WP students in medicine. Workshop participants identified support needs of students from WP backgrounds, and these were prioritised and used to drive intervention development. We outline two interventions that were developed from the research: adaptation of the existing personal tutor scheme and implementation of a WP peer network. The theory-based intervention strategy outlines a foundation that could be utilised to develop and evaluate interventions to support students from WP backgrounds in medicine. This study has demonstrated how an intervention development framework (BCW) using a theoretical base can be used to develop interventions for students from WP backgrounds. Two intervention ideas were developed from the research and were designed to promote support seeking, social connection and a sense of belonging in students from WP backgrounds.

Unravelling facilitation complexity in community pharmacy: A pragmatic tool for implementation strategy selection

INTRODUCTION

Pharmacy practice is becoming increasingly patient-centric with the development of community pharmacy services. Their implementation appears to be affected by causal relationships and interdependencies of determinants. To address these determinants, change agents need to select, operationalise strategies, and measure their impact. However, there is little real-world guidance on efficiently selecting strategies tailored to determinants.

OBJECTIVES

The aims of this study were to (1) explore the relationships between determinants and implementation strategies identified during the implementation of a Minor Ailment Service in Spanish community pharmacies and (2) develop a visual tool that links implementation strategies tailored to specific determinants for change agents to use during the facilitation process.

METHODS

The study employed a mixed methods approach within a three-year pragmatic type 3 hybrid effectiveness-implementation design. Data collection was facilitated by change agents, who utilised on-site and remote communication methods. The objectives of the change agents were to identify determinants, design and operationalise tailored implementation strategies. These data were documented and transformed into Sankey diagrams.

RESULTS

Ten change agents systematically documented 4236 determinant-strategy relationships in 92 pharmacies. The most common primary determinant domain they identified was "intervention characteristics" (n = 1843, 43.5 %). The most common secondary determinant domain was "characteristics of the individuals involved" (n = 3069, 72.5 %). The most common strategy category was "other" (n = 1808, 42.7 %). A Sankey diagram tool was developed to allow change agents to receive feedback on the effect of their strategies and select appropriate future implementation strategies.

CONCLUSIONS

The findings of this study inform the development of future visual tools for assisting change agents during the facilitation process. Sankey diagrams act as a generic and real-time tool, which will reduce the complexity inherent to the facilitation activity. This will facilitate prospective implementation researchers to plan implementation interventions and train change agents more efficiently, thereby optimising the change management process.

Behavior change techniques in low-calorie and very low-calorie diet interventions for weight loss: A systematic review with meta-analysis

BACKGROUND

There is limited evidence and clinical guidelines on the behavior change support required for low-calorie diet programs. This systematic review aimed to establish the behavior change technique(s) (BCT) implemented in weight loss interventions (≤1200 kcal/d) and how these contribute to effectiveness.

METHODS

Databases were searched from inception to April 2022. Screening, data extraction, BCT coding, and quality appraisal were conducted in duplicate using the Template for Intervention Description and Replication framework, Behavior Change Technique Taxonomy, and Cochrane Risk of Bias 2 tool. Data were analyzed via narrative synthesis and random effects multi-level meta-analyses.

RESULTS

Thirty-two papers reporting on 27 studies were included. Twenty-four BCTs were identified across studies. Eight BCTs were significantly associated with a larger reduction in weight at the end-of-diet time-point; one BCT was statistically significant at the end of weight maintenance. Physical activity, Type 2 Diabetes, and BMI category moderated intervention effects.

CONCLUSIONS AND IMPLICATIONS

This is the first meta-analysis to examine how specific BCTs contribute to the effectiveness of low-calorie diets. It is recommended that a) these findings are used to develop clinical guidelines specific to behavioral support in low-calorie diet programs, and b) program commissioners stipulate the use of these BCTs in their service specifications.

Primum non nocere: Toward a Greater Understanding of the Potential for Harm in Psychological Treatments for Youth

The field of clinical psychological science has made considerable progress over the years in developing, testing, and disseminating psychological interventions for youth mental health conditions. Despite these achievements, the question of whether certain treatments may actually be inert, or at worst, iatrogenic, has been relatively underexamined compared to affirmative questions of efficacy. Fortunately, interest in the topic of harm within psychological treatments is growing. However, much of this work has taken place from a general theoretical perspective and has primarily focused on adults, and adaptations to youth populations remain limited. Thus, this special issue fills an important gap in the literature in terms of furthering our understanding of the potential for harm in youth mental health treatment. The articles in this collection contain a balance of conceptual, methodological, and empirical research focused on better understanding the potential for harm in youth mental health treatment with regard to particular populations, settings, and psychological disorders. In this introductory article, we: (a) explicate a brief background review of previous conceptual and empirical knowledge development efforts concerning potential for harm in psychological treatments, (b) outline unique considerations for specifically addressing this topic in youth, and (c) provide an overview and synthesis of articles in the collection. This special issue raises awareness of the ways in which youth may inadvertently be adversely affected by psychological interventions. We hope this will lead to greater refinement of beneficial evidence-based interventions and more nuanced attention given to potential areas of pitfall in clinical practice with youth.

Implementation Mapping to Identify Strategies to Increase Timely Postoperative Radiotherapy Initiation for Head/Neck Cancer

OBJECTIVE

Timely initiation of postoperative radiotherapy (PORT) for head and neck squamous cell carcinoma (HNSCC) is associated with improved survival, but rates of timely PORT initiation are low. To support uptake in a tertiary academic center, we aimed to identify implementation determinants (eg, barriers and facilitators) to timely PORT initiation and to design context-specific implementation strategies.

METHODS

We created an implementation blueprint through a sequential mixed-methods study where we (1) identified determinants by fielding a 15-item survey based on the Theoretical Domains Framework (TDF), (2) prioritized determinants through focus groups with relevant stakeholders, (3) mapped barriers to implementation strategies using the Consolidated Framework for Implementation Research (CFIR)-Expert Recommendations for Implementing Change (ERIC) matching tool, and (4) operationalized strategies using the Action, Actor, Context, Target, Time (AACTT) framework.

RESULTS

Twenty-three participants from three departments (61% Radiation Oncology, 35% Otolaryngology, 4% Medical Oncology) in a variety of roles (35% physicians, 39% nurses or advanced practice providers, 22% radiation therapists or dosimetrists, and 4% research coordinators) completed surveys. Participants identified 10 determinants affecting timely PORT initiation. After strategy selection and operationalization by focus group participants (n = 13), three ERIC strategies were selected for clinical implementation: remind clinicians, conduct educational meetings, and facilitate relay of clinical data to providers.

DISCUSSION

This work developed a menu of implementation strategies for future deployment to support timely PORT initiation. Codesign centered the voice of frontline workers, increasing the likelihood of successful implementation.

IMPLICATIONS FOR PRACTICE

The systematic approaches to development can serve as a model for process improvement in other contexts.

Diagnostic safety and quality optimization in sepsis study protocol

BACKGROUND

Sepsis ranks among the "Big Three" conditions most prone to harmful diagnostic errors. Despite its high prevalence and severity, health systems lack effective and contextually tailored strategies to optimize diagnostic accuracy for sepsis.

OBJECTIVES

The purpose of this study is to understand factors related to high sepsis diagnostic accuracy using principles and tools of safety and implementation science.

METHODS

This is a multi-site study involving 20 hospitals across four states in the United States. The primary objectives are to (1) describe hospital-level variability and understand barriers and facilitators to sepsis diagnostic accuracy and (2) apply cross-case and coincidence analysis to determine minimally sufficient and necessary conditions for optimal sepsis diagnosis that minimizes under- and overtreatment. To identify barriers and facilitators of acute sepsis diagnosis, we will conduct electronic surveys and in-depth interviews with key informants from each hospital. We will use data from electronic health records (EHR) and data warehouses to operationalize sepsis diagnostic accuracy.

RESULTS

We have enrolled 20 hospitals and begum data collection. The findings of this study will be used to develop a context-specific toolkit that guides the selection of feasible and important strategies to promote optimal sepsis diagnosis in diverse hospitals settings.

CONCLUSIONS

The study uses tools and principles from safety and implementation science to generate first-of-its-kind evidence to improve diagnostic excellence in sepsis.

Developing an Intervention to Enhance Aging in Place for Older Veterans Living in Permanent Supportive Housing

BACKGROUND AND OBJECTIVES

The Housing and Urban Development-Veterans Affairs Supported Housing (HUD-VASH) program provides rental subsidies, case management, and supportive services to Veterans who are currently or formerly homeless, 77% of whom are aged ≥50. Few interventions have been developed to address the needs of older Veterans in HUD-VASH.

RESEARCH DESIGN AND METHODS

We conducted a 2-stage study to inform the development of an intervention to promote aging in place in HUD-VASH. First, we completed qualitative interviews with 21 older Veterans in HUD-VASH and focus groups with 13 staff members to identify unmet needs for supporting aging in place. Second, we used a modified Delphi process with 9 staff and 1 Veteran to prioritize 66 intervention elements based on perceived feasibility and importance.

RESULTS

We identified 4 main themes: need for services to support aging in place, expanding the HUD-VASH workforce, focus on home delivery, and importance of trust. The top-rated intervention elements spanned 5 categories: (1) staffing (by social workers, primary care providers, nurses, home health aides); (2) focus (on geriatric needs, mental health needs, dementia care, medication management); (3) modality (in the home or medical center); (4) timing (delivery of the intervention when Veterans have functional impairment, memory impairment, mental health problems, trouble caring for themselves, or are new to HUD-VASH); and (5) duration (regularly scheduled or ongoing as needed).

DISCUSSION AND IMPLICATIONS

Veterans and staff members identified key intervention elements which can help inform Veterans Affairs (VA) efforts to develop and implement interventions to enhance aging in place in HUD-VASH.

Interventional pharmacoepdemiology: design and evaluation of interventions to improve prescribing

Despite the value of modern therapeutics, many obstacles prevent their optimal use. Overuse, underuse, and misuse are common, resulting in morbidity and mortality affecting billions of individuals across the world. Pharmacoepidemiology provides important insights into drug utilization, safety, and effectiveness in large populations, and it is an important method to identify opportunities to improve the value of therapeutics in clinical practice. However, for these opportunities to be realized, interventions to improve prescribing must be developed, evaluated, and implemented in the real world. We provide an overview of this process, focusing especially on how such interventions can be designed and deployed to maximize scalability, adoption, and impact. Prescribing represents a complex behavior with barriers and enablers, and interventions to improve prescribing will be most successful when developed, piloted and refined to maximize provider and patient acceptability. Carefully developed evaluations of interventions are also critical, and varied methods are available to empirically evaluate the intended and potential unintended consequences of interventions. With illustrative examples from the peer-reviewed literature, we provide readers with an overview of approaches to the essential and growing field of interventional pharmacoepidemiology. This article is part of a Special Collection on Pharmacoepidemiology.

Prepare: Improving End-of-Life Care Practice in Stroke Care: Insights from a National Survey and Semi-Structured Interviews

Background: Stroke has high mortality. Challenges in providing end-of-life care include uncertainty among healthcare professionals about when to start care. While generic tools and guidelines exist, which outline components of quality end-of life care, they may not fully address stroke's unpredictable trajectories, complicating care planning. Objective: To enhance understanding of end-of-life care post-stroke. Methods: We undertook an explanatory sequential mixed methods approach, including a cross-sectional survey and semi-structured interviews. All 286 United Kingdom (UK) National Health Service (NHS) hospitals providing inpatient stroke care were approached for participation in an on-line cross-sectional survey. The survey of healthcare professionals from UK stroke units was used to map current stroke end-of-life care and models of care. Fourteen staff who completed the survey and agreed to a future interview were purposively selected. The semi-structured interviews with healthcare professionals involved in delivering end-of-life care post-stroke were conducted and interpreted using the Theoretical Domains Framework. We aimed to enhance our understanding of the experiences, expectations, challenges and barriers in providing end-of-life care post-stroke, including effective clinical decision-making. Results: Across 108 responding survey sites, 317 responses were received. Results showed a lack of structured tools and approaches, an absence of stroke-specific guidance and variable delivery of end-of-life care post-stroke. Thirteen staff (nurses, occupational therapists, medical stroke consultants, and a speech and language therapist) agreed to be interviewed. The data provided a fuller understanding of the context within which end-of-life care post-stroke is delivered. The varied challenges faced include: uncertain prognosis, complex decision-making process, varying skill levels, staffing levels, the hospital environment, emotional strain on both families and staff, inequitable access to specialist palliative care, and difficulties associated with different models of care (stroke service structures and cultural context). Conclusions: Provision of end-of-life care post-stroke is complex, challenging, uncertain, and inconsistent. There is limited evidence or guidance to support healthcare professionals. There is a need for implementation support, which includes education, to better enable quality and more consistent end-of-life care post-stroke. Further research is required to assess interventions that can support end-of-life care post-stroke to aid clinicians in providing quality palliative care for stroke patients.

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

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

An evaluation of barriers and facilitators to implementing multiplex rapid antigen testing for SARS-CoV-2 and influenza A and B in congregate living settings

Introduction

Point of care multiplex rapid antigen testing (RAT) is a tool that can be used to mitigate and respond to facility-based infectious disease outbreaks. However, little is known about how to optimally implement this testing in congregate living settings (CLSs), including long term care homes (LTCHs), retirement homes (RHs), and shelters serving people experiencing homelessness. Our objective was to explore the barriers and facilitators to implementing a new device for multiplex RAT for COVID-19 and influenza across CLSs in the Greater Toronto Area, Canada.

Materials and methods

Using key informant interviews, we assessed barriers and facilitators to implementing multiplex RAT across CLSs. Qualitative coding using the framework approach was used to identify themes. We used the Theoretical Domains Framework (TDF) and the Consolidated Framework for Implementation Research (CFIR) to identify individual and contextual-level barriers and facilitators to implementation. Identified barriers were then mapped to implementation strategies using theoretically-rooted frameworks and tools.

Results

We completed 45 interviews with staff at CLSs (8 LTCHs, 4 RHs, 12 shelters) between January 2022 and March 2023. Four barriers to RAT implementation in CLSs emerged including: limited material resources for implementation; insufficient staff capacity to perform RAT testing; complexity of RAT implementation; and reluctance among staff to adopt a new testing process. Five facilitators to implementation were described including: training and implementation support for staff at the CLSs; site-level implementation champions; access to materials to support testing; perceived advantages of simultaneous testing for COVID-19 and influenza; and the usability and functionality of the RAT testing device. Twenty implementation strategies were identified through implementation strategy mapping.

Discussion

Multiplex RAT options can empower CLS staff to promptly identify and respond to viral respiratory outbreaks. The use of evidence-based implementation strategies can enhance the effectiveness of using multiplex RAT to control outbreaks in CLSs.

Patient and healthcare professionals' perception of weekly prophylactic catheter washout in adults living with long-term catheters: qualitative study of the CATHETER II trial

OBJECTIVES

To explore trial participants' experience of long-term catheters (LTC), the acceptability of washout policies, their experience of the CATHETER II trial (a randomised controlled trial comparing the clinical effectiveness of various washout policies versus no washout policy in preventing catheter associated complications in adults living with long-term catheters) and their satisfaction with the outcomes. The objectives of the healthcare professionals (HCPs) focus group and interview were to explore their attitudes towards weekly prophylactic catheter washout, views on the provision of training and participants' ability to enact washout behaviours.

METHODOLOGY

A longitudinal qualitative study embedded within the CATHETER II randomised controlled trial, which included semi-structured interviews and focus groups with participants from multiple trial sites. Data were analysed using the Theoretical Framework of Acceptability and Theoretical Domains Framework. This UK community-based study included 50 (24 female, 26 male) CATHETER II trial participants, aged between 23 and 100 years, with LTC and able to self-manage the washout and study documentation either independently or with the help of a carer. Seven HCPs (five female, two male) also participated.

RESULTS

The participants had positive attitudes towards weekly prophylactic saline or acidic catheter washouts and other trial elements, such as washout training, catheter calendar and monthly phone calls. Participants and HCPs found the 'ask' of the CATHETER II trial and the weekly self-administered prophylactic washout policies to be feasible. The participants reported that the catheter washout training provided during the trial enhanced their self-efficacy, skills and self-reported capability to carry out the washouts. Participants reported having positive outcomes from the weekly washout. These included reduced blockage, pain or infection, reduced need for HCP support and greater psychological reassurance. HCPs attested to the participants' understanding of and adherence to the weekly washouts and other elements of the trial.

CONCLUSIONS

This study shows acceptability, feasibility and self-reported fidelity of the CATHETER II trial on a behavioural level. Self-management for prophylactic catheter washouts is both feasible and, following training, achievable without any need for additional support.

TRIAL REGISTRATION NUMBER

ISRCTN17116445.

Accelerating the Delivery of Psychological Therapies After Stroke: A Feasibility Stepped-Wedge Cluster Randomised Controlled Trial

Background: Psychological problems post-stroke are common and debilitating, yet insufficient evidence-based psychological support exists for stroke survivors, either in stroke or general mental health services. Many stroke survivors with significant needs remain unsupported. To address this problem, we need pathways to identify, treat and manage psychological difficulties after stroke. The Accelerating Delivery of Psychological Therapies after Stroke (ADOPTS) study aimed to explore the feasibility of collaboratively developing, implementing and evaluating intervention packages (IPs) to facilitate access to, and increase the provision of, psychological support post-stroke. Methods: Stakeholder groups were formed across four sites in north-west England, comprising stroke and psychological services, to collaboratively develop site-specific IPs incorporating a psychological care pathway, staff training, a staff manual for stroke-specific psychological support and supervision. A feasibility stepped-wedge cluster randomised trial recruited patients admitted with stroke during the usual care (pre-implementation of the IP) and intervention (post-implementation) periods. The feasibility of IP implementation and their potential usefulness were evaluated through assessing wellbeing and the support received, and through a process evaluation incorporating interviews with staff, patients and carers. Feasibility evaluation included the recruitment rate and attrition rate; exploratory analysis (mixed-effects linear or logistic regression models) was used to assess the 'promise' of the intervention in achieving psychological distress outcomes (mood (PHQ-9), anxiety (GAD-7)), assessed using validated measures at 6 weeks and 6 months. Results: IPs were collaboratively developed at each site but implementation took longer than the per-study-protocol duration of three months. Nineteen training sessions (152 attendees) were delivered for nursing, therapy, NHS Talking Therapies and voluntary staff. Nursing staff were underrepresented due to difficulties with releasing staff. Manuals were developed for each site, incorporating a mood screening and referral algorithm, but these were not finalised at one site. Stroke and NHS Talking Therapies champions were identified in each site to facilitate cross-service staff supervision. A total of 270 patients were recruited over 14 months (133 usual care, 137 intervention), with 227 and 198 at 6 weeks and 6 months, respectively. Stroke staff found the training, manual and pathway helpful, and reported greater confidence in managing and referring psychological issues. NHS Talking Therapies staff found the training useful for adapting their therapy. However, the intervention took longer to implement in all sites, requiring an additional time period to be added to the stepped-wedge design. Conclusions: It is feasible to collaboratively develop and implement IPs for post-stroke psychological support. However, an alternative to the stepped-wedge design used here would be more appropriate for a future study. This study was registered in ISRCTN-the UK's Clinical Study Registry (trial registration: ISRCTN12868810, registration date: 4 February 2016).

Barriers and Facilitators to Medicines Use in Patients With Vision Impairment: A Theory-Informed Qualitative Study of Patients and Caregivers

INTRODUCTION

Previous studies have highlighted numerous challenges with medicines use for patients with vision impairment, but evidence is lacking on interventions to support safe and effective medicine use for this population. This study aimed to identify potential barriers/facilitators of medicines use from the viewpoint of patients/caregivers, to establish a theory-informed foundation for a future intervention.

METHODS

Semi-structured interviews were conducted with patients with vision impairment and their caregivers in Saudi Arabia. Participants were recruited from low-vision clinics and a non-profit organisation. The Theoretical Domains Framework (TDF) informed the topic guide and served as the theoretical basis for examining participants' behaviours. Interviews explored the barriers/facilitators to obtaining and taking medicines (i.e. the target behaviours). Data were analysed using the framework method and content analysis. Key TDF domains were identified by assessing the relative frequency of themes, the existence of conflicting themes and the perceived theme impact on target behaviours.

RESULTS

Twelve patient/caregiver dyads and 18 individual patients were interviewed. Patients' ages ranged from 19 to 88 years, with 21 females and 9 males. Patients/caregivers demonstrated good knowledge of medicines used, and resourcefulness in finding methods to manage medication use (Domains: 'Knowledge' and 'Skills'). 'Environmental context and resources (ECR)' and 'Social influences' were the two most coded domains. Participants reported the usefulness of several resources including pill organisers and smartphones but described problems with pharmacy environments (Domain: 'ECR'). Caregivers played a major role in assisting patients with medicines. Participants had some positive encounters with pharmacists but reported difficulties in discussing medication issues with them. Many participants had a narrow view of the pharmacist's role (Domain: 'Social influences'). Maintaining a routine was a major facilitator under the 'Memory, attention and decision processes' and 'Behavioural regulation' domains. Six TDF domains were considered 'key' to participants' behaviours.

CONCLUSIONS

This study is the first to utilise a theoretical approach to understand the behaviour of patients with vision impairment in relation to medication use. It provides a comprehensive understanding of the role of caregivers and what influences their own behaviours. Findings will inform the future development of an intervention to support safe and effective medicine use for patients with vision impairment.

PATIENT OR PUBLIC CONTRIBUTION

An author met with an administrator at the 'National Association of the Blind' (Kafeef) in Riyadh to enhance the research team's understanding of vision impairment, and the practicality and logistics for identifying and recruiting patients. A draft of the interview guides was piloted with two patients and their caregivers and they were asked for feedback on the questions with amendments made accordingly.

Exploring the role of healthcare partners in referrals to a community-based exercise program with a healthcare-community partnership designed for people with balance and mobility limitations

PURPOSE

To explore how healthcare partners in community-based exercise programs for people with balance and mobility limitations perceive and enact referral in the context of their role.

MATERIALS AND METHODS

We conducted a descriptive, qualitative study involving semi-structured interviews and reflexive thematic analysis.

RESULTS

Twelve healthcare partners from the Together In Movement and Exercise (TIMETM) program completed interviews. Seven (58%) participants were clinicians and 5 (42%) held non-clinical roles. The most common professional background of participants was physical therapy (n = 9, 75%). Clinicians made direct referrals while non-clinical participants facilitated referral by promoting the program. The main theme was healthcare partners perceive their role in referrals as secondary to their role as educators and trainers. Subthemes were: (1) healthcare partners fulfill educator and trainer roles when conducting formal training of instructors, educating instructors during program visits, and fielding questions; (2) almost all healthcare partners facilitate referral by sharing program information formally and informally; and (3) healthcare partners in clinical practice make direct referrals depending on the clientele.

CONCLUSIONS

Healthcare partners perceive their roles as educators and trainers as taking precedence over their role in referrals. Findings can be used to guide selection and training of healthcare partners, design of clinical education programs, and research on competencies.

Evaluation of a Canadian social media platform for communicating perinatal health information during a pandemic

Social media platforms, such as Instagram, are increasingly used as a source of health information; however, it is unclear how to effectively leverage these platforms during public health emergencies. @PandemicPregnancyGuide (PPG) was an Instagram account created by Canadian physicians to provide perinatal health information during the COVID-19 pandemic. We conducted a cross-sectional survey, and assessed Instagram analytics, to determine how and why users followed PPG and its impact on health decision-making. Respondents most valued posts explaining scientific articles in lay language and the delivery of content by medical experts. Topics of greatest interest were COVID-19 vaccination while pregnant (76%), COVID-19 infection during pregnancy (71%), and labour and delivery during the pandemic (69%). Respondents self-reported being more likely to use COVID-19 protective measures while pregnant (80%), receive COVID-19 vaccines in pregnancy (87%), and vaccinate their children against COVID-19 (58%) due to the information shared by PPG. Taken together, we demonstrate how healthcare professionals can effectively leverage social media to disseminate health information and improve uptake of public health recommendations. We recommend consideration of our findings in the development of future health-based social media platforms, particularly during public health emergencies or campaigns.

Barriers and facilitators of adherence to clinical practice guidelines in Germany-A systematic review

RATIONALE

Clinical Practice Guidelines (CPGs) represent evidence-based tools designed to assist healthcare practitioners and patients in decisions in clinical practice. Evidence supports the clinical benefits of adhering to CPGs. However, their successful implementation and adherence in clinical settings often encounter challenges.

AIMS AND OBJECTIVES

This systematic review aimed to explore barriers and facilitators influencing adherence to CPGs in Germany.

METHOD

The protocol of this study was registered in the Open Science Framework (OSF) registry (DOI: 10.17605/OSF. IO/GMFUB). In November 2022 we searched on PubMed and Embase for primary studies employing qualitative, quantitative and mixed-methods approaches that focus on barriers or facilitators to CPGs adherence in the Germany. Two reviewers independently screened articles, extracted data, and evaluated the quality of the studies. The collected data on barriers and facilitators of CPG adherence were systematically categorized and analyzed using the Theoretical Domains Framework (TDF).

RESULTS

A total of 24 studies were included, mainly focusing on adherence to national CPGs. This review introduces a new domain, guideline characteristics, reflecting the need to address barriers and facilitators to CPG development, implementation, dissemination and format, which couldn't be encompassed within the existing 14 domains of TDF framework. Among healthcare professionals, the most frequently reported influencing factors were related to the environmental context and resources (encompassing aspects such as employer support for CPG utilization), the CPG development and dissemination process (including layout, wording, and interactive tools) and beliefs about consequences (such as contradictions with practical experience). Knowledge (knowledge about the content of CPGs, awareness about published CPGs), primarily as a barrier, and reinforcement facilitators (notably financial support), were also frequently reported.

CONCLUSION

The findings revealed multilevel factors contributing to CPG adherence, with environmental context and resources emerging as the most frequently reported considerations. This systematic review offer holistic insights into the barriers and facilitators of CPG adherence in Germany. The results contribute to a better understanding of the topic and serve as a resource for developing targeted strategies to enhance CPG adherence and implementation within the German healthcare system.

Factors influencing healthy dietary behavior changes among patients with gestational diabetes mellitus during pregnancy: A meta-synthesis using the theoretical domains framework

AIMS

To examine factors that facilitate and impede healthy dietary behavior modification in patients with gestational diabetes mellitus (GDM). Additionally, it sought to assess the strength of the evidence for these factors and offer insights into promoting positive behaviors.

METHODS

This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting standards. We searched seven databases in February 2023 to include qualitative studies related to patients with GDM that explored their perceptions of and changes in healthy eating behaviors. Two researchers independently screened the articles, assessed their quality, extracted data, and coded the factors using the theoretical domain framework. For the factors involved, we performed a meta-synthesis based on their frequency and assigned a confidence level to determine their level of evidence.

RESULTS

We included 32 of the 536 extracted articles. Barriers identified by high levels of evidence include: "Environmental context and resources," "Social influences," "Knowledge," "Emotion," and "Social/professional roles and Identity." The facilitators identified by high levels of evidence include the following: "Beliefs about consequences," "Social influences," "Environmental context and resources," "Skill," and "Memory, attention, and decision processes."

CONCLUSION

This meta-synthesis highlights that healthy eating behavior change is influenced by the interaction of factors at different levels of individuals, organizations, and sociocultural environments. Furthermore, we established a framework that displayed the associations between these factors, giving prominence to those with higher levels of evidence. This framework will aid researchers in identifying priority areas for intervention and facilitating the implementation of high-quality strategies.

Barriers and facilitators to caring for patients living with dementia in the emergency department: a qualitative study

PURPOSE

Patients living with dementia are complex and visit the emergency department (ED) more frequently than other populations. There is a knowledge gap regarding challenges in care delivery for these patients from the perspective of interdisciplinary healthcare providers. The aim of this study was to identify the barriers and facilitators to caring for people living with dementia in the ED as perceived by healthcare providers to gain a deeper understanding of current care gaps and inform best care practices.

METHODS

Semi-structured interviews were conducted with healthcare providers to understand their experiences in caring for people living with dementia in the ED. Healthcare providers currently employed within in a Calgary zone ED and with experience in caring for people living with dementia in the ED were eligible for participation. The Framework Method based on the Theoretical Domains Framework and the Behavior Change Wheel was used in the analysis to inform change interventions by addressing key factors that influence behavior.

RESULTS

A total of 11 providers participated. Key facilitators to care included collaborative team approaches; collateral information from care partners, EMS, and care homes; geriatric medicine staff; addressing non-medical needs; and person-centered care. Key barriers to care included the ED environment encompassing challenges with lack of resources, staff, and time constraints; deteriorating cognition and behavioral challenges; and a lack of dementia-specific guidance and training.

CONCLUSION

This study highlights key issues in emergency care delivery at the system, unit, provider, and patient levels for people living with dementia through the analysis of healthcare provider experiences. Environmental context and resources, skills, and social/professional role and identity were key domains correlating to the major barriers and facilitators in these findings. Key opportunities for change are identified through which targeted interventions and policies may address dementia-related care gaps within the ED context.

The use of robotic upper limb therapy in routine clinical practice for stroke survivors: Insights from Australian therapists

INTRODUCTION

There is a limited understanding of therapist acceptance and use of robot-assisted upper limb therapy (RT-ULT) in routine practice. The aim of this study was to explore the factors that influence Australian therapist acceptance and use of RT-ULT.

METHODS

Two discipline-specific focus groups were conducted involving occupational therapists (n = 5) and physiotherapists (n = 4) who had used RT-ULT. Focus group questions were developed, and transcriptions analysed using the Theoretical Domains Framework (TDF). Additionally, participants scored the overall usability of the RT-ULT device with the System Usability Scale (SUS).

CONSUMER AND COMMUNITY INVOLVEMENT

There was no direct involvement from consumers or community in this study.

FINDINGS

Nine of the 14 domains of the TDF were covered in depth by participants during the focus groups: environmental context and resources, beliefs about consequences, knowledge, skills, decision-making, reinforcement, social influences, social/professional role and identity (single domain), and beliefs about capabilities. Physiotherapists recorded higher scores of the device on the SUS than the occupational therapists.

CONCLUSION

Both disciplines were accepting of RT-ULT, but it was physiotherapists who predominantly used RT-ULT in part due to the device being located in the physiotherapy rehabilitation gym. Other factors facilitating RT-ULT acceptance in practice included (1) increase in repetitive, intensive independent practice for stroke survivors, (2) ease of use, (3) strong patient acceptance, and (4) implementation process being clinician-led. Functional-based UL practice took priority over RT-ULT once stroke survivors demonstrated sufficient active movement and RT-ULT was not used in isolation but part of a combination of UL interventions.

PLAIN LANGUAGE SUMMARY

There is a little known about what therapists think about using robot-assisted upper limb therapy in their daily practice. The aim of this study was to explore Australian therapist perceptions of the use of robotics. Focus groups were conducted separately with five occupational therapists and four physiotherapists who had used robotics at their rehabilitation facility. In addition to the focus groups, each therapist scored the user-friendliness of the robotic device by completing a short survey. Both occupational therapists and physiotherapists believed the robotics was a beneficial addition to the rehabilitation facility. Physiotherapists used the device more than the occupational therapists with the device being located in the physiotherapy area of the rehabilitation facility. Therapists explained that robotics increased the amount of practice stroke survivors could do, was easy to use, and was motivating for stroke survivors. However, once stroke survivors had gained enough arm movement, the focus moved to practicing actual daily tasks rather than robotics. Also, robotics was not the only form of upper limb therapy offered to stroke survivors with multiple upper limb treatments used to aid their recovery.

Evaluation of Co-Developed Strategies to Support Staff of a Mental Health Community Managed Organisation Implement Preventive Care: A Pilot Controlled Trial

BACKGROUND

Mental health community managed organisations (CMOs) are well placed to provide preventive care, including behaviour change conversations to address smoking, nutrition, alcohol and physical activity (snap). This study evaluates the impact of co-developed preventive care implementation support strategies, including Healthy Conversation Skills (HCS) training on CMO staff attitudes and perceptions relating to preventive care for snap behaviours.

METHODS

A non-randomised controlled pilot trial was undertaken (October 2021-May 2022) with two branches of a mental health CMO (n = 1 target; n = 1 control) in NSW, Australia. Target group staff received a three-month implementation support package co-developed by staff and researchers, including HCS training and educational materials. Staff from both groups completed an online survey at baseline and follow-up, reporting barriers and facilitators and perceived individual and organisational ability to provide preventive care for each behaviour. Pre and post HCS training, target staff completed surveys reporting barriers and facilitators to having behaviour change conversations, and competency of using 'open discovery questions' (a key HCS skill).

RESULTS

Baseline (n = 27) and follow-up (n = 17) surveys showed mean scores increased for the target group and decreased for the control group for n = 4/8 barrier and facilitator outcomes, and n = 7/8 perceived individual and organisational ability of providing care outcomes. Sixteen target group staff participated in HCS training and surveys, with scores improving for skills (p = 0.0009), beliefs about capabilities (p = 0.0035), intentions (p = 0.0283), participant confidence (p = 0.0043), perceived usefulness (p = 0.004), and competence in using open discovery questions (p < 0.0001).

CONCLUSIONS

This pilot trial demonstrates the feasibility and potential effectiveness of a co-developed implementation support package at increasing mental health CMO staff capacity to provide preventive care for multiple health behaviours. SO WHAT?: This evidence can inform future research trials and health policy aimed at supporting CMO staff in delivering comprehensive preventive care.

Development and evaluation of Goal setting and Action Planning (G-AP) training to support person-centred rehabilitation practice

Background

Stroke survivor's goals reflect their individual priorities and hopes for the future. Person-centred goal setting is recommended in rehabilitation clinical guidelines, but evidence-based training to support its implementation in practice is limited. We aimed to develop, describe and evaluate a new Goal setting and Action Planning (G-AP) rehabilitation training resource to support person-centred goal setting practice in community neuro-rehabilitation settings.

Methods

A clinical-academic team, advisory group and web-design company were convened to co-develop the G-AP training resource. G-AP training was then delivered to multi-disciplinary staff (n = 48) in four community neuro-rehabilitation teams. A mixed methods evaluation utilising a staff questionnaire and focus group discussion was conducted to investigate staff experiences of G-AP training and their early G-AP implementation efforts. Questionnaire data were analysed descriptively; focus group data were analysed using a Framework approach. An integrated conceptual overview of data was developed to illustrate findings.

Results

A fully online G-AP training resource comprising a training website and two interactive webinars was developed. Following training, 41/48 (85%) staff completed the online questionnaire and 8/48 (17%) participated in the focus group. Nearly all staff rated the training website as excellent (n = 25/40; 62%) or good (n = 14/40; 35%) and the webinars as excellent (n = 26/41; 63%) or good (n = 14/41; 34%). Following training, staff agreed they were knowledgeable about G-AP (37/41; 90%) and had the confidence (35/40; 88%) and skills (35/40; 88%) to use it in practice. Within one month of training, staff described implementing G-AP individually, but transitioning to implementation at a team level required more time to develop new working practices. Team context including staff beliefs about G-AP, leadership support and competing demands impacted (positively and negatively) on staff training engagement, learning experience and implementation efforts.

Conclusions

The new G-AP training resource was positively evaluated and supported early G-AP implementation efforts. This study advances our understanding of training evaluation by highlighting the training-context interaction the temporal nature of training effects. A follow up study evaluating longer term G-AP implementation is underway.

Preventing and managing urinary tract infections: Exploring interventions and strategies implemented by NHS commissioning organisations in English primary care, 2017-2022

Background

The majority of antibiotics are prescribed in primary care. Urinary tract infections (UTIs) are the second most common reason for antibiotic prescribing in this sector. This study explores activities used by English Clinical Commissioning Groups (CCGs) to improve UTI prevention and management 2017-2022.

Methods

An online questionnaire was sent to CCG primary care chief nurses and medicines optimisation leads August-September 2022. Qualitative data was mapped to the Theoretical Domains Framework.

Results

Participant response rate was 14.1% (56/397), with representation from 29.2% (31/106) CCGs and across a range of roles. Education and training were the most reported intervention types, while changing the environment to facilitate behaviours was the least. Most interventions targeted general practice staff and patients, followed by care home staff, and residents and their families.The most reported success measures included reduction in antibiotic prescribing (54.5%, 97/178 interventions); positive stakeholder feedback (42.1%, 75/178); and increased adherence to diagnostic guidelines (32.6%, 58/178). 48.8% (20/41) stated their UTI activities had not been formally evaluated. Barriers and facilitators to intervention implementation included: availability of resources and time; staff collaboration; availability and accuracy of information; public and staff beliefs; systems and processes; and staff roles and responsibilities.

Conclusions

UTI interventions rolled out through English health authorities could be further improved through structures that increase capacity to effectively evaluate activities and share learning. Staff engagement and collaboration are key facilitators to implementation and should be leveraged in further initiatives, while support and guidance are provided to adapt initiatives to fit in the changing healthcare landscape.

Co-producing an intervention to reduce sedentary behaviour in community-dwelling older adults aged ≥ 75 informed by behaviour change theory

BACKGROUND

Older adults are the fastest-growing and most sedentary group in society. With sedentary behaviour associated with negative health outcomes, reducing sedentary time may improve overall well-being. Adults aged ≥ 75 years are underrepresented in sedentary behaviour research, and tailored strategies to reduce sedentary time may be warranted. The development of an intervention to reduce sedentary behaviour in adults aged ≥ 75 years using co-production and behaviour change theory is reported.

METHODS

Four co-production workshops with community-dwelling older adults aged ≥ 75 years were held between October-December 2022. The intervention development process was informed by the Behaviour Change Wheel (BCW) and Theoretical Domains Framework (TDF). Audio recordings and workshop notes were iteratively analysed, with findings used to inform subsequent workshops.

RESULTS

The co-production group consisted of six community-dwelling older adults aged ≥ 75 years and two researchers. The developed intervention consists of four components (activity monitoring, educational material, group sessions and researcher follow-up), maps to 24 behaviour change techniques and targets barriers to reducing sedentary time. Participants were receptive of the co-production process.

CONCLUSIONS

Integrating co-production with the BCW can provide several benefits, with the BCW providing structure to the intervention development process, and co-production increasing the likelihood of the developed intervention being viewed as feasible by older adults. Furthermore, coding intervention components to the BCW may further our understanding of what approaches are successful at influencing behavioural change. Transparent reporting of the intervention development process may benefit researchers developing interventions with older adults. Future research will pilot the co-produced intervention.

Talking About Barriers to Disease-Modifying Anti-Rheumatic Drugs: Content Analysis of Audio-Recorded Routine Clinical Visits of Patients with Rheumatoid Arthritis

Purpose

Effective healthcare professional-patient communication is essential for medication adherence. Conversations about patient's barriers to medication use, for example, could help to enhance adherence and consequently improve treatment outcomes. However, it is unclear whether and how barriers to medication use are discussed during routine rheumatology consultations. The aims of this study were to examine 1) the barriers and facilitators to medication use raised by patients during real-life rheumatology outpatient consultations, and whether the issue of medication (non)adherence was discussed (communication content); and 2) how rheumatologists responded to the barriers (communication process).

Methods

A total of 134 audio-recordings of real-life outpatient rheumatology consultations were analysed. Barriers and facilitators for the current use of disease-modifying anti-rheumatic drugs were identified and categorized using a previously adapted Theoretical Domains Framework. The way rheumatologists responded to the barriers brought up by the patients was analysed using relevant parts of the Roter Interaction Analysis System.

Results

In 58 of the 134 consultations, at least one barrier or facilitator to current medication use was brought up by the patient; in 31 out of 134 consultations, medication (non)adherence was addressed. Most facilitators were related to the quality of the needles, the use of an injection pen instead of a syringe, dose reduction because of low disease activity and timing of the medication. The majority of barriers were related to experiencing side effects and doubts about efficacy and resistance of (long-term use of) medication. Rheumatologists' responses to barriers related to disease-modifying anti-rheumatic drugs were mostly a combination of instrumental (counselling) and affective (agreement) communication.

Conclusion

Barriers to current disease-modifying anti-rheumatic drugs' use raised by patients and discussed during routine rheumatology consultations were primarily related to side effects and concerns about the efficacy and long-term use. Continuous attention of these barriers and tailored responses to patients' concerns are key to promote better adherence to treatment.

Qualitative study exploring the barriers and facilitators to low-dose aspirin adherence in pregnant women with placental dysfunction risk in the UK

INTRODUCTION

Placental dysfunction is estimated to affect 10% of pregnancies and is associated with adverse perinatal outcomes. Low-dose aspirin (LDA) reduces placental dysfunction risk. However, adherence to LDA is suboptimal in pregnant women and may reduce its effectiveness.

OBJECTIVES

We aimed to explore the barriers and facilitators to LDA adherence in pregnant women with placental dysfunction risk.

DESIGN

Qualitative semi-structured individual interviews were undertaken, and data were inductively thematically analysed.

SETTING

A single NHS Trust in South West England, UK.

PARTICIPANTS

Pregnant women aged>18, recommended daily LDA for pregnancy indications. We purposively recruited those with a range of adherence patterns (non-adherent, suboptimally adherent, adherent).

RESULTS

15 women participated (93% white British, 73% university educated). Five were adherent (6-7 doses per week), five suboptimally adherent (4-5 doses per week) and five non-adherent (<3 doses per week). Indications for LDA were pre-eclampsia risk, low PAPP-A and previous intrauterine growth restriction. Four themes and related subthemes were identified addressing motivational and implementation issues. Motivational barriers and facilitators included (1) risk perceptions: participants described limited understanding of their indications for LDA and the maternal and fetal impacts of placental dysfunction, feeling stigmatised by their body mass index being an indicator for LDA and perceiving it to be unlikely they would experience serious consequences of placental dysfunction. Facilitators were direct/indirect experiences of placental dysfunction. (2) Concerns about taking LDA, including bleeding risk. (3) Interactions with healthcare professionals: participants described receiving limited information from healthcare professionals, with limited attention given to LDA compared with other antenatal recommendations. Distrust and trust in healthcare professionals impacted non-adherence/adherence. Implementation barriers were (4) difficulties with establishing habits, tailing off and difficulties swallowing. Established habits and swallowing LDA whole supported taking it.

CONCLUSIONS

We identified motivational and implementation-related barriers and facilitators to LDA adherence in a clinical sample of women with placental dysfunction risk. Women require more information to enhance understanding and inform their decision, and require support to establish effective habits. Theory-informed behaviour change techniques could address these barriers. Adherence barriers and facilitators should be explored in minority ethnicity and economically deprived women, and healthcare staff providing LDA-related care to inform optimally effective interventions.

Impact of a team-based versus individual clinician-focused training approach on primary healthcare professionals' intention to have serious illness conversations with patients: A theory-informed process evaluation embedded within a cluster randomized trial

BACKGROUND

Cluster randomized trials (cRTs) on the effectiveness of training programs face complex challenges when conducted in real-world settings. Process evaluations embedded within cRTs can help explain their results by exploring possible causal mechanisms impacting training effectiveness.

OBJECTIVE

To conduct a process evaluation embedded within a cRT by comparing the impact of team-based vs. individual clinician-focused SICP training on primary healthcare professionals' (PHCPs) intention to have serious illness conversations with patients.

METHODS

The cRT involved 45 primary care practices randomized into a team-based (intervention) or individual clinician-focused (comparator) training program and measured primary outcomes at the patient level: days at home and goals of care. To perform this theory-informed mixed-methods process evaluation embedded within the cRT, a different outcome was measured at the level of the PHCPs, namely, PHCPs' intention to have serious illness conversations with patients as measured with CPD-Reaction. Barriers and facilitators to implementing the conversations were identified through open-ended questions and analyzed using the Theoretical Domains Framework. The COM-B framework was used to triangulate data. Results were reported using the CONSORT and GRAMMS reporting guidelines.

RESULTS

Of 535 PHCPs from 45 practices, 373 (69.7%) fully completed CPD-Reaction (30.8% between 25-34 years old; 78.0% women; 54.2% had a doctoral degree; 50.1% were primary care physicians). Mean intention scores for the team-based (n = 223) and individual clinician-focused arms (n = 150) were 5.97 (standard error (SE): 0.11) and 6.42 (SE: 0.13), respectively. Mean difference between arms was 0.0 (95% CI -0.29; 0.30; p = 0.99) after adjusting for age, education and profession. The team-based arm reported barriers with communication, workflow, and more discomfort in having serious illness conversations with patients.

CONCLUSIONS

Team-based training did not outperform individual clinician-focused in influencing PHCPs' intention to have serious illness conversations. This process evaluation suggests that team-based training could improve intervention effectiveness by focusing on interprofessional communication, better organized workflows, and better support and training for non-clinician team members. Registration: ClinicalTrials.gov (ID: NCT03577002).

Psychometric evaluation of a Theoretical Domains Framework based questionnaire on community pharmacists' pharmaceutical care service for breastfeeding women

BACKGROUND

There is a lack of validated Theoretical Domains Framework (TDF) based instruments to investigate barriers and facilitators for community pharmacists (CPs) to provide effective care for breastfeeding women.

AIM

The aim of this study was to evaluate the psychometric properties of a TDF-14 (v2) based questionnaire to identify barriers and facilitators faced by Turkish CPs in provision of pharmaceutical care to breastfeeding women.

METHOD

This observational study was carried out among CPs in Türkiye. After generating the English form of the questionnaire, translation and cultural adaptation of the questionnaire, an expert panel and pilot study were conducted. Data were collected through an online survey between October 2023 and January 2024. The psychometric properties of the questionnaire were tested by performing test-retest reliability, confirmatory factor analysis (CFA), and internal consistency analysis.

RESULTS

The test-retest reliability analysis (n = 30) indicated that the intraclass correlation coefficient values of each domain were between 0.75 and 0.96 (p < 0.001). Four hundred and sixteen CPs completed the questionnaire (response rate: 37.5%). Out of a total of 36 items, six items were excluded. The final questionnaire covered 13 out of the 14 TDF (v2) domains. Chi square/degree of freedom ( χ 2/df), comparative fit index (CFI), root mean square error of approximation (RMSEA), and standardized root mean square residual (SRMR) were 2.01, 0.96, 0.05, and 0.04; respectively. Cronbach's alpha values of each domain ranged from 0.63-0.90.

CONCLUSION

This TDF-based questionnaire is a valid and reliable tool for evaluating CPs' enablers and barriers to providing pharmaceutical care to breastfeeding women.

Complex breathlessness intervention in idiopathic pulmonary fibrosis (BREEZE-IPF): a feasibility, wait-list design randomised controlled trial

INTRODUCTION

Breathlessness is common and impairs the quality of life of people with idiopathic pulmonary fibrosis (IPF) and non-IPF fibrotic interstitial lung diseases (ILD). We report the findings of a multicentre, fast-track (wait-list), mixed-methods, randomised controlled, feasibility study of a complex breathlessness intervention in breathless IPF and non-IPF fibrotic ILD patients.

METHODS

Breathless IPF and non-IPF fibrotic ILD patients were randomised to receive the intervention within 1 week (fast-track) or after 8 weeks (wait-list). The intervention comprised two face-to-face and one telephone appointment during a 3-week period covering breathing control, handheld fan-use, pacing and breathlessness management techniques, and techniques to manage anxiety. Feasibility and clinical outcomes were assessed to inform progression to, and optimal design for, a definitive trial. A qualitative substudy explored barriers and facilitators to trial and intervention delivery.

RESULTS

47 patients (M:F 38:9, mean (SD) age 73.9 (7.2)) were randomised with a recruitment rate of 2.5 participants per month across three sites. The adjusted mean differences (95% CI) for key clinical outcomes at 4 weeks post randomisation were as follows: Chronic Respiratory Questionnaire breathlessness mastery domain (0.45 (-0.07, 0.97)); and numerical rating scales for 'worst' (-0.93 (-1.95, 0.10)), 'best' (-0.19 (-1.38, 1.00)), 'distress caused by' (-1.84 (-3.29, -0.39)) and 'ability to cope with' (0.71 (-0.57, 1.99)) breathlessness within the past 24 hours. The qualitative substudy confirmed intervention acceptability and informed feasibility and acceptability of study outcome measures.

CONCLUSION

A definitive trial of a complex breathlessness intervention in patients with IPF and non-IPF fibrotic ILD is feasible with preliminary data supporting intervention effectiveness.

TRIAL REGISTRATION NUMBER

ISRCTN13784514.

Barriers and Facilitators to Assessment Practices in Linguistically Diverse Children: A Preliminary Application of Theoretical Domains Framework

PURPOSE

Linguistically diverse children face health disparities in special education services in part due to limited linguistic responsivity in communication assessment practices. This study uses the first application of the Theoretical Domains Framework (TDF) to reveal the various factors that affect the implementation of linguistically responsive practices and their respective barriers and facilitators.

METHOD

Two focus groups were conducted in Oregon with a total of nine speech-language pathologists, most of whom were multilingual. A deductive and inductive analytical approach in a two-stage process was employed, whereby barriers and facilitators were deductively coded using TDF domains (content analysis) and analyzed for subthemes within each domain as well as barriers and facilitators for each domain. Barriers and facilitators were summarized across overarching themes.

RESULTS

A total of 33 themes were extracted from all the domains. The most commonly coded TDF domains in the focus group transcript were knowledge (69%), beliefs about consequences (48%), and environmental context and resources (33%). The overarching themes identified across domains were related to the role of family, flexibility and adaptability, limitations of assessment tools, need for help through experts, research and training, and approach to language differences.

CONCLUSIONS

The findings from this study offer a precise initial characterization of the barriers and facilitators to linguistically responsive communication assessment of children from birth to age 5 years. Future research should focus on supporting facilitators while eliminating barriers to ensure equitable service provision for all children.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.28516196.

Caregiver and care team perspectives of caregiver psychological distress and well-being during critical care hospitalization: a qualitative study

BACKGROUND

Family caregiver psychological distress during an older adult's critical care hospitalization can compromise their well-being and ability to function in a supportive role for patient recovery. Understanding factors influencing family caregiver distress and well-being during this period is crucial for developing approaches to support caregiver health. We sought to better understand and compare caregiver and care team member perspectives about factors and strategies that affect psychological distress and well-being among family caregivers during a critical care hospitalization.

METHODS

Using a qualitative design, we conducted a directed content analysis of semi-structured interview data collected from 20 family caregivers of Veterans in critical care and 12 care team members at a US Veterans Affairs medical and surgical intensive care unit between October 2020 and July 2021. We examined factors related to caregiver psychological distress or well-being. The Consolidated Criteria for Reporting Qualitative Research guidelines were followed.

RESULTS

Factors identified as related to caregiver psychological distress by caregivers and care team members included unfamiliarity with the health system, care team, and treatment processes; uncertainties about the illness and patient appearance; and responsibilities associated with the caregiver role. Factors related to caregiver well-being included proactive and personal communication, and a comfortable and respectful environment. Within these factors, however, there were differences in focus between caregivers and care teams. Caregivers focused on unfamiliar treatment processes, with unmet expectations around predictable communication. Few care team members indicated awareness of this concern. Other family, home, or caregiving responsibilities were described by caregivers as contributing to distress but were not mentioned by care team members. Caregivers discussed proactive communication by the care team that occurred either in-person or over the phone as emotionally supportive. Care team members emphasized in-person communication and videoconference options as beneficial and comforting to caregivers during visitor restrictions. The impact of a comfortable and respectful environment was recognized as promoting caregiver well-being by primarily non-clinical care team members.

CONCLUSIONS

We found parallels between the factors identified by caregivers and care teams related to caregiver psychological distress and well-being, yet often with differences in focus. These findings provide essential information for addressing factors contributing to distress and developing practices that support caregiver well-being.

Healthcare workers' perspectives on barriers and facilitators to referral to type 2 diabetes prevention programmes: a systematic review

OBJECTIVES

Diabetes is a growing global health concern. International guidelines recommend referral to diabetes prevention programmes (DPPs) for those at high risk of type 2 diabetes. However, many of those eligible to participate in DPPs are not referred. Healthcare workers (HCWs) are pivotal to the referral processes. This study aimed to identify, appraise and synthesise barriers and facilitators to referral to DPPs from the perspective of HCWs.

DESIGN

Systematic review using the best-fit framework synthesis.

DATA SOURCES

MEDLINE, Embase, CINAHL, PsychINFO, Web of Science and Scopus were searched from January 1997 to July 2023.

ELIGIBILITY CRITERIA

Qualitative, quantitative and mixed methods primary studies exploring HCWs' perspectives of barriers and facilitators to referral to DPPs.

DATA EXTRACTION AND SYNTHESIS

One author screened, extracted and appraised the literature while a second author independently verified at least a 20% sample at each stage. Quality was assessed using the Mixed Methods Appraisal Tool. The best-fit framework approach was used to synthesise the evidence with the Theoretical Domains Framework as the a priori framework.

RESULTS

Of 9998 studies identified, 31 met the inclusion criteria, with a further six identified from reference and citation searching. Barriers and facilitators were coded to 11 of the 14 TDF domains and to another category 'Expectation of Patient Barriers'. The most frequently occurring domains for both barriers and facilitators were Environmental Context and Resources, Expectation of Patient Barriers and Knowledge. HCWs felt that clear easy referral pathways to the programmes and additional staff or resources were essential to improve referral. HCWs' were concerned that attending the DPP would place a (time and/or financial) burden on their patients which left them conflicted about referral. HCWs lacked knowledge of the effectiveness, availability and accessibility of DPPs.

CONCLUSIONS

Future strategies to improve referral to DPPs should include clear referral pathways and the resourcing of referral. Strategies are also needed to build awareness of DPPs and to address concerns among HCWs about their patients.

Polysomnographic titration of non-invasive ventilation in motor neurone disease (3TLA): protocol for a process evaluation of a clinical trial

BACKGROUND

We are undertaking a multicentre randomised controlled trial to determine the effectiveness of including a sleep study (polysomnography (PSG)) to assist the commencement of non-invasive ventilation (NIV) in people with motor neurone disease (MND): the Polysomnographic titration of non-invasive ventilation in motor neurone disease (PSG4NIVinMND; 3-three letter acronym; 3TLA) trial. A process evaluation will be conducted alongside the clinical trial to understand: (1) the implementation of the 3TLA intervention in the trial sites, including barriers and enablers, and (2) the mechanisms through which the 3TLA intervention produces change. This protocol paper describes the rationale, aims and methods of the 3TLA process evaluation.

METHODS

To guide the design of the process evaluation, a logic model representing the 3TLA intervention, the likely mechanisms of impact, potential external contextual factors and assumptions, and the anticipated outcomes was developed by the researchers in collaboration with the 3TLA Trial Steering Committee. From this, five key process evaluation research questions were identified, a priori. The mixed-methods design is guided by three implementation frameworks: the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework, the Theoretical Domains Framework (TDF), and the Theoretical Framework of Acceptability (TFA). We will conduct semi-structured interviews with approximately 20-30 clinical trial participants (people with MND) and their carers, and focus groups and surveys with approximately 60 health professionals involved in delivering the intervention at each site. Quantitative process data will also be collected from the main clinical trial. Qualitative and quantitative data will be analysed iteratively throughout the trial, independent of the main trial outcome analyses. Process evaluation findings will be triangulated with the results of the clinical trial.

DISCUSSION

This process evaluation incorporates a mixed-methods design and is informed by three theoretical frameworks. It will provide insights into how the 3TLA intervention was implemented, for whom and how the 3TLA intervention was (and was not) effective, and what adaptations may be needed to facilitate future implementation into routine clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05136222. Registered on November 25, 2021.

Combined use of the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework with other implementation frameworks: a systematic review

BACKGROUND

Appropriately and comprehensive applying implementation frameworks is one of the key challenges in implementation science resulting in increased use of multiple implementation frameworks within projects. This is particularly true for frameworks such as PARIHS/i-PARIHS. Therefore, this systematic review aimed to examine if and why the PARIHS/i-PARIHS framework has been applied in research with other implementation frameworks.

METHODS

We searched six databases from 2016 (the year following i-PARIHS' publication) to April 2024 and supplemented this with a citation search of the seminal i-PARIHS paper. We included studies that 1) were peer-reviewed with a protocol or empirical study design, 2) have applied the PARIHS or i-PARIHS framework for implementation planning, delivery, analysis, or evaluation and 3) also used at least one other implementation framework. Descriptive statistics were conducted to report on study characteristics and frequency for each implementation framework used with PARIHS/i-PARIHS. A qualitative, content analysis was used to analyse the answers to open-ended extraction questions.

RESULTS

Thirty-six articles met criteria for inclusion and included 16 protocols and 20 empirical articles (twelve intervention and eight cross-sectional studies). Thirty-four of the studies used one additional implementation framework and two studies used two additional implementation frameworks. In total, nine implementation frameworks were applied with PARIHS/i-PARIHS, including: 1) RE-AIM, 2) CFIR, 3) NPT, 4) REP, 5) TDF, 6), DSF, 7) KTA, 8) Stetler's Model, and 9) SIF. Thirty-four reported a rationale for using PARIHS/i-PARIHS and 34 reported a rationale for using the other implementation framework. Only eleven reported a rationale for using more than one implementation framework. Only three reported strengths of combining implementation frameworks.

CONCLUSIONS

Overall, this review identified that implementation researchers are using PARIHS/i-PARIHS in combination with other implementation frameworks and providing little to no rationale for why. Use of multiple implementation frameworks without detailed rationales compromises our ability to evaluate mechanisms of effectiveness. Implementation researchers and practitioners need to be more explicit about their framework selection, detailing the complementary strengths of the frameworks that are being used in combination, including why using one is not sufficient.

TRIAL REGISTRATION

This systematic review was registered with PROSPERO: ID: 392147.

Influences on Physical Activity Participation Among Older Adults: Perspectives of Exercise Professionals and Older Adult Exercise Participants

We compared perceptions of enablers, barriers, and motivators to greater physical activity by older adults in two respondent groups: individuals 55+ years of age participating in a research exercise program and exercise professionals who plan and deliver programming to older adults. We developed and administered a questionnaire on potential factors influencing physical activity participation among older adults. Questionnaire items were transformed into scales and analyzed using independent sample Mann-Whitney U tests and principal component analyses (PCA). Statistically significant differences emerged between the respondent groups. Compared to older adults, exercise professionals rated the influence of physical capabilities (p < 0.001), social (p < 0.001) and physical opportunities (p < 0.001), and reflective motivations on barriers to physical activity (p < 0.001) higher. Older adults rated reflecting on the consequences of physical inactivity (p < 0.05) higher. Respondent groups differed in their perspectives regarding the relative influence of enablers, barriers, and motivators to physical activity participation, and these differences may inform physical activity messaging for older adults.

Barriers and facilitators to seeking psychological support among healthcare professionals: a qualitative study using the Theoretical Domains Framework

BACKGROUND

Despite facing significant mental health risks, healthcare professionals often demonstrate a low frequency of seeking psychological support. This study aimed to explore the factors influencing healthcare professionals' psychological help-seeking behaviours in order to enhance the mental health of this critical population.

METHODS

Semi-structured interviews were conducted with registered clinical doctors, nurses, and hospital managers aged 21-55 years, recruited from comprehensive public hospitals in China. Participants were selected through purposive and snowball sampling to ensure diversity in roles, specialities, and work experiences. The interview guide was developed using the Theoretical Domains Framework (TDF) to explore the reasons for seeking psychological support. Data were analyzed using framework analysis and relevant domains were identified according to the frequency of participants' belief statements. The facilitators and barriers in each domain were summarized using the coded reference points.

RESULTS

A total of 34 participants were interviewed (12 nurses, 8 physicians, 14 hospital managers). We identified seven relevant domains in influencing the behaviour of seeking psychological support: knowledge, beliefs about capabilities, environmental context and resources, social/professional role and identity, emotion, social influences, and behavioural regulation. The most common facilitators of psychological help-seeking include accessible resources, positive interpersonal relationships, increased awareness, effective behavioural strategies, and emotional acknowledgement, while barriers include privacy concerns, stigma, time constraints, doubts about the effectiveness of psychological services, limited knowledge, and perceived professional role conflicts.

CONCLUSION

The behaviour of healthcare professionals seeking psychological support is complex and influenced by the interaction of multiple factors. The findings highlight the need for targeted interventions that enhance mental health literacy, address stigma, provide accessible psychological support resources, and cultivate a supportive organisational culture to improve their well-being.

Deprescribing for nursing home residents with limited life expectancy: A qualitative study to identify barriers and enablers for healthcare professionals

Nursing home residents with limited life expectancy often take many medications eligible to deprescribing. Deprescribing is crucial but not yet routinely implemented. Therefore the aim of this study was to explore healthcare professionals (HCPs) barriers to and enablers for deprescribing and to identify theoretical domains for behavior change to be included into future interventions. A qualitative descriptive study using semi-structured interviews was conducted among 28 HCPs working in Belgian nursing homes. The data were analysed inductively using thematic analysis followed by mapping barriers and enablers to theoretical domain framework (TDF), and linking the domains to behavioral change techniques (BCTs). We identified multifaceted barriers and enablers across six themes: healthcare system and policy factors, resource- and organization-level factors, professional role and competency factors, interprofessional collaboration and communication factors, attitudes and perceptions towards deprescribing, and triadic dynamics in deprescribing. These barriers and enablers were mapped to 13 of the 14 TDF domains.

Enhancing Occupational Therapists' Intervention Capabilities With Adolescents With Neurodevelopmental Disorders

Background. Adolescents with neurodevelopmental disorders (NDDs) have an increased risk of participation limitations. Occupational therapy faces knowledge-to-practice gaps among this population. Purpose. To examine the effectiveness of a continuing-education program for occupational therapists working with adolescents with NDDs. Method. The study used a mixed-method design, including pre-post comparisons of competence and sense of self-efficacy of occupational therapists to work with adolescents with NDDs. Interviews regarding the program's perceived contribution to practice were conducted. Results. Post-program results showed significantly (p < .001) higher professional competence and self-efficacy for interventions and evaluation skills with NDD's adolescents and transition programs as well as higher knowledge about adolescence and NDDs characteristics. Contrary, there was no change in competence and self-efficacy regarding client-centred interventions with adolescents. Program participants increased their professional confidence and incorporated evidence-based methods into routine practice. Implications. The continuing-education program that was examined expanded the occupational therapy practitioner's knowledge and professional skills, resulting in a change in their capacity to practice with adolescents narrowing the knowledge-to-practice gap. Future studies involving the client perspective, regarding their participation may validate and support continuing-education program for occupational therapists.

Understanding variations in the use of tranexamic acid in surgery: A qualitative interview study

Despite robust supporting evidence, around a third of eligible surgical patients do not receive tranexamic acid (TXA). Effective strategies based on an understanding of clinical behaviour are needed to increase use and improve patient outcomes. We conducted semi-structured interviews with clinicians involved in perioperative care to explore perceived influences on TXA use. We identified key influences on practice using the theoretical domains framework. We matched these to behaviour change techniques and evidence-informed implementation intervention components. Across 22 interviews, we identified eight key influences within three overarching themes of capability, opportunity and motivation. Capability influences included the clinical context and variable familiarity with TXA. Opportunity concerned the availability of both TXA and checklists to support decision-making and whether TXA use was consistent with professional expectations and perceived responsibilities. Motivation concerned confidence in administering TXA, perceived benefits and risks and training received around potential risk factors. These influences varied across participants and specialities. Our resulting proposed implementation strategy included training, clinical prompts, comparative performance feedback and opinion leadership supported by specialty-specific guidance. Any strategy to increase TXA use that improves knowledge and skills without addressing wider influences on clinical behaviour is only likely to meet with limited success.

Linking Cardiac Psychology and Cardiovascular Medicine via Self-Determination Theory and Shared Decision-Making

Despite considerable progress in recent years, research in cardiac psychology is not widely translated into routine practice by clinical cardiologists or clinical health psychologists. Self-determination theory (SDT), which addresses how basic psychological needs of autonomy, competence, and relatedness contribute to the internalization of motivation, may help bridge this research-practice gap through its application to shared decision-making (SDM). This narrative review discusses the following: (a) brief background information on SDT and SDM, (b) the application of SDT to health behavior change and cardiology interventions, and (c) how SDT and SDM may be merged using a dissemination and implementation (D&I) framework. We address barriers to implementing SDM in cardiology, how SDM and SDT address the need for respect of patient autonomy, and how SDT can enhance D&I of SDM interventions through its focus on autonomy, competence, and relatedness and its consideration of other constructs that facilitate the internalization of motivation.

Treatment Engagement in Adolescents: The Associations of Sociodemographic Characteristics, Caregiver Perceived Barriers, and Clinical Impairment

OBJECTIVE

To examine the associations between sociodemographic characteristics, perceived barriers to treatment, clinical impairment, and youth treatment engagement.

METHOD

Participants included 196 families (youth: ages 12 to 18; 64.3% cis-gender female; 23.5% Black, 60.7% White, and 12.2% Mixed/Other race; 41.3% Hispanic or Latinx ethnicity) recruited as part of a comparative effectiveness trial for adolescent anxiety and depression. Self-report measures of sociodemographic characteristics and caregiver perceived barriers were completed at intake. Youth clinical impairment was assessed at baseline via clinical interview. Measures of engagement were collected throughout treatment, including initiation status, session attendance, and termination status. Relationships were examined using analyses of variances and hierarchal linear and logistic modeling.

RESULTS

Perceived barriers did not differ by sociodemographic characteristics. Greater perceived stressors and obstacles predicted fewer sessions attended and a lower likelihood of successful termination. Youth of caregivers with an advanced degree and those with caregivers who were employed part time attended more sessions and were more likely to initiate and terminate treatment successfully compared to youth with caregivers of a lower education level or student or unemployed status. At higher levels of youth clinical impairment, greater perceived treatment demands and issues predicted reduced likelihood of treatment initiation.

CONCLUSIONS

Perceived barriers, sociodemographic characteristics, and clinical impairment were all associated with levels of engagement in the treatment process. Baseline and continued assessment of perceived and experienced barriers to treatment may promote individualized strategies for families identified as at-risk for reduced engagement.

Operation Rate for Displaced Distal Radius Fractures in the Elderly Decreased by 68% After the Implementation of Evidence-Based Practice

Background The increasing demand for orthopedic trauma surgery resources highlights the need for an efficient approach to implementing scientifically based interventions and de-implementation of interventions already in use that have been found no better than non-surgical treatments. Several factors have been identified as barriers or facilitators for translating evidence into clinical practice and behavioral changes. To facilitate a structured approach to applying these factors, we have adapted the generic theoretical domains framework (TDF) into the "CEBO model," providing a practical framework for implementing evidence in clinical decision-making in the hospital department of Zealand University Hospital, Koege, Denmark. Aim This study aims to evaluate the feasibility of the CEBO model for facilitating surgeon behavior change in an orthopedic surgery department. We will present clinical decision-making regarding the treatment of dorsally displaced distal radius fractures (DDDRF) in the elderly as an example. Methods Our department's standard of care for DDDRF in the elderly was surgical treatment. Under the evolving body of evidence, the CEBO model was applied to facilitate change in treating surgeons' behavior toward the increased use of non-surgical care. Following the four steps of the CEBO model, 1) leadership support was obtained, and relevant evidence was disseminated to all colleagues across the department; 2) stakeholders were invited to a symposium discussing best evidence and future practice; 3) conclusions from the symposium were summarized in a local clinical guideline stating non-surgical treatment as a new department standard and 4) to monitor the changes in treatment, patient charts were retrospectively reviewed from one year before and after the application of the CEBO model. Results In the first period, 95 of 120 (79%) were surgically treated, compared to 16 of 146 (11%) in the second period. An absolute decrease in the operation rate of 68% was observed. Conclusion We found the CEBO model highly feasible for facilitating surgeon behavior change in our orthopedic surgery department. Future studies will investigate the model's feasibility in other institutions and compare it to other behavior-targeted interventions.

Barriers and facilitators in implementing intra-abdominal pressure measurement by nurses in paediatric intensive care units: A qualitative study

BACKGROUND

Intra-abdominal hypertension has been proven to be an independent risk factor for death in critically ill patients. Accurate monitoring of intra-abdominal pressure is of great significance for early identification and timely intervention of intra-abdominal hypertension to prevent further progression to abdominal compartment syndrome. Paediatric critical care nurses play an important role in constant observation and recognition of subtle and dynamic changes in intra-abdominal pressure of critically ill children.

OBJECTIVES

The objective of this study was to explore paediatric critical care nurses's views on the barriers and facilitators in clinical practice of intra-abdominal pressure measurement.

METHODS

A qualitative, open-ended, and exploratory study was conducted in the paediatric intensive care unit of a tertiary hospital in China. Semistructured interviews were conducted with nurses and nursing managers who were involved in the management of intra-abdominal pressure. The interview guide was developed using the Theoretical Domains Framework to explore the barriers and facilitators to intra-abdominal pressure measurement in the paediatric intensive care unit. Data analysis followed the framework approach, drawing on the Theoretical Domains Framework.

RESULTS

Fourteen participants (10 nurses and four nursing managers) were interviewed. We identified seven domains related to intra-abdominal pressure measurement mapping to six "barrier" domains and four "facilitator" domains. The six "barrier" domains were knowledge, social influences, behavioural regulation, beliefs about consequences, beliefs about capabilities, and environmental context and resources, and the four "facilitator" domains were social influences, beliefs about consequences, environmental context and resources, and social/professional role and identity.

CONCLUSIONS

The findings confirm the need for interventions to support paediatric critical care nurses in their intra-abdominal pressure measurement practices, with a particular focus on increasing knowledge, improving skills and measurement equipment, promoting nurse-physician interprofessional collaboration, providing a standardised measurement process, and establishing a supportive environment. Using the Theoretical Domains Framework will enhance the design of a targeted intervention, which should facilitate the standardised management of intra-abdominal pressure in the paediatric intensive care unit.

Everyday living with osteoarthritis in the global South: A qualitative focus group inquiry in Nigeria

Objective

Africa contributes significantly to the increasing global prevalence (>37 ​%), unmet need and treatment burden for people with osteoarthritis. Despite this, little research has examined the expressed needs of patients with osteoarthritis (OA) and joint pain in West-Africa. This study aimed to explore lived experiences, expressed needs and current care gaps for people living with osteoarthritis in low-health resource contexts using Nigeria as a case study.

Design

Qualitative study using Focus Groups. People aged 45 years and over living with osteoarthritis and joint pain were recruited at local health services or via wide advertisements in the community. Discussions were recorded and transcribed verbatim. Data were analyzed using thematic analysis (inductive approach).

Results

Three focus groups were conducted with people living with osteoarthritis (n ​= ​30, age range 45-90 years) across socio-demographic strata. Participants described their experiences of living with osteoarthritis as emotionally, physically, and socio-economically challenging. Four main themes (and 14 sub-themes) were identified. Participants expressed the need for an information and health education campaign and access to appropriate health professionals (especially physiotherapists) for providing support, guidance, and assistance with self-management.

Conclusions

The provision of an accessible, and contextually appropriate patient education package, in line with evidence-based recommendations is a critical need for people living with osteoarthritis in Nigeria. This will promote evidence-based care for OA in low-resource settings, empowering patients to self-manage and reducing confusion related to inconsistent advice and mixed messages about cause, healthcare access and OA care.

Barriers and facilitators for patients' acceptance and adherence to auriculotherapy: A qualitative systematic review using the theoretical domains framework

BACKGROUND

Auriculotherapy has become a promising complementary therapy and is widely used to manage various symptoms and diseases. However, little is known about patients' knowledge and attitudes. This study aimed to identify and synthesize the factors that influence acceptance and adherence related to auriculotherapy from patients' perspectives.

METHODS

The thematic synthesis developed by Thomas and Harden was applied to guide this review. Six common English databases (PubMed, Web of Science, Embase, Cochrane Library, CINAHL, and PsycINFO) and four common Chinese databases (CNKI, VIP, WangFang, and Sinomed) were searched in December 2023. The quality of the included studies was assessed using the Critical Appraisal Skills Programme. Data synthesis was conducted using the theoretical domains framework.

RESULTS

Ten studies with eleven publications were included. Twenty-four barriers and fourteen facilitators on patients' acceptance and adherence to auriculotherapy were identified under nine of the theoretical domains framework domains. Among these domains, "knowledge (n = 2)", "memory, attention and decision processes (n = 2)", and "environmental context and resources (n = 5)" reported only barriers. Besides, the most frequently mentioned domains in the included studies were "beliefs about consequences (n = 10)" and "emotions (n = 6)".

CONCLUSIONS

Our findings provide a comprehensive overview of the factors affecting the patients' behavior in receiving and complying with auriculotherapy, which may help healthcare professionals deeply understand the factors that influence patients' intentions to use auriculotherapy and better interact with them. Further research that addresses these modifiable factors and develops relevant interventions may aid in meeting the growing use of auriculotherapy by patients.

TRIAL REGISTRATION

This study was registered with PROSPERO in Dec 2023 (Registration number: CRD42023488856).

Barriers and facilitators to the use of personal protective equipment in long-term care: a qualitative study

BACKGROUND

Long-term Care (LTC) residents are vulnerable to invasive infection. Appropriate use and training on personal protective equipment (PPE) is important for protecting residents and healthcare workers (HCWs). Studies on the barriers and facilitators to PPE use are limited in LTC settings.

OBJECTIVE

Characterize HCWs' perceptions of barriers and facilitators to the uptake and appropriate use of PPE in LTC facilities Calgary, Alberta.

METHODS

Semi-structured interviews were conducted with HCWs from April to October 2022. Interview transcripts were analyzed deductively to identify themes from the Theoretical Domains Framework.

RESULTS

Seven HCWs were interviewed. Barriers and facilitators fell within six overarching themes including: availability and quality of PPE; knowing how to use PPE; familial obligations; convenience and comfort; sense of professional duty; and social influences and identity. Additional factors such as understaffing and the need for more training sessions were highlighted. Strategies to improve PPE use were identified by HCWs, including the use of PPE champions, regular audits, and constructive feedback.

CONCLUSION

Identification of unique barriers and facilitators regarding PPE use by HCWs in LTC will facilitate targeted interventions to improve PPE use in this setting.

Development and evaluation of tailored, theory-informed training to support the implementation of an outcome measure: an explanatory sequential mixed method study

PURPOSE

We aimed to describe the development of a tailored, theory-informed training session for an outcome measure (the Mayo-Portland Adaptability Inventory), and evaluate the session's impact on clinician reactions, learning, and behavioural intent.

MATERIALS AND METHODS

We developed the training session using an integrated knowledge translation approach with stroke outpatient rehabilitation clinicians in Québec, Canada. We conducted a mixed-method explanatory sequential evaluation informed by the New World Kirkpatrick Model (reaction, learning, behavioural intent) composed of three surveys followed by interviews. We analyzed survey data using cumulative link mixed models, and interviews using directed content analysis.

RESULTS

Eighty clinicians attended the training session, of which 51 responded to the surveys and 6 participated in interviews. Odds ratios indicate that individuals were more likely to rate themselves higher post-training on most outcomes. During the interviews, participants indicated that: they experienced positive reactions, learning and behavioural impacts from the session, negative attitudes and commitment were due to perceived limitations in the outcome measure, and training impacts were affected by contextual factors including a provincial mandate for the measure.

CONCLUSION

Implementation teams could adapt this training design process to their context. Further research to understand how educational strategies work would produce more robust guidance.

The Cancer Tracking System (CATSystem): Study protocol of a randomized control trial to evaluate a systems level intervention for cervical cancer screening, treatment, referral and follow up in Kenya

BACKGROUND

Cervical cancer (CC) is preventable, yet remains a significant public health threat, particularly in Sub-Saharan Africa. Despite considerable awareness, screening rates for CC in Kenya are low and loss to follow-up following treatment for premalignant cervical lesions remains high. This study investigates the efficacy of the Cancer Tracking System (CATSystem), a web-based intervention, to improve CC screening and treatment retention.

METHODS

A matched, cluster randomized controlled trial will be conducted in Kenyan government hospitals (n = 10) with five intervention and five standard-of-care (SOC) sites. The primary outcome is the proportion of women with a positive screen who receive appropriate treatment (onsite or referral). Secondary outcomes include CC screening uptake among all women and timeliness of treatment initiation. We will utilize mixed methods to assess intervention feasibility, acceptability, and cost-effectiveness.

DISCUSSION

The CATSystem has the potential to improve CC care in Kenya by leveraging existing technology to address known barriers in the screening and treatment cascade. This study will provide valuable evidence for potential scale-up of the intervention.

Preparing to deliver a stepped wedge cluster-randomised trial to test the effectiveness of daily symptom tracking integrated into electronic health records for managing rheumatoid arthritis: a mixed-methods feasibility trial

BACKGROUND

We sought to assess the feasibility of a stepped-wedge cluster-randomised trial testing the effectiveness of a complex mHealth intervention called REMORA: a co-designed smartphone app enabling daily, weekly and monthly symptom tracking integrated into electronic health records for people with rheumatoid arthritis (RA).

METHODS

We conducted a mixed-methods feasibility trial using a convergent approach with some explanatory sequential elements. Patients were eligible to take part if they were older than ≥18 years of age, had (suspected) RA or undifferentiated inflammatory arthritis, and consented to take part from two outpatient departments. We analysed quantitative app and electronic health record data descriptively. We analysed qualitative data from interviews and clinic observations thematically. We assessed four feasibility domains: recruitment and consent (target: 15 patients per site), intervention uptake (≥70% of recruited participants completed on-boarding, i.e., registered with the app and submitted at least one symptom report), intervention adherence (>50% daily symptom reports provided), and measuring disease activity as the primary outcome (scores available for ≥80% of people with a follow-up clinic visit). Due to time constraints, we only recruited patients to the intervention group, leaving us unable to test the logistics of randomising sites in accordance with the trial's cluster stepped wedge design.

RESULTS

Of 130 people screened, 52 consented. Of those, 32 (62%) completed on-boarding. On-boarded participants provided symptom data on 2384/3771 (63%) of possible days. Among the 48 people who had ≥1 follow-up appointment, at least one disease activity scored was obtained for 46 (96%) of them. Factors related to intervention uptake formed the biggest threat to trial feasibility, including lack of clarity of communication and guidance, access to technology, and personal challenges (e.g., being busy or unwell).

CONCLUSION

We found that delivering a trial to test the effectiveness of integrated symptom tracking in rheumatology outpatient settings was feasible. The future REMORA trial will contribute to the much-needed evidence base for the impact of integrated symptom tracking on care delivery and patient outcomes, including decision-making, patient experience, disease activity, and symptom burden.

TRIAL REGISTRATION

This feasibility trial was registered at https://www.isrctn.com/ on 23-Jan-2023 (ISRCTN21226438).