Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework

Interprofessional education interventions for healthcare professionals to improve patient safety: a scoping review

BACKGROUND

Patient safety incidents, such as adverse events and medical errors, are often caused by ineffective communication and collaboration. Interprofessional education is an effective method for promoting collaborative competencies and has attracted great attention in the context of patient safety. However, the effectiveness of interprofessional education interventions on patient safety remains unclear. This scoping review aimed to synthesize existing studies that focused on improving patient safety through interprofessional education interventions for healthcare professionals.

METHODS

Six databases, including Medline (via PubMed), Embase, Cochrane Library, CINAHL (via EBSCO), Scopus and Web of Science, were last searched on 20 December 2023. The search records were independently screened by two researchers. The Joanna Briggs Institute Critical Appraisal Tool for Quasi-Experimental Studies was used for quality appraisal. The data were extracted by two researchers and cross-checked. Finally, a narrative synthesis was performed. The protocol for this scoping review was not registered.

RESULTS

Thirteen quasi-experimental studies with moderate methodological quality were included. The results revealed that the characteristics of current interprofessional education interventions were diverse, with a strong interest in simulation-based learning strategies and face-to-face delivery methods. Several studies did not assess the reduction in patient safety incidents involving adverse events or medical errors, relying instead on the improvements in healthcare professionals' knowledge, attitude or practice related to patient safety issues. Less than half of the studies examined team performance, based primarily on the self-evaluation of healthcare professionals and observer-based evaluation. There is a gap in applying newer tools such as peer evaluation and team-based objective structured clinical evaluation.

CONCLUSION

Additional evidence on interprofessional education interventions for improving patient safety is needed by further research, especially randomized controlled trials. Facilitating simulation-based interprofessional education, collecting more objective outcomes of patient safety and selecting suitable tools to evaluate teamwork performance may be the focus of future studies.

Barriers and facilitators for healthy lifestyle and recommendations for counseling in endometrial cancer follow-up care: a qualitative study

OBJECTIVES

Lifestyle promotion during follow-up consultations may improve long-term health and quality of life in endometrial cancer patients. This study aimed to identify barriers and facilitators to improve and sustain a healthy lifestyle that can be translated to behavioral methods and strategies for lifestyle counseling.

METHODS

Endometrial cancer patients from three hospitals were recruited to participate in a semi-structured interview. The data were transcribed and coded. Thematic analysis was applied to identify themes and the behavior change wheel was used as a theoretical framework. Data saturation was confirmed after 18 interviews.

RESULTS

Barriers included knowledge gaps as well as lack of motivation and environmental opportunities to engage in health-promoting behavior. Facilitators included applying incremental lifestyle changes, social support, positive reinforcements, and the ability to overcome setbacks.

CONCLUSIONS

We propose the following intervention functions: education, persuasion, training, environmental restructuring, and enablement. Suitable behavior change techniques to deliver the intervention functions include information about the consequences of certain behavior, feedback on behavior, credible source, graded tasks, habit formation, restructuring of the environment, prompts/cues, goal setting, action planning, and social support. Including these recommendations in lifestyle counseling could aid lasting lifestyle change since it suits the needs and preferences of patients.

Evaluating the impact of a standardised intervention for announcing decisions of withholding and withdrawing life-sustaining treatments on the stress of relatives in emergency departments (DISCUSS): protocol for a stepped-wedge randomised controlled trial

INTRODUCTION

The decisions of withholding or withdrawing life-sustaining treatments are difficult to make in the context of emergency departments (EDs) because most patients are unable to communicate. Relatives are thus asked to participate in the decision-making process, although they are unprepared to face such situations. We therefore aimed to develop a standardised intervention for announcing decisions of withholding or withdrawing life-sustaining treatments in EDs and assess the efficacy of the intervention on the stress of relatives.

METHODS AND ANALYSIS

The DISCUSS trial is a multicentre stepped-wedge cluster randomised study and will be conducted at nine EDs in France. A standardised intervention based on human simulation will be codesigned with partner families and implemented at three levels: the relatives, the healthcare professionals (HCP) and the EDs. The intervention will be compared with a control based on treatment as usual. A total of 538 families are planned to be included: 269 in the intervention group and 269 in the control group. The primary endpoint will be the symptoms of post-traumatic stress disorder (PTSD) at 90 days. The secondary endpoints will be symptoms of PTSD at 7 and 30 days, diagnosis of PTSD at 90 days and anxiety and depression scores at 7, 30 and 90 days. Satisfaction regarding the training, the assertiveness in communication and real-life stress of HCPs will be measured at 90 days.

ETHICS AND DISSEMINATION

This study was approved by the ethics committee Est III from Nancy and the French national data protection authority. All relatives and HCPs will be informed regarding the study objectives and data confidentiality. Written informed consent will be obtained from participants, as required by French law for this study type. The results from this study will be disseminated at conferences and in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT06071078.

Establishing enablers and barriers to implementing the HIRAID® emergency nursing framework in rural emergency departments

BACKGROUND

Rural Australia has large geographic distances between emergency departments with variability of services and medical support. Emergency nurses must be appropriately skilled to assess and manage unpredictable and diverse presentations. HIRAID® is an evidence-based framework to support emergency nurses in assessment and care delivery. To inform implementation, the study aimed to identify the enablers and barriers to introducing HIRAID® in practice.

METHODS

This embedded mixed methods study was conducted in 11 rural, regional emergency departments in Southern New South Wales, Australia. Respondents completed a 22-item survey, indicating their level of agreement on statements related to practice change, free text responses were optional. Quantitative data were analysed using descriptive statistics and qualitative data using content analysis. Results were identified as barriers or enablers, then integrated and mapped to the Theoretical Domains Framework.

RESULTS

The survey was completed by 102 (54 %) nurses. Two enablers and four barriers to implementation were identified and mapped to 10 Theoretical Domains Framework domains. Key barriers were workplace limitations, such as time and resources, and knowledge of the HIRAID® intervention.

CONCLUSION

Barriers varied between facilities related to adequate support to implement and the impact on patient care. The results will inform a strategy to implement HIRAID®.

The unmet mental health needs of adolescents with HIV in eastern Tanzania: Experiences of healthcare providers, adolescents, and caregivers

Adolescents with Human Immunodeficiency Virus (HIV) are at greater risk for mental health problems than their HIV-negative counterparts. However, there is a dearth of evidence on the need for mental health services, including interventions for depression in adolescents with HIV (AWHIV), in most low- and middle-income countries (LMICs). This study's objective was to explore the unmet mental health needs of AWHIV to inform the development and implementation of a psychological intervention for depression in AWHIV in Dar es Salaam, Tanzania. A descriptive phenomenological qualitative study design was used. Consultative meetings with providers and 45 in-depth interviews were conducted with AWHIV, caregivers, and healthcare providers (HCPs) to explore their experiences and unmet mental health needs for AWHIV. Data from the consultative meetings were triangulated to validate the obtained information with those from interviews. Data were organized and managed with the aid of NVIvo-11. The thematic analysis framework guided data analysis. Five major themes emerged: Experience of complex symptoms, unmet need for services, impact of the unmet needs, ways utilized in managing symptoms, and preferred intervention. Complex depressive symptoms expressed as physical, behavioral, or somatic complaints adversely affected ART adherence and academic performance, led to substance use, and compromised overall quality of life in AWHIV. HIV-Care and Treatment Centers (HIV-CTCs) did not conduct formal mental health screenings. Instead, caregivers and HCPs addressed the symptoms of mental health problems with death threats and corporal punishments. No evidence-based depression interventions existed in HIV-CTCs for observed symptoms. This study reports on unmet mental health needs with a clear impact on the lives of AWHIV, which may have significant implications for treatment adherence. There is an urgent need to develop and implement effective and scalable interventions to address these mental health needs.

Leveraging implementation science theories to develop and expand the use of a penicillin allergy de-labeling intervention

BACKGROUND

Penicillin allergy is the most frequently reported drug allergy, yet most patients can tolerate the drug if challenged. Despite this discrepancy, large scale penicillin allergy de-labeling interventions have not been widely implemented in many health care systems. The application of a multi-method implementation science approach can provide key tools to study this evidence to practice gap and provide insight to successfully operationalize penicillin allergy evaluation in real-world clinical settings.

METHODS

We followed a four-step process that leverages qualitative analysis to design evidence-based, actionable strategies to develop an intervention. First, we specified the clinician-perceived barriers to penicillin allergy de-labeling (intervention targets). We then mapped intervention targets onto Theoretical Domains Framework (domains and constructs) and found the root causes of behavior. Next, we linked root causes of behavior with intervention functions (BCW). In the final step, we synthesized participants' suggestions for process improvement with implementation strategies aligning with the intervention functions.

RESULTS

Evidence-based strategies such as focused education and training in penicillin allergy evaluation can address knowledge and confidence barriers reported by frontline clinicians. Other key strategies involve developing a system of champions, improving communications systems, and restructuring the healthcare team. Implementation mapping can provide a powerful multi-method framework to study, design, and customize intervention strategies.

CONCLUSION

Empowering clinicians beyond allergy specialists to conduct penicillin allergy assessments requires designing new workflows and systems and providing additional knowledge to those clinicians.

Promotion of legume intake-Israeli dietitians' knowledge, beliefs and practices

BACKGROUND

The health and environmental benefits of legume consumption are reflected in dietary guidelines worldwide. However, legume intake fails to meet recommendations. Dietitians' legume counseling practices can impact consumption patterns. This cross-sectional study assessed Israeli dietitians' knowledge, attitudes, perceptions and practices regarding legume counseling and identified pertinent barriers and facilitators.

METHODS

An electronic survey among Israeli dietitians (n = 309) was performed. Multivariable logistic regression assessed associations between recommending legumes with participants' socio-demographic and professional characteristics, knowledge, perceptions, attitudes toward legume counseling and personal legume intake.

RESULTS

Almost half (47.4%) of the participants recommended that 76% or more of their patients increase legume intake. Factors that were associated with recommending legumes were perceptions of fewer barriers to consumption [adjusted OR (aOR) 1.92 (95% CI 1.24-2.96)] and positive attitudes toward legume counseling pertaining to its importance [aOR 1.95 (95% CI 1.12-3.4)]. Negatively associated factors were a low level of personal legume consumption [aOR 0.38 (95% CI 0.15-0.94)] and working in hospitals [aOR 0.43 (95% CI 0.19-0.98)].

CONCLUSIONS

Israeli dietitians' recommendations for legume consumption were well below current guidelines. These findings indicate the need for a tailored intervention for nutrition professionals to increase the frequency of legume counseling and overall consumption.

Theoretical Domains Framework: A Bibliometric and Visualization Analysis from 2005-2023

Background

The Theoretical Domains Framework (TDF) is among the most extensively utilised foundational frameworks in implementation science. It was developed from 33 psychological theories, with the latest version identifying 14 domains encompassing 84 theoretical constructs. These domains and constructs capture the complexity of factors that affect behaviours, making the framework a valuable tool for designing and implementing interventions within health and social care settings.

Objective

To summarise the development, hot topics, and future trends in TDF-related research and provide implementation practitioners with more information on the application of TDF.

Methods

We used TDF as the topic and searched the ISI Web of Science Core Collection, identifying 1382 relevant publications. We used analytical tools such as Excel, Tableau, VOSviewer, and Citespace to conduct a bibliometric analysis of the relevant publication.

Results

We identified the United Kingdom as the primary contributor, with University College London as the key institution. Susan Michie ranked highest in total citations. The analysis highlighted cancer and stroke as primary clinic medicine-related topics using TDF. Emerging themes encompass abuse, violence, maternal health, antenatal care, patient involvement, and trauma-informed care et al. "Nurse" and "qualitative research" emerged as recent and enduring hotspots, possibly indicating future research trends.

Conclusion

This article represents the first attempt to summarise the TDF using bibliometric analysis. We suggest this method can be used to analyse other theoretical frameworks in scientific implementation of its objectivity and quantifiability. Overall, the application scope of TDF is shifting from public health towards more specialised clinical directions, although its application in the field of public health is continuously expanding. In the future, the number of users of TDF is also expected to expand from implementation scientists to professional technical personnel.

Expert consensus on multilevel implementation hypotheses to promote the uptake of youth care guidelines: a Delphi study

BACKGROUND

The implementation of youth care guidelines remains a complex process. Several evidence-based frameworks aid the identification and specification of implementation determinants and strategies. However, the influence of specific strategies on certain determinants remains unclear. Therefore, we need to clarify which active ingredients of strategies, known as behaviour change techniques (BCTs), elicit behaviour change and improve implementation outcomes. With this knowledge, we are able to formulate evidence-based implementation hypotheses. An implementation hypothesis details how determinants and in turn, implementation outcomes might be influenced by specific implementation strategies and their BCTs. We aimed to identify (1) determinants relevant to the implementation of youth care guidelines and (2) feasible and potentially effective implementation hypotheses.

METHODS

A four-round online modified Delphi study was conducted. In the first round, experts rated the implementation determinants based on their relevance. Next, experts formulated implementation hypotheses by connecting BCTs and implementation strategies to determinants and were asked to provide a rationale for their choices. In round three, the experts reconsidered and finalised their hypotheses based on an anonymous overview of all formulated hypotheses, including rationales. Finally, the experts rated the implementation hypotheses based on their potential effectiveness and feasibility.

RESULTS

Fourteen experts completed the first, second, and third rounds, with 11 completed the final round. Guideline promotion, mandatory education, presence of an implementation leader, poor management support, knowledge regarding guideline use, and a lack of communication skills were reported as most relevant determinants. In total, 46 hypotheses were formulated, ranging from 6 to 9 per determinant. For each determinant, we provide an overview of the implementation hypotheses that were most commonly deemed feasible and potentially effective.

CONCLUSION

This study offers valuable insights into youth care guideline implementation by systematically identifying relevant determinants and formulating hypotheses based on expert input. Determinants related to engagement and to knowledge and skills were found to be relevant to youth care guideline implementation. This study offers a set of hypotheses that could help organisations, policymakers, and professionals guide the implementation process of youth care guidelines to ultimately improve implementation outcomes. The effectiveness of these hypotheses in practice remains to be assessed.

Development of an implementation strategy for routine collection of generic patient reported outcome measures: a qualitative study in multidisciplinary community rehabilitation

PURPOSE

To explore staff perceptions of barriers and enablers towards implementing the EQ-5D-5L in community rehabilitation, and develop a theory-informed implementation approach for routine administration of generic patient-reported outcome measures (PROMs) using implementation science frameworks.

MATERIALS AND METHODS

A qualitative study was conducted at three sites. Multidisciplinary rehabilitation staff completed individual semi-structured interviews, which were transcribed and coded against the Theoretical Domains Framework (TDF). We identified and selected potentially effective behaviour change techniques using the Behavior Change Wheel. Hypothetical strategies were operationalised.

RESULTS

Twenty-one interviews were conducted, and four themes emerged: (1) The Impact of PROMs on patient centered-care; (2) Considerations for validity of PROMs; (3) Service-level impact of embedding PROMs; (4) Practical issues of embedding PROMs within the service. Barriers and enablers were mapped to seven of the TDF domains; relating most to clinicians' "belief about consequences", "reinforcement", and "environmental context and resources". Five hypothetical strategies were developed to overcome identified barriers and strengthen enablers. Key behaviour change techniques underpinning the strategies include: restructuring the physical environment, incentivisation, persuasion and education, enablement, and, social support.

CONCLUSIONS

Our implementation approach highlights the importance of automating processes, engaging site champions, routinely reporting, and using PROM data to inform service provision.

Development of a Behavior-Change Intervention toward Benzodiazepine Deprescribing in Older Adults Living in Nursing Homes

OBJECTIVE

We aimed to develop a context-specific intervention toward benzodiazepine deprescribing in nursing homes (NHs), with insights from behavior-change theories and involvement of stakeholders.

DESIGN

Selection of behavior change techniques (BCTs), through online survey and group discussion, followed by operationalization of these BCTs into intervention components.

SETTING AND PARTICIPANTS

The intervention was developed for Belgian NHs, involving various stakeholders: health care professionals (HCPs), NH administrators, and policy makers.

METHODS

Using the Theory and Techniques Tool, we preselected the BCTs linked to one of the 9 Theoretical Domain Framework domains identified as being the main barriers for benzodiazepine deprescribing in Belgian NHs. These were then presented to stakeholders. Based on the APEASE (Acceptability, Practicability, Effectiveness, Affordability, Side-effects, and Ethics) criteria, participants ranked BCTs through an online survey, and then performed final selection during a group discussion. Selected BCTs were operationalized into intervention components, with specific contents and methods of delivery validated by stakeholders.

RESULTS

Thirty-seven potential BCTs were identified. Eighteen stakeholders participated in the survey, and 7 in the group discussion. This led to the final inclusion of 9 BCTs: instruction on how to perform the behavior, information about health consequences, pros and cons, problem solving, goal setting (behavior), social comparison, restructuring physical environment, restructuring social environment, and graded tasks. These BCTs were operationalized into a 6-component intervention: process and goal setting, HCP education, physical environment adaptations, audit and feedback, NH residents' and relatives' increased awareness, and multidisciplinary work.

CONCLUSION AND IMPLICATIONS

Use of a theory-based approach toward intervention development has the potential to improve the probability of its feasibility and effectiveness in tackling barriers to benzodiazepine deprescribing. By doing so, we have developed a multifaceted approach with actions taken at the patient, HCP, and NH levels. Our novel 6-component intervention will be evaluated in a pilot cluster-randomized controlled trial to assess its feasibility.

Digital screening for mental health in pregnancy and postpartum: A systematic review

PURPOSE

This systematic review aimed to determine if digital screening for mental health in pregnancy and postpartum is acceptable, feasible and more effective than standard care (paper-and pen-based screening or no screening). The second aim was to identify barriers and enablers to implementing digital screening in pregnancy and postpartum.

METHOD

OVID MEDLINE, PsycINFO, SCOPUS, CINAHL, Embase, Web of Science, Joanna Briggs Database and All EMB reviews incorporating Cochrane Database of Systematic Reviews (OVID) were systematically searched for articles that evaluated digital screening for mental health in pregnancy and postpartum between 2000 and 2021. Qualitative articles were deductively mapped to the Theoretical Domains Framework (TDF).

RESULTS

A total of 34 articles were included in the analysis, including qualitative, quantitative and mixed-methods studies. Digital screening was deemed acceptable, feasible and effective. TDF domains for common barriers included environmental context and resources, skills, social/professional role and identity and beliefs about consequences. TDF domains for common enablers included knowledge, social influences, emotion and behavioural regulation.

CONCLUSION

When planning to implement digital screening, consideration should be made to have adequate training, education and manageable workload for healthcare professionals (HCP's). Organisational resources and support are important, as well as the choice of the appropriate digital screening assessment and application setting for women. Theory-informed recommendations are provided for both healthcare professionals and women to inform future clinical practice.

Understanding barriers and facilitators to integrated HIV and hypertension care in South Africa

BACKGROUND

The burden of hypertension among people with HIV is high, particularly in low-and middle-income countries, yet gaps in hypertension screening and care in these settings persist. This study aimed to identify facilitators of and barriers to hypertension screening, treatment, and management among people with HIV in primary care clinics in Johannesburg, South Africa. Additionally, different stakeholder groups were included to identify discordant perceptions.

METHODS

Using a cross-sectional study design, data were collected via interviews (n = 53) with people with HIV and hypertension and clinic managers and focus group discussions (n = 9) with clinic staff. A qualitative framework analysis approach guided by COM-B and the Theoretical Domains Framework were used to identify and compare determinants of hypertension care across stakeholder groups.

RESULTS

Data from clinic staff and managers generated three themes characterizing facilitators of and barriers to the adoption and implementation of hypertension screening and treatment: 1) clinics have limited structural and operational capacity to support the implementation of integrated care models, 2) education and training on chronic care guidelines is inconsistent and often lacking across clinics, and 3) clinicians have the goal of enhancing chronic care within their clinics but first need to advocate for health system characteristics that will sustainably support integrated care. Patient data generated three themes characterizing existing facilitators of and barriers to clinic attendance and chronic disease self-management: 1) the threat of hypertension-related morbidity and mortality as a motivator for lifestyle change, 2) the emotional toll of clinic's logistical, staff, and resource challenges, and 3) hypertension self-management as a patchwork of informational and support sources. The main barriers to hypertension screening, treatment, and management were related to environmental resources and context (i.e., lack of enabling resources and siloed flow of clinic operations) and patients' knowledge and emotions (i.e., lack of awareness about hypertension risk, fear, and frustration). Clinical actors and patients differed in perceived need to prioritize HIV versus hypertension care.

CONCLUSIONS

The convergence of multi-stakeholder data highlight key areas for improvement, where tailored implementation strategies targeting motivations of clinic staff and capacity of patients may address challenges to hypertension screening, treatment, and management recognized across groups.

Telemedicine in primary care of older adults: a qualitative study

BACKGROUND

The COVID-19 pandemic changed the healthcare system, leading to the rapid evolution and implementation of telemedicine (TM). TM has the potential to improve the quality of primary health care and increase accessibility for the population. However, its use may represent challenges for older people, as they may have distinct needs from the general population due to age-related changes in perceptual, motor, and cognitive capacities. We, thus, aimed to identify potential facilitators and barriers to TM use in primary care for older adults and develop recommendations accordingly.

METHODS

We conducted a qualitative study to explore the challenges associated with TM use among older adults and healthcare professionals (HCPs) in primary care practice. Interviews were conducted with 29 older adults, and three focus groups involving HCPs from four McGill family medicine sites were organized. Employing a hybrid codebook thematic analysis, guided by the Consolidated Framework for Implementation Research (CFIR), we identified facilitators and barriers affecting the optimal use of TM by older adults and HCPs. We synthesized the results from semi-structured interviews and focus groups. These findings were then presented during a deliberative dialogue with eight participants, including family physicians, nurses, a social worker, and a government-level TM expert, to validate our results. The purpose was to gather feedback, identify and refine actionable recommendations. Subsequently, we utilized a thematic analysis using the same codebook to synthesize findings from the deliberative dialogue.

RESULTS

Participants agreed that TM contributed to maintaining the continuity of care and was particularly convenient when there was an existing or established patient-physician relationship or for addressing minor health issues. TM was found to be beneficial for people with limited mobility, reducing their exposure to potentially high-risk environments. However, participants expressed concerns about the lack of visual contact, causing essential details to be overlooked. Additionally, issues related to miscommunication due to language or hearing barriers were identified. HCPs perceived that most older adults did not consider phone consultations a medical act. Participants were open to a hybrid approach, combining in-person consultations and TM, based on their specific health conditions. Building upon these results, we formulated seven key recommendations.

CONCLUSIONS

Both older adults and HCPs consider TM a good alternative for accessing healthcare services. To improve the effective use of TM, it's crucial to advocate for a hybrid approach that integrates both in-person and virtual methods. This approach should actively encourage and support individuals in becoming familiar with technological tools.

Falling short in bariatric surgery: An exploration of key barriers and motivators of attrition

BACKGROUND

In the United States, obesity-related diseases pose significant healthcare challenges, with bariatric surgery offering a potential solution. However, bariatric surgery completion rates, particularly among Black and Hispanic populations, remain low.

OBJECTIVE

This study applied the Theoretical Domains Framework (TDF) to explore behavioral factors influencing bariatric surgery program attrition among a majority Black participant population to inform interventions for improving attrition.

METHODS

We conducted semi-structured interviews with 40 surgical and non-surgical participants and conducted deductive content analysis informed by six TDF constructs to explore factors influencing bariatric surgery program attrition.

RESULTS

Participants' decision-making regarding bariatric surgery is influenced by behavioral factors, including knowledge, skills, social roles, beliefs about capabilities, optimism, and beliefs about consequences.

CONCLUSION

Understanding multifaceted factors influencing bariatric surgery attrition will inform the development of tailored interventions that address knowledge gaps, enhance skills, and consider social role conflicts to improve patient engagement and decision-making in managing obesity, especially for Black populations.

Exploring barriers and facilitators to the adoption of regular exercise practice in patients at risk of a recurrence of low back pain (MyBack project): a qualitative study

PURPOSE

This study aimed to explore potential barriers and facilitators to the adoption of regular exercise practice in patients at risk of a recurrence of low back pain (LBP).

MATERIALS AND METHODS

Eleven patients, who recovered from a previous episode of LBP, participated in two focus groups. The semi-structured interview schedule was informed by the Behaviour Change Wheel and the Theoretical Domains Framework. Focus groups were held through videoconference, audio and video recorded and transcribed verbatim. A deductive content analysis was performed by two researchers independently.

RESULTS

Eighteen barriers and 19 facilitators were identified. The most common barriers included "lack of knowledge on how to manage a recurrence of LBP," "lack of behavioural regulation strategies and having other priorities" and "lack of self-efficacy/confidence to practice exercise autonomously and deal with a new episode of LBP." "Knowledge on exercise and recurrences," "regular exercise habits," "having specific behavioural regulation strategies," "exercise practice with others," "willingness to practice exercise and considering it a priority," and "presence of positive emotions related with exercise practice" were the most common facilitators.

CONCLUSIONS

These findings will inform the development of a behaviour change-informed exercise intervention to promote regular exercise practice among patients at risk of a recurrence of LBP.

Optimizing implementation: elucidating the role of behavior change techniques and corresponding strategies on determinants and implementation performance: a cross-sectional study

INTRODUCTION

Behavior change techniques (BCTs) are considered as active components of implementation strategies, influencing determinants and, ultimately, implementation performance. In our previous Delphi study, experts formulated 'implementation hypotheses', detailing how specific combinations of BCTs and strategies (referred to as BCT-strategy combinations) might influence determinants and guideline implementation within youth care. For example, educational meetings providing instructions on guideline use were hypothesized to enhance practitioners' knowledge and, consequently, guideline implementation. However, these hypotheses have not been verified in practice yet.

METHOD

We conducted a cross-sectional study involving practitioners and management professionals from youth (health)care organizations. Using questionnaires, we obtained data on the presence of BCT-strategy combinations and their perceived influence on determinants and implementation performance. Chi-squared tests and regression analyses were employed to determine the influence of specific BCT-strategy combinations on determinants and implementation performance.

RESULTS

Our analyses included data from 104 practitioners and 34 management professionals. Most of the management professionals indicated that the BCT-strategy combinations positively influenced or had the potential to influence their implementation performance. At the practitioner level, half of the combinations were perceived to have a positive influence on determinants and implementation performance. Furthermore, practitioners who reported the absence of BCT-strategy combinations were more skeptical about their potential influence on determinants and implementation performance.

CONCLUSION

Several BCT-strategy combinations were perceived to improve or potentially improve implementation performance of both practitioners and management professionals. In the development and evaluation of implementation efforts, we advocate for clearly describing the implementation effort's objective and using frameworks that detail the BCTs inducing behavior change, the strategy employed, and the processes driving the observed changes. Understanding these interconnected processes is important in designing targeted, evidence-based behavior change interventions. This understanding optimizes resource allocation and contributes to the overall success of implementation efforts in youth care.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Investigating the acceptability of modified constraint-induced movement therapy among stroke survivors and carers: a qualitative study

PURPOSE

To investigate the acceptability of modified constraint-induced movement therapy (mCIMT) among stroke survivors and carers within an early-supported discharge (ESD) service, and to inform further adaptations of the program to enhance acceptability.

METHODS

Qualitative study within a mixed methods process evaluation of mCIMT implementation. Semi-structured interviews were analysed using reflexive thematic analysis and mapped to the Capability, Opportunity, Motivation- Behaviour (COM-B) model.

RESULTS

Fifteen stroke survivors and ten carers participated. Five themes were generated and mapped to the COM-B. Participants attributed functional improvements to the program whilst also encountering several challenges with returning home after stroke (Capability- physical); the importance of education (Capability- psychological); the benefits afforded by the structured nature of the program (Opportunity- physical); the challenges for carers to support mCIMT programs whilst navigating new relationship roles (Opportunity- social); the desire to improve (Motivation- automatic); and the influence each of the mCIMT program's components had in facilitating long term upper limb use (Motivation- reflective).

CONCLUSION

mCIMT was an acceptable intervention for stroke survivors and carers within the ESD service, offering considerable benefits compared to other therapies. The findings suggest that multifaceted education strategies could increase stroke survivor preparedness. Extending the mCIMT program duration may maximise functional improvements.

Enablers and barriers to implementing an interdisciplinary experiential learning program for university students in a Canadian rehabilitation centre

Objective

This qualitative study aims to identify a comprehensive set of enablers and barriers to implementing an interdisciplinary experiential learning program for university students at a Canadian rehabilitation centre.

Methods

A researcher conducted one-on-one semi-structured interviews with individuals from four key stakeholder groups (i.e., rehabilitation centre leadership, clinicians, university clinical coordinators, and health and rehabilitation students). Interviews and data analysis followed the Theoretical Domains Framework (TDF), which is designed to identify possible cognitive, affective, social, and environmental influences on program implementation. Interviews were transcribed verbatim, and two researchers coded data independently to identify the major themes of enablers and barriers to implementing an interdisciplinary experiential learning approach to rehabilitation care.

Results

From a total of 12 interviews, domains of the TDF were identified to represent overarching themes, which were (1) enablers (i.e., reinforcement, beliefs and consequences, optimism, professional identity, knowledge, and skills), (2) barriers (i.e., environment/resources and beliefs and capabilities), and (3) program development (i.e., goals and evaluation that was not previously a TDF domain). A list of recommendations for implementing an interdisciplinary experiential learning program was created that represented qualitative data from each stakeholder group.

Conclusion

This study provides insight into the potential enablers and barriers to developing an interdisciplinary experiential learning program for university students within rehabilitation centres. This type of program could enhance educational curriculums, student and clinical experiences, and patient outcomes. In this study, the findings inform recommendations for developing an interdisciplinary program in teaching hospitals and explore their potential impact. Future research and pilot studies must be conducted to fully understand the effects of implementing an interdisciplinary experiential learning approach within rehabilitation centres.

Barriers and Facilitators to Participation in Vigorous Lifestyle Physical Activity in Adults Aged 55-75 Years: A Scoping Review

Despite the well-known benefits of physical activity, less than half of adults aged 55-75 years participate in sufficient physical activity. Short bouts of vigorous intermittent lifestyle physical activity (VILPA) accumulated throughout the day can contribute toward the recommended volume of physical activity. A rich characterization of the barriers and facilitators to participation in VILPA is needed to develop targeted interventions. This scoping review aimed to identify barriers and facilitators to participation in different components of VILPA in adults aged 55-75 years, and to map barriers and facilitators to the Theoretical Domains Framework. Within the 18 eligible studies, the most prevalent barriers were related to a person's skills, environmental context, and social influences. Most facilitators were related to a person's goals, social influences, and environmental context. Interventions to promote VILPA should test the effectiveness of behavioral change measures related to the unique barriers and facilitators in this age group.

Effectiveness of early diagnosis of cerebral palsy guideline implementation: a systematic review

INTRODUCTION

Tailored implementation interventions are required to overcome the diagnostic research-practice gap for cerebral palsy (CP). Evaluating the impact of interventions on patient outcomes is a priority. This review aimed to summarize the established evidence for the effectiveness of guideline implementations in lowering the age of CP diagnosis.

EVIDENCE ACQUISITION

A systematic review was conducted according to PRISMA. CINAHL, Embase, PubMed and MEDLINE were searched (2017-October 2022). Inclusion criteria were studies that evaluated effect of CP guideline interventions on health professional behaviour or patient outcomes. GRADE was used to determine quality. Studies were coded for use of theory (Theory Coding Scheme). Meta-analysis was performed and a standardized metric used to summarize statistics of intervention effect estimates.

EVIDENCE SYNTHESIS

Of (N.=249) records screened, (N.=7) studies met inclusion, comprising interventions following infants less than 2 years of age with CP risk factors (N.=6280). Guideline feasibility in clinical practice was established through health professional adherence and patient satisfaction. Efficacy of patient outcome of CP diagnosis by 12 months of age was established in all studies. Weighted averages were: (1) high-risk of CP (N.=2) 4.2 months and (2) CP diagnosis (N.=5) at 11.6 months. Meta-analysis of (N.=2) studies found a large, pooled effect size Z = 3.00 (P=0.003) favoring implementation interventions lowering age of diagnosis by 7.50 months, however study heterogeneity was high. A paucity of theoretical frameworks were identified in this review.

CONCLUSIONS

Multifaceted interventions to implement the early diagnosis of CP guideline are effective in improving patient outcomes by lowering the age of CP diagnosis in high-risk infant follow-up clinics. Further targeted health professional interventions including low-risk infant populations are warranted.

Promoting planting in front gardens: a systematic approach to intervention development

Planting in front gardens is associated with a range of human and environmental health benefits. Effective interventions aimed at cultivating this practice are, however, hampered by the paucity of theory- and evidence-based behavioural research in this context. This study aims to systematically determine a set of behaviour change interventions likely to be effective at promoting planting in front gardens amongst UK householders. The Behaviour Change Wheel framework was applied. Behavioural systems mapping was used to identify community actors relevant to front gardening. Potential behavioural influences on householders' front gardening were identified using the Capability, Opportunity, Motivation, Behaviour model. Using peer-reviewed scientific findings as evidence, behavioural influences were systematically linked to potential intervention strategies, behaviour change techniques and real-world implementation options. Finally, intervention recommendations were refined through expert evaluations and local councillor and public stakeholder feedback, evaluating them against the Acceptability, Practicability, Effectiveness, Affordability, Side effects and Equity criteria in a UK implementation context. This study formulated 12 intervention recommendations, implementable at a community level, to promote front gardening. Stakeholder feedback revealed a preference for educational and supportive (social and practical) strategies (e.g., community gardening workshops, front gardening 'starter kits') over persuasive and motivational approaches (e.g., social marketing, motivational letters from the council to householders). Householders' front gardening behaviour is complex and influenced by the behaviour of many other community actors. It also needs to be understood as a step in a continuum of other behaviours (e.g., clearing land, gardening, waste disposal). This study demonstrates the application of behavioural science to an understudied implementation context, that is, front gardening promotion, drawing on a rigorous development process promoting a transparent approach to intervention design. Stakeholder consultation allowed relevance, feasibility and practical issues to be considered. These improve the likely effectiveness of interventions in practice. The next steps include evaluating the proposed interventions in practice.

Perspectives on low-value care and barriers to de-implementation among primary care physicians: a multinational survey

BACKGROUND

Healthcare costs are rising worldwide. At the same time, a considerable proportion of care does not benefit or may even be harmful to patients. We aimed to explore attitudes towards low-value care and identify the most important barriers to the de-implementation of low-value care use in primary care in high-income countries.

METHODS

Between May and June 2022, we email surveyed primary care physicians in six high-income countries (Austria, Finland, Greece, Italy, Japan, and Sweden). Physician respondents were eligible if they had worked in primary care during the previous 24 months. The survey included four sections with categorized questions on (1) background information, (2) familiarity with Choosing Wisely recommendations, (3) attitudes towards overdiagnosis and overtreatment, and (4) barriers to de-implementation, as well as a section with open-ended questions on interventions and possible facilitators for de-implementation. We used descriptive statistics to present the results.

RESULTS

Of the 16,935 primary care physicians, 1,731 answered (response rate 10.2%), 1,505 had worked in primary care practice in the last 24 months and were included in the analysis. Of the respondents, 53% had read Choosing Wisely recommendations. Of the respondents, 52% perceived overdiagnosis and 50% overtreatment as at least a problem to some extent in their own practice. Corresponding figures were 85% and 81% when they were asked regarding their country's healthcare. Respondents considered patient expectations (85% answered either moderate or major importance), patient's requests for treatments and tests (83%), fear of medical error (81%), workload/lack of time (81%), and fear of underdiagnosis or undertreatment (79%) as the most important barriers for de-implementation. Attitudes and perceptions of barriers differed significantly between countries.

CONCLUSIONS

More than 80% of primary care physicians consider overtreatment and overdiagnosis as a problem in their country's healthcare but fewer (around 50%) in their own practice. Lack of time, fear of error, and patient pressures are common barriers to de-implementation in high-income countries and should be acknowledged when planning future healthcare. Due to the wide variety of barriers to de-implementation and differences in their importance in different contexts, understanding local barriers is crucial when planning de-implementation strategies.

Perceptions and behaviors of healthcare providers towards rehabilitation support to children with severe malaria-related disability in Ethiopia: A qualitative descriptive study using the Theoretical Domains Framework

INTRODUCTION

Severe malaria often results in childhood disability. The prevalence of disability related to severe malaria is significant and is estimated to affect up to 53% of severe malaria survivors. In contrast, information is sparse about how healthcare providers in Africa think about or provide rehabilitation support in acute and post-acute phases respectively. Understanding the perceptions and behaviors of healthcare providers treating malaria could help inform malaria-related disability research, policy, and practice, aimed at the providers themselves. This study explored the perceptions and behaviors of healthcare providers towards rehabilitation for children with severe malaria-related disability. The Theoretical Domains Framework was used to describe the findings relative to wider literature on health provider behavior change.

METHODS

A qualitative descriptive approach was used to interview thirteen healthcare providers recruited purposively based on their clinical professions, roles, and settings. Data were analyzed using directed content analysis. We decided on the most prominent theoretical domains considering the frequency of specific perceptions and behaviors across the participants, the frequency of perceptions and behaviors in each domain, and evidence of strong perceptions and behaviors.

RESULTS

Nine out of fourteen theoretical domains were identified. These domains were: Beliefs about consequences, environmental context and resources, goals, knowledge, skills, optimism, reinforcement, social influences, and social or professional role and identity. Healthcare providers' beliefs about their roles in screening for disability or referring to rehabilitation were less positive.

CONCLUSIONS

The findings of this study suggest the need for interventions to support healthcare providers in acute phases (prevention and control of severe malaria) and post-acute phases (disability screening, referral, and rehabilitation care). Recommended interventions should focus on developing clinical guidelines, training clinicians, addressing institutional factors, and modifying external social influences such as socio-cultural factors.

Optimizing Teamwork in the Operating Room: A Scoping Review of Actionable Teamwork Strategies

Suboptimal teamwork in the operating room (OR) is a contributing factor in a significant proportion of preventable complications for surgical patients. Specifying behaviour is fundamental to closing evidence-practice gaps in healthcare. Current teamwork interventions, however, have yet to be synthesized in this way. This scoping review aimed to identify actionable strategies for use during surgery by mapping the existing literature according to the Action, Actor, Context, Target, Time (AACTT) framework. The databases MEDLINE (Medical Literature Analysis and Retrieval System Online), Embase, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Education Resources Information Center (ERIC), Cochrane, Scopus, and PsycINFO were searched from inception to April 5, 2022. Screening and data extraction were conducted in duplicate by pairs of independent reviewers. The search identified 9,289 references after the removal of duplicates. Across 249 studies deemed eligible for inclusion, eight types of teamwork interventions could be mapped according to the AACTT framework: bundle/checklists, protocols, audit and feedback, clinical practice guidelines, environmental change, cognitive aid, education, and other), yet many were ambiguous regarding the actors and actions involved. The 101 included protocol interventions appeared to be among the most actionable for the OR based on the clear specification of ACCTT elements, and their effectiveness should be evaluated and compared in future work.

Feasible Peer-Mediated Intervention for Autistic Children Using Minimal Speech: A Qualitative Intervention Development Process

PURPOSE

Qualitative engagement with stakeholders in the development of interventions can provide insight into strategies to maximize feasibility in real-life settings. We engaged stakeholders (autistic adults, early childhood educators, early childhood sector leaders and policy influencers, parents of autistic children, and speech-language pathologists) to inform the development of an educator-led peer-mediated intervention (PMI) for autistic preschoolers who use minimal speech that is feasible to implement in inclusive early childhood education and care (ECEC) settings.

METHOD

A qualitative iterative intervention design process was utilized. Stakeholders (N = 15) attended an online workshop and completed a document review exploring the acceptability and feasibility of the proposed embedded PMI. A two-step analysis procedure using the Theoretical Domains Framework and template analysis was conducted to identify the barriers, enablers, and supports to the implementation of embedded PMI in early childhood settings.

RESULTS

While embedded PMI was unanimously acceptable to stakeholders, several participants expressed concerns regarding feasibility. Barriers to the successful integration and implementation of PMI in inclusive preschool contexts included access to skills, knowledge, and resources. Participants identified strategies to overcome modifiable barriers and to enhance the existing enablers. These strategies are reflected in the following themes: build on the familiar, build capacity in augmentative and alternative communication, adopt a whole center approach, adapt to meet the needs of the ECEC setting, and engage in proactive implementation.

CONCLUSION

To address barriers to the implementation of embedded PMI, action is needed at various levels: macro (national/policy), meso (organization/setting), and micro (individual).

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.25155770.

Multicomponent processes to identify and prioritise low-value care in hospital settings: a scoping review

OBJECTIVES

This scoping review mapped and synthesised original research that identified low-value care in hospital settings as part of multicomponent processes.

DESIGN

Scoping review.

DATA SOURCES

Electronic databases (EMBASE, PubMed, CINAHL, PsycINFO and Cochrane CENTRAL) and grey literature were last searched 11 July and 3 June 2022, respectively, with no language or date restrictions.

ELIGIBILITY CRITERIA

We included original research targeting the identification and prioritisation of low-value care as part of a multicomponent process in hospital settings.

DATA EXTRACTION AND SYNTHESIS

Screening was conducted in duplicate. Data were extracted by one of six authors and checked by another author. A framework synthesis was conducted using seven areas of focus for the review and an overuse framework.

RESULTS

Twenty-seven records were included (21 original studies, 4 abstracts and 2 reviews), originating from high-income countries. Benefit or value (11 records), risk or harm (10 records) were common concepts referred to in records that explicitly defined low-value care (25 records). Evidence of contextualisation including barriers and enablers of low-value care identification processes were identified (25 records). Common components of these processes included initial consensus, consultation, ranking exercise or list development (16 records), and reviews of evidence (16 records). Two records involved engagement of patients and three evaluated the outcomes of multicomponent processes. Five records referenced a theory, model or framework.

CONCLUSIONS

Gaps identified included applying systematic efforts to contextualise the identification of low-value care, involving people with lived experience of hospital care and initiatives in resource poor contexts. Insights were obtained regarding the theories, models and frameworks used to guide initiatives and ways in which the concept 'low-value care' had been used and reported. A priority for further research is evaluating the effect of initiatives that identify low-value care using contextualisation as part of multicomponent processes.

Effect of implementation strategies on the routine provision of antenatal care addressing smoking in pregnancy: study protocol for a non-randomised stepped-wedge cluster controlled trial

INTRODUCTION

Globally, guideline-recommended antenatal care for smoking cessation is not routinely delivered by antenatal care providers. Implementation strategies have been shown to improve the delivery of clinical practices across a variety of clinical services but there is an absence of evidence in applying such strategies to support improvements to antenatal care for smoking cessation in pregnancy. This study aims to determine the effectiveness and cost effectiveness of implementation strategies in increasing the routine provision of recommended antenatal care for smoking cessation in public maternity services.

METHODS AND ANALYSIS

A non-randomised stepped-wedge cluster-controlled trial will be conducted in maternity services across three health sectors in New South Wales, Australia. Implementation strategies including guidelines and procedures, reminders and prompts, leadership support, champions, training and monitoring and feedback will be delivered sequentially to each sector over 4 months. Primary outcome measures will be the proportion of: (1) pregnant women who report receiving a carbon monoxide breath test; (2) smokers or recent quitters who report receiving quit/relapse advice; and (3) smokers who report offer of help to quit smoking (Quitline referral or nicotine replacement therapy). Outcomes will be measured via cross-sectional telephone surveys with a random sample of women who attend antenatal appointments each week. Economic analyses will be undertaken to assess the cost effectiveness of the implementation intervention. Process measures including acceptability, adoption, fidelity and reach will be reported.

ETHICS AND DISSEMINATION

Ethics approval was obtained through the Hunter New England Human Research Ethics Committee (16/11/16/4.07; 16/10/19/5.15) and the Aboriginal Health and Medical Research Council (1236/16). Trial findings will be disseminated to health policy-makers and health services to inform best practice processes for effective guideline implementation. Findings will also be disseminated at scientific conferences and in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry-ACTRN12622001010785.

"I'm Torn": Qualitative Analysis of Dental Practitioner-Perceived Barriers, Facilitators, and Solutions to HPV Vaccine Promotion

The human papillomavirus (HPV) vaccine can prevent HPV-related oropharyngeal cancers. Dental practitioners are uniquely positioned to promote HPV vaccines during routine dental care but experience barriers to doing so. Qualitative interviews were conducted with dental practitioners to understand barriers and inform intervention strategies to promote HPV vaccines. Dental practitioners were invited to participate in phone interviews about knowledge, self-efficacy, and the fear of negative consequences related to HPV vaccine promotion as well as feedback on potential interventions to address these barriers. Interviews were audio recorded, transcribed, and analyzed using rapid qualitative analysis with a sort-and-sift matrix approach. Interviews were completed with 11 practitioners from six dental clinics (avg. 31 min). Though most thought HPV vaccination was important, they lacked detailed knowledge about when and to whom the vaccine should be recommended. This led to a hypothesized need for discussions of sexual history, feelings of limited self-efficacy to make the recommendation, and fear of patient concerns. Still, practitioners were supportive of additional training opportunities and provided input into specific interventions. The nuance of how these barriers were described by practitioners, as well as the possible solutions they identified, will help shape future interventions supporting HPV vaccine promotion in dental care.

Breaking Boundaries in Pneumonia Diagnostics: Transitioning from Tradition to Molecular Frontiers with Multiplex PCR

The advent of rapid molecular microbiology testing has revolutionized infectious disease diagnostics and is now impacting pneumonia diagnosis and management. Molecular platforms offer highly multiplexed assays for diverse viral and bacterial detection, alongside antimicrobial resistance markers, providing the potential to significantly shape patient care. Despite the superiority in sensitivity and speed, debates continue regarding the clinical role of multiplex molecular testing, notably in comparison to standard methods and distinguishing colonization from infection. Recent guidelines endorse molecular pneumonia panels for enhanced sensitivity and rapidity, but implementation requires addressing methodological differences and ensuring clinical relevance. Diagnostic stewardship should be leveraged to optimize pneumonia testing, emphasizing pre- and post-analytical strategies. Collaboration between clinical microbiologists and bedside providers is essential in developing implementation strategies to maximize the clinical utility of multiplex molecular diagnostics in pneumonia. This narrative review explores these multifaceted issues, examining the current evidence on the clinical performance of multiplex molecular assays in pneumonia, and reflects on lessons learned from previous microbiological advances. Additionally, given the complexity of pneumonia and the sensitivity of molecular diagnostics, diagnostic stewardship is discussed within the context of current literature, including implementation strategies that consider pre-analytical and post-analytical modifications to optimize the clinical utility of advanced technologies like multiplex PCR.

Dutch GPs' perspectives on addressing obesity: a qualitative study

BACKGROUND

Early diagnosis and treatment of obesity in primary care may help to tackle the obesity pandemic. Nonetheless, GPs frequently fail to address obesity and demonstrate limited adherence to guidelines.

AIM

To explore Dutch GPs' perspectives on addressing obesity regarding the following three target behaviours: discussing weight; diagnosing; and referring patients with obesity.

DESIGN & SETTING

A qualitative focus group study with Dutch GPs.

METHOD

Six focus groups were conducted with a purposive sample of 21 GPs. Thematic analysis was performed using deductive coding, according to the Theoretical Domains Framework (TDF).

RESULTS

For discussing weight, the main barriers identified were a presented complaint unrelated to obesity (environmental context and resources), concerns about a negative response from the patient (beliefs about consequences), and worries about obesity being a sensitive subject to discuss (emotions). A long-term trustworthy relationship (social influences) facilitated discussing weight. For diagnosing patients with obesity, the main barriers were related to resources; for example, lack of (appropriate) measuring equipment and time (environmental context and resources). For referring patients with obesity, the main barriers were no referral options nearby (environmental context and resources), and doubts about the positive effects of the referral on weight change (beliefs about consequences).

CONCLUSION

Different barriers for discussing weight, diagnosing, and referring patients with obesity were identified, underscoring the importance for tailored interventions to these specific behaviours. Improving knowledge and skills of GPs seems insufficient as this study showed that particular attention should be paid to establishing long-term relationships, addressing GPs' beliefs about consequences, and creating a supportive environment with sufficient time and resources.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023421845.

Development of food literacy in children and adolescents: implications for the design of strategies to promote healthier and more sustainable diets

Food literacy has emerged as a key individual trait to promote the transformation of food systems toward healthy and sustainable diets. Childhood and adolescence are key periods for establishing the foundations of eating habits. Different food literacy competencies are acquired as children develop different cognitive abilities, skills, and experiences, contributing to the development of critical tools that allow them to navigate a complex food system. Thus, the design and implementation of programs to support the development of food literacy from early childhood can contribute to healthier and more sustainable eating habits. In this context, the aim of the present narrative review is to provide an in-depth description of how different food literacy competencies are developed in childhood and adolescence, integrating the extensive body of evidence on cognitive, social, and food-related development. Implications for the development of multisectoral strategies to target the multidimensional nature of food literacy and promote the development of the 3 types of competencies (relational, functional, and critical) are discussed.

Increasing venous thromboembolism risk assessment through a whole hospital-based intervention: a pre-post service evaluation to demonstrate quality improvement

Venous thromboembolism (VTE) is a primary cause of morbidity and mortality in hospitalized patients. VTE risk assessment is a crucial part of the VTE prevention guideline. However, VTE risk assessment was not consistently undertaken for admitted patients. The aim of this study was to identify whether a quality improvement project implemented to change documentation of VTE risk assessment for hospitalized patients impacted patient safety by decreasing the rate of VTE incidences. The study was set in a 600+ bed acute hospital that provides medical and surgical services for adult patients during the period October 2018-September 2020. The hospital adopted the American College of Chest Physicians (ACCP) 9th edition VTE prevention guidelines and followed the Modified Caprini risk assessment tool. Following the FOCUS-Plan-Do-Check-Act (FOCUS PDCA) improvement methodology, the improvement team implemented multicomponent interventions over a 3-month period, including conducting educational sessions, sharing VTE documentation compliance results, giving reminders during rounds, assigning a VTE liaison physician within each clinical specialty, and updating and communicating the hospital adopted VTE guidelines. A total of 17 612 patients were included, respectively, 8971 in pre-intervention and 8641 post-intervention period. Documentation of VTE risk assessment upon admission increased significantly in the post quality improvement intervention period (60% vs. 42%, relative increase of 30%, χ2 = 1.43, P < 0.001). The run chart trend analysis demonstrated significant improvement shift and improvement trend after quality improvement project implementation, and it was sustained for 15 months. There was no impact on patient safety with a slight not statistically significant decrease in the VTE incidences rate post intervention period (0.4% vs. 0.5%, relative decrease of 1%, χ2 = 0.82, P < 0.397). The quality improvement project intervention significantly increased the percentage of patients assessed for VTE risk in a hospital setting.

"We have to change our mindsets": a qualitative study of barriers and facilitators in research collaboration across integrated care system organisations

The introduction of Integrated Care Systems (ICS) in England aimed to increase joint planning and delivery of health and social care, and other services, to better meet the needs of local communities. There is an associated duty to undertake collaborative research across ICS partners to inform this new integrated approach, which might be challenging given that organisations span health, local authority, voluntary and community sector, and research. This study aimed to explore the appetite for collaborative Research and Innovation (R&I) across ICSs, potential barriers and solutions. This qualitative study involved semi-structured interviews with 24 stakeholders who held senior positions within organisations across two ICS areas (Staffordshire and Stoke-on-Trent; Shropshire, Telford and Wrekin). Interview transcripts were analysed using inductive and deductive analysis, first mapping to the Theoretical Domains Framework (TDF), then considering key influences on organisational behaviour in terms of Capability, Opportunity and Motivation from the COM-B Behaviour Change Wheel. There were fundamental limitations on organisational opportunities for collaborative R&I: a historical culture of competition (rather than collaboration), a lack of research culture and prioritisation, compounded by a challenging adverse economic environment. However, organisations were motivated to undertake collaborative R&I. They recognised the potential benefits (e.g., skill-sharing, staff development, attracting large studies and funding), the need for collaborative research that mirrors integrated care, and subsequent benefits for care recipients. Related barriers included negative experiences of collaboration, fear of failing and low confidence. Capability varied across organisations in terms of research skills and confidence, which reflected the range of partners (from local authorities to NHS Trusts, primary care, and academic institutions). These findings indicate a need to shift from a culture of competition to collaboration, and to help organisations across ICS to prioritise research, and share resources and skills to mitigate the limiting effects of a constrained economic environment. This could be further explored using a systems change approach, to develop the collaborative research efforts alongside the overarching move towards integrated care.

Characteristics of patients who return unplanned to the ED, and factors that contribute to their decision to return: Integrated results from an explanatory sequential mixed methods inquiry

AIM

To identify common characteristics of patients who return to the ED unplanned and factors that may contribute to their decision to return.

BACKGROUND

Return visits to the Emergency Department (ED) have been associated with adverse events and deficits in initial care provided. There is increasing evidence to suggest that many return visits may be preventable.

METHODS

The results of primary quantitative measures (QUAN) followed by qualitative measures (qual) were integrated to build on and explain the quantitative data found in the initial phase of the research.

RESULTS

Integration of results produced three new findings. 1) Most return visits occurred beyond 48 hrs because patients intentionally delayed going back to the ED despite their persisting symptoms; 2) Clinical urgency and deterioration were rarely evident in patients who made return visits in patients and 3) Ineffective communication between the clinician and the patient at discharge may have contributed to patients making the decision to return to the ED.

CONCLUSION

The decision to return unplanned to the ED is not an immediate response for most patients, and several potentially avoidable factors may influence their decision-making process. Future research should focus on strategies which contribute to the avoidance of unplanned return visits.

The Gestational Obesity Weight Management: Implementation of National Guidelines (GLOWING) study: a pilot cluster randomised controlled trial

BACKGROUND

Pregnancy weight management interventions can improve maternal diet, physical activity, gestational weight gain, and postnatal weight retention. UK guidelines were published in 2010 but health professionals report multiple complex barriers to practice. GLOWING used social cognitive theory to address evidence-based barriers to midwives' implementation of weight management guidelines into routine practice. This paper reports the pilot trial outcomes relating to feasibility and acceptability of intervention delivery and trial procedures.

METHODS

GLOWING was a multi-centre parallel-group pilot cluster RCT comparing the delivery of a behaviour change intervention for midwives (delivered as training workshops) with usual practice. The clusters were four NHS Trusts in Northeast England, randomised to intervention or control arms. Blinding of allocation was not possible due to the nature of the intervention. We aimed to deliver the intervention to all eligible midwives in the intervention arm, in groups of 6 midwives per workshop, and to pilot questionnaire data collection for a future definitive trial. Intervention arm midwives' acceptability of GLOWING content and delivery was assessed using a mixed methods questionnaire, and pregnant women's acceptability of trial procedures by interviews. Quantitative data were analysed descriptively and qualitative data thematically.

RESULTS

In intervention arm Trusts, 100% of eligible midwives (n = 67) were recruited to, and received, the intervention; however, not all workshops had the planned number of attendees (range 3-8). The consent rate amongst midwives randomised (n = 100) to complete questionnaires was 74% (n = 74) (95% CI 65%, 83%), and overall completion rate 89% (n = 66) (95% CI 82%, 96%). Follow-up response rate was 66% (n = 49) (95% CI 55%, 77%), with a marked difference between intervention (39%, n = 15) and control (94%, n = 34) groups potentially due to the volume of research activities. Overall, 64% (n = 47) (95% CI 53%, 75%) completed both baseline and follow-up questionnaires. Midwives viewed the intervention as acceptable and directly relevant to routine practice. The least popular components related to scripted role-plays. Pregnant women viewed the recruitment and trial processes to be acceptable.

CONCLUSIONS

This rigorously conducted pilot study demonstrated feasibility intervention delivery and a high level of acceptability amongst participants. It has provided information required to refine the intervention and trial protocol, enhancing confidence that a definitive trial could be carried out.

TRIAL REGISTRATION

ISRCTN46869894; retrospectively registered 25th May 2016, www.isrctn.com/ISRCTN46869894 .

Health professionals' practices and perspectives of post-stroke coordinated discharge planning: a national survey

Background It is best practice for stroke services to coordinate discharge care plans with primary/community care providers to ensure continuity of care. This study aimed to describe health professionals' practices in stroke discharge planning within Australia and the factors influencing whether discharge planning is coordinated between hospital and primary/community care providers. Methods A mixed-methods survey informed by the Theoretical Domains Framework was distributed nationally to stroke health professionals regarding post-stroke discharge planning practices and factors influencing coordinated discharge planning (CDP). Data were analysed using descriptive statistics and content analysis. Results Data from 42 participants working in hospital-based services were analysed. Participants reported that post-stroke CDP did not consistently occur across care providers. Three themes relating to perceived CDP needs were identified: (1) a need to improve coordination between care providers, (2) service-specific management of the discharge process, and (3) addressing the needs of the stroke survivor and family . The main perceived barriers were the socio-political context and health professionals' beliefs about capabilities . The main perceived facilitators were health professionals' social/professional role and identity, knowledge, and intentions . The organisation domain was perceived as both a barrier and facilitator to CDP. Conclusion Australian health professionals working in hospital-based services believe that CDP promotes optimal outcomes for stroke survivors, but experience implementation challenges. Efforts made by organisations to ensure workplace culture and resources support the CDP process through policies and procedures may improve practice. Tailored implementation strategies need to be designed and tested to address identified barriers.

Management of Sleep-Disordered Breathing in a Spinal Cord Injury Rehabilitation Center: Model of Care Adaptation and Implementation

Background

Obstructive sleep apnea (OSA) is highly prevalent and poorly managed in spinal cord injury (SCI). Alternative management models are urgently needed to improve access to care. We previously described the unique models of three SCI rehabilitation centers that independently manage uncomplicated OSA.

Objectives

The primary objective was to adapt and implement a similar rehabilitation-led model of managing OSA in an SCI rehabilitation center in Australia. Secondary objectives were to identify the local barriers to implementation and develop and deliver tailored interventions to address them.

Methods

A clinical advisory group comprised of rehabilitation clinicians, external respiratory clinicians, and researchers adapted and developed the care model. A theory-informed needs analysis was performed to identify local barriers to implementation. Tailored behavior change interventions were developed to address the barriers and prepare the center for implementation.

Results

Pathways for ambulatory assessments and treatments were developed, which included referral for specialist respiratory management of complicated cases. Roles were allocated to the team of rehabilitation doctors, physiotherapists, and nurses. The team initially lacked sufficient knowledge, skills, and confidence to deliver the OSA care model. To address this, comprehensive education and training were provided. Diagnostic and treatment equipment were acquired. The OSA care model was implemented in July 2022.

Conclusion

This is the first time a rehabilitation-led model of managing OSA has been implemented in an SCI rehabilitation center in Australia. We describe a theory-informed method of adapting the model of care, assessing the barriers, and delivering interventions to overcome them. Results of the mixed-methods evaluation will be reported separately.

What influences the inclusion of skin tone diversity when teaching skin assessment? Findings from a survey

BACKGROUND

Understanding the variances in visual skin changes across all skin tones is important in clinical care. However, the experiences of those teaching skin assessment to pre- and post-registrant nurses are unknown.

AIMS

To determine the barriers and facilitators experienced in teaching skin assessment across a range of skin tones to pre- and post-registrant nurses.

METHODS

A cross-sectional, mixed-methods online survey was undertaken throughout February and March 2023 based on the Theoretical Domains Framework of behaviour change.

FINDINGS

In this self-selecting sample, most participants were aware of why it was important to include all skin tones when teaching skin assessment and were professionally motivated to include this in their practice. However, resources and support are needed to overcome an unconscious bias in teaching skin tone diversity, resulting in a lack of availability of good quality photographs and educator confidence in their own skills. Educators not considering skin tone when selecting patient cases and relying on people with dark skin tones to highlight where practice is not inclusive may also lead to insufficient exposure for students.

CONCLUSION

There is some awareness of the importance of including diverse skin tones in teaching, but further education and resources are needed.

Feasibility and acceptability of the smart pillbox and medication label with differentiated care to support person-centered tuberculosis care among ASCENT trial participants - A multicountry study

Introduction

Digital adherence technologies (DATs) can offer alternative approaches to support tuberculosis treatment medication adherence. Evidence on their feasibility and acceptability in high TB burden settings is limited. We conducted a cross-sectional survey among adults with drug-sensitive tuberculosis (DS-TB), participating in pragmatic cluster-randomized trials for the Adherence Support Coalition to End TB project in Ethiopia (PACTR202008776694999), the Philippines, South Africa and Tanzania (ISRCTN 17706019).

Methods

From each country we selected 10 health facilities implementing the DAT intervention (smart pillbox or medication labels, with differentiated care support), ensuring inclusion of urban/rural and public/private facilities. Adults on DS-TB regimen using a DAT were randomly selected from each facility. Feasibility of the DATs was assessed using a standardized tool. Acceptability was measured using a 5-point Likert-scale, using the Capability, Opportunity, Motivation, Behavior (COM-B) model. Mean scores of Likert-scale responses within each COM-B category were estimated, adjusted for facility-level clustering. Data were summarized by country and DAT type.

Results

Participants using either the pillbox (n = 210) or labels (n = 169) were surveyed. Among pillbox users, phone ownership (79%), use of pillbox reminders (87%) and taking treatment without the pillbox (22%) varied by country. Among label users, phone ownership (81%), paying extra to use the labels (8%) and taking treatment without using labels (41%) varied by country. Poor network, problems with phone charging and access, not having the pillbox and forgetting to send text were reasons for not using DATs. Overall, people with TB had a favorable impression of both DATs, with mean composite scores between 4·21 to 4·42 across COM-B categories. Some disclosure concerns were reported.

Conclusion

From client-perspective, pillboxes and medication labels with differentiated care support were feasible to implement and acceptable in variety of settings. However, implementation challenges related to network, phone access, stigma, additional costs to people with TB to use DATs need to be addressed.

Barriers and facilitators to giving prehabilitation advice by clinical nurse specialists and advanced nurse practitioners in oncology patients

PURPOSE

This is the second article in this series on the knowledge, attitudes and beliefs of clinical nurse specialists (CNSs) and ANPs (advanced nurse practitioners) regarding prehabilitation advice in oncology patients, exploring the barriers and facilitators to giving prehabilitation advice by CNSs and ANPs in oncology patients.

METHODS

A Cross-sectional online questionnaire opens for 3 months to establish the knowledge, attitudes and beliefs of ANPs and CNSs to prehabilitation disseminated through professional organisations and social media.

RESULTS

The questionnaire gained (n = 415) responses. Prehabilitation advice was routinely given by 89% (n = 371) of respondents. Many (60%) identified a lack of guidance and referral processes as a barrier to giving prehabilitation advice; this corresponded between respondents' confidence to give prehabilitation advice and subsequent referrals (< 0.001). Other factors included time (61%), a lack of patient interest (44%) and limited relevance to patients (35%).

CONCLUSION

The implementation of standardised nurse prehabilitation advice resources would enable CNSs and ANPs to provide personalised prehabilitation advice in their consultations.

Understanding Barriers and Facilitators to Integrated HIV and Hypertension Care in South Africa

Background The burden of hypertension among people with HIV is high, particularly in low-and middle-income countries, yet gaps in hypertension screening and care in these settings persist. The objective of this study was to identify facilitators of and barriers to hypertension screening, treatment, and management among people with HIV seeking treatment in primary care clinics in Johannesburg, South Africa. Methods Using a cross-sectional study design, data were collected via interviews (n = 53) with people with HIV and hypertension and clinic managers and focus group discussions (n = 9) with clinic staff. A qualitative framework analysis approach guided by the Theoretical Domains Framework was used to identify and compare determinants of hypertension care across different stakeholder groups. Results Data from clinic staff and managers generated three themes characterizing facilitators of and barriers to the adoption and implementation of hypertension screening and treatment: 1) clinics have limited structural and operational capacity to support the implementation of integrated care models, 2) education and training on chronic care guidelines is inconsistent and often lacking across clinics, and 3) clinicians have the goal of enhancing chronic care within their clinics but first need to advocate for health system characteristics that will sustainably support integrated care. Patient data generated three themes characterizing existing facilitators of and barriers to clinic attendance and chronic disease self-management: 1) the threat of hypertension-related morbidity and mortality as a motivator for lifestyle change, 2) the emotional toll of clinic's logistical, staff, and resource challenges, and 3) hypertension self-management as a patchwork of informational and support sources. The main barriers to hypertension screening, treatment, and management were related to environmental resources and context (i.e., lack of enabling resources and siloed flow of clinic operations) the patients' knowledge and emotions (i.e., lack of awareness about hypertension risk, fear, and frustration). Clinical actors and patients differed in perceived need to prioritize HIV versus hypertension care. Conclusions The convergence of multi-stakeholder data regarding barriers to hypertension screening, treatment, and management highlight key areas for improvement, where tailored implementation strategies may address challenges recognized by each stakeholder group.

Clinical and cost-effectiveness of DREAMS START (Dementia RElAted Manual for Sleep; STrAtegies for RelaTives) for people living with dementia and their carers: a study protocol for a parallel multicentre randomised controlled trial

INTRODUCTION

Many people living with dementia experience sleep disturbance and there are no known effective treatments. Non-pharmacological treatment options should be the first-line sleep management. For family carers, relatives' sleep disturbance leads to interruption of their sleep, low mood and breakdown of care. Our team developed and delivered DREAMS START (Dementia RElAted Manual for Sleep; STrAtegies for RelaTives), a multimodal non-pharmacological intervention, showing it to be feasible and acceptable. The aim of this randomised controlled trial is to establish whether DREAMS START is clinically cost-effective in reducing sleep disturbances in people living with dementia living at home compared with usual care.

METHODS AND ANALYSIS

We will recruit 370 participant dyads (people living with dementia and family carers) from memory services, community mental health teams and the Join Dementia Research Website in England. Those meeting inclusion criteria will be randomised (1:1) either to DREAMS START or to usual treatment. DREAMS START is a six-session (1 hour/session), manualised intervention delivered every 1-2 weeks by supervised, non-clinically trained graduates. Outcomes will be collected at baseline, 4 months and 8 months with the primary outcome being the Sleep Disorders Inventory score at 8 months. Secondary outcomes for the person with dementia (all proxy) include quality of life, daytime sleepiness, neuropsychiatric symptoms and cost-effectiveness. Secondary outcomes for the family carer include quality of life, sleep disturbance, mood, burden and service use and caring/work activity. Analyses will be intention-to-treat and we will conduct a process evaluation.

ETHICS AND DISSEMINATION

London-Camden & Kings Cross Ethics Committee (20/LO/0894) approved the study. We will disseminate our findings in high-impact peer-reviewed journals and at national and international conferences. This research has the potential to improve sleep and quality of life for people living with dementia and their carers, in a feasible and scalable intervention.

TRIAL REGISTRATION NUMBER

ISRCTN13072268.

Development of a co-created online self-management program for people with lower limb loss: self-management for amputee rehabilitation using technology (SMART)

PURPOSE

To develop an online self-management program for individuals with recent lower limb loss, called Self-Management for Amputee Rehabilitation using Technology (SMART).

MATERIALS AND METHODS

We used the Intervention Mapping Framework as a blueprint and involved stakeholders throughout the process. A six-step study was conducted including (1) needs assessment using interviews, (2) translating needs to content, (3) applying the content into a prototype using theory-based methods, (4) a usability assessment using think-aloud cognitive testing, (5) planning for future adoption and implementation, and (6) assessing feasibility using mixed-methods to generate a plan to assess the effectiveness on health-outcomes in a randomized controlled trial.

RESULTS

Following interviews with healthcare professionals (n = 31) and people with lower limb loss (n = 26), we determined the content of a prototype version. We then tested usability (n = 9) and feasibility (n = 12) by recruiting individuals with lower limb loss from different pools. We modified SMART to be assessed in a randomized controlled trial. SMART is a six-week online program with weekly contact of a peer mentor with lower limb loss who supported patients with goal-setting and action-planning.

CONCLUSIONS

Intervention mapping facilitated the systematic development of SMART. SMART may improve health outcomes, but this would need to be confirmed in future studies.Implications for rehabilitationLearning new coping strategies and habits are essential after lower limb loss.Given the limitations and inaccessibility of educational and rehabilitation programs, online self-management education can assist patients in their recovery.Self-Management for Amputee Rehabilitation using Technology (SMART) has the potential to augment the self-management behaviors in individuals with lower limb loss through an improvement in access to educational content, skill-based videos, and support of a peer.

Achieving Benchmarks for National Quality Indicators Reduces Recurrence and Progression in Non-muscle-invasive Bladder Cancer

BACKGROUND

Noncompliance with evidence-based interventions and guidelines contributes to significant and variable recurrence and progression in patients with non-muscle-invasive bladder cancer (NMIBC). The implementation of a quality performance indicator (QPI) programme in Scotland's National Health Service (NHS) aimed to improve cancer outcomes and reduce nationwide variance.

OBJECTIVE

To evaluate the effect of hospitals achieving benchmarks for two specific QPIs on time to recurrence and progression in NMIBC.

DESIGN, SETTING, AND PARTICIPANTS

QPIs for bladder cancer (BC) were enforced nationally in April 2014. NHS health boards collected prospective data on all new BC patients. Prospectively recorded surveillance data were pooled from 12 collaborating centres.

INTERVENTION

QPIs of interest were (1) hospitals achieving detrusor muscle (DM) sampling target at initial transurethral resection of bladder tumour (TURBT) and (2) use of single instillation of mitomycin C after TURBT (SI-MMC).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary and secondary endpoints were time to recurrence and progression, respectively. Kaplan-Meier and Cox multivariable regression analyses were performed.

KEY FINDINGS AND LIMITATIONS

Between April 1, 2014 and March 31, 2017, we diagnosed 3899 patients with new BC, of which 2688 were NMIBC . With a median follow up of 60.3 mo, hospitals achieving the DM sampling target had a 5.4% lower recurrence rate at 5 yr than hospitals not achieving this target (442/1136 [38.9%] vs 677/1528 [44.3%], 95% confidence interval [CI] = 1.6-9.2, p = 0.005). SI-MMC was associated with a 20.4% lower recurrence rate (634/1791 [35.4%] vs 469/840 [55.8%], 95% CI = 16.4-24.5, p < 0.001). On Cox multivariable regression, meeting the DM target and SI-MMC were associated with significant improvement in recurrence (hazard ratio [HR] 0.81, 95% CI = 0.73-0.91, p = 0.0002 and HR 0.66, 95% CI = 0.59-0.74, p < 0.004, respectively) as well as progression-free survival (HR 0.62, 95% CI = 0.45-0.84, p = 0.002 and HR 0.65, 95% CI = 0.49-0.87, p = 0.004, respectively). We did not have a national multicentre pre-QPI control.

CONCLUSIONS

Within a national QPI programme, meeting targets for sampling DM and SI-MMC in the real world were independently associated with delays to recurrence and progression in NMIBC patients.

PATIENT SUMMARY

Following the first 3 yr of implementing a novel quality performance indicator programme in Scotland, we evaluated compliance and outcomes in non-muscle-invasive bladder cancer. In 2688 patients followed up for 5 yr, we found that achieving targets for sampling detrusor muscle and the single instillation of mitomycin C during and after transurethral resection of bladder tumour, respectively, were associated with delays in cancer recurrence and progression.

Physiotherapists' barriers and facilitators to the implementation of a behaviour change-informed exercise intervention to promote the adoption of regular exercise practice in patients at risk of recurrence of low back pain: a qualitative study

BACKGROUND

Recurrences of low back pain (LBP) are frequent and associated with high levels of disability and medical costs. Regular exercise practice may be an effective strategy to prevent recurrences of LBP, however, the promotion of this behaviour by physiotherapists seems to be challenging. This study aims to explore physiotherapists' perceived barriers and facilitators to the implementation of a behaviour change-informed exercise intervention to promote the adoption of regular exercise practice by patients at risk of recurrence of low back pain.

METHODS

Two focus groups with primary healthcare physiotherapists were conducted, based on a semi-structured interview schedule informed by the Behaviour Change Wheel, including the Capability, Opportunity, Motivation-Behaviour (COM-B) model and the Theoretical Domains Framework (TDF). All focus groups were held through videoconference, audio and video recorded and transcribed verbatim. A deductive content analysis, using a coding matrix based on the COM-B and TDF, was performed by two independent researchers. A third researcher was approached to settle disagreements.

RESULTS

In total, 14 physiotherapists participated in the focus groups. The analysis revealed a total of 13 barriers (4 COM-B components and 7 TDF domains) and 23 facilitators (5 COM-B and 13 TDF) to physiotherapists' implementation of a behaviour change-informed exercise intervention. The most common barriers were the lack of skills and confidence to implement the proposed intervention. These were explained by the fact that it differs from the usual practice of most participants and requires the learning of new skills applied to their contexts. However, for those who had already implemented other similar interventions or whose rationale is aligned with the new intervention, there seemed to exist more positive determinants, such as potential benefits for physiotherapists and the profession, improvement of quality of care and willingness to change clinical practice. For others who did not previously succeed in implementing these types of interventions, more context-related barriers were mentioned, such as lack of time to implement the intervention, schedule incompatibilities and lack of material and human resources.

CONCLUSIONS

This study identified modifiable barriers and facilitators to physiotherapists' implementation of a behaviour change-informed exercise intervention for patients at risk of recurrence of LBP in primary healthcare. The findings of this study will allow the systematic and theory-based development of a behaviour change-informed training programme, aimed at physiotherapists and supporting the successful implementation of the exercise intervention.

Effectiveness of nurse-led interventions versus usual care to manage hypertension and lifestyle behaviour: a systematic review and meta-analysis

AIMS

This review aimed to investigate the effectiveness of nurse-led interventions vs. usual care on hypertension management, lifestyle behaviour, and patients' knowledge of hypertension and associated risk factors.

METHODS

A systematic review with meta-analysis was conducted following Joanna Briggs Institute (JBI) guidelines. MEDLINE (Ovid), EmCare (Ovid), CINAHL (EBSCO), Cochrane library, and ProQuest (Ovid) were searched from inception to 15 February 2022. Randomized controlled trials (RCTs) examining the effect of nurse-led interventions on hypertension management were identified. Title and abstract, full text screening, assessment of methodological quality, and data extraction were conducted by two independent reviewers using JBI tools. A statistical meta-analysis was conducted using STATA version 17.0.

RESULTS

A total of 37 RCTs and 9731 participants were included. The overall pooled data demonstrated that nurse-led interventions may reduce systolic blood pressure (mean difference -4.66; 95% CI -6.69, -2.64; I2 = 83.32; 31 RCTs; low certainty evidence) and diastolic blood pressure (mean difference -1.91; 95% CI -3.06, -0.76; I2 = 79.35; 29 RCTs; low certainty evidence) compared with usual care. The duration of interventions contributed to the magnitude of blood pressure reduction. Nurse-led interventions had a positive impact on lifestyle behaviour and effectively modified diet and physical activity, but the effect on smoking and alcohol consumption was inconsistent.

CONCLUSION

This review revealed the beneficial effects of nurse-led interventions in hypertension management compared with usual care. Integration of nurse-led interventions in routine hypertension treatment and prevention services could play an important role in alleviating the rising global burden of hypertension.

REGISTRATION

PROSPERO: CRD42021274900.