Discriminant content validity of a theoretical domains framework questionnaire for use in implementation research

Implementation behavior of communities regarding relatives caring for people with dementia : A quantitative study among German communities

BACKGROUND

Actors from the community (CAs) play a fundamental role in the support of caring relatives (CRs) of people with dementia (PWD). As their support is not sufficient, the implementation of support services needs to be optimized; however, little is known about the factors associated with the implementation behavior of CAs.

AIM

This study aimed to investigate the association of person-related factors with the implementation behavior of CAs.

METHODS

In a cross-sectional study, 205 CAs from 16 German communities were surveyed with the community implementation behaviour questionnaire (CIBQ), which is based on the theoretical domains framework. Logistic regression analyses were conducted to identify person-related factors associated with the implementation behavior regarding support services for CRs of PWD.

RESULTS

Implementing support services for CRs of PWD is positively and significantly (p < 0.001) associated with the agreement of CAs with the CIBQ domains. Higher scores in the CIBQ increase the chance that CAs implemented support services for the target group.

CONCLUSION

The CIBQ is a tool to determine the status of implementation behavior of communities. This enables an analysis of the areas CAs need to work on in order to optimize the implementation of support services for CRs of PWD or other health and care-related topics.

What factors are associated with infant hearing aid use? A parent survey using the Theoretical Domains Framework

OBJECTIVE

Hearing aid use is lowest in 0-3-year-olds with hearing loss, placing spoken language development at risk. Existing interventions lack effectiveness and are typically not based on a theoretically driven, comprehensive understanding of the factors influencing infant hearing aid use. The present study is the first to address this gap in understanding.

DESIGN AND STUDY SAMPLE

A 55-item online survey based on the Theoretical Domains Framework (TDF) was completed by 56 parents of 0-3-year-old hearing aid users.

RESULTS

Participants reported a wide range of barriers across TDF domains, which were associated with parent-reported hearing aid use and more pronounced in parents of lower hearing aid users. The most strongly reported domains across participants were "emotion" (e.g. feelings of worry when using hearing aids), "beliefs about capabilities" (e.g. belief in ability to use hearing aids consistently), and "environmental context and resources" (e.g. child removing hearing aids).

CONCLUSIONS

Parents report a wider range of barriers to infant hearing aid use than existing investigations suggest and current interventions address. Interventions would benefit from: (i) targeting a wider range of TDF domains in their design; and (ii) implementing the present TDF survey to identify and target family-specific barriers to infant hearing aid use.

Scaling up a brief alcohol intervention to prevent HIV infection in Vietnam: a cluster randomized, implementation trial

BACKGROUND

Evidence-based interventions (EBIs) often address normative behaviors. If a behavior is also common among clinicians, they may be skeptical about the necessity or effectiveness of an EBI. Alternatively, clinicians' attitudes and behaviors may be misaligned, or they may lack the knowledge and self-efficacy to deliver the EBI. Several EBIs address unhealthy alcohol use, a common and often culturally acceptable behavior. But unhealthy alcohol use may be particularly harmful to people with HIV (PWH). Here, we present an implementation trial using an experiential implementation strategy to address clinicians' knowledge, attitudes, and behaviors. Clinicians receive the experiential intervention before they begin delivering an evidence-based brief alcohol intervention (BAI) to PWH with unhealthy alcohol use.

METHODS

Design: In this hybrid type 3 implementation-effectiveness cluster randomized controlled trial, ART clinics (n = 30) will be randomized 1:1 to facilitation, a flexible strategy to address implementation barriers, or facilitation plus the experiential brief alcohol intervention (EBAI). In the EBAI arm, clinicians, irrespective of their alcohol use, will be offered the BAI as experiential learning. EBAI will address clinicians' alcohol-related attitudes and behaviors and increase their knowledge and confidence to deliver the BAI.

PARTICIPANTS

ART clinic staff will be enrolled and assessed at pre-BAI training, post-BAI training, 3, 12, and 24 months. All PWH at the ART clinics who screen positive for unhealthy alcohol use will be offered the BAI. A subset of PWH (n = 810) will be enrolled and assessed at baseline, 3, and 12 months.

OUTCOMES

We will compare implementation outcomes (acceptability, fidelity, penetration, costs, and sustainability) and effectiveness outcomes (viral suppression and alcohol use) between the two arms. We will assess the impact of site-level characteristics on scaling-up the BAI. We will also evaluate how experiencing the BAI affected clinical staff's alcohol use and clinic-level alcohol expectations in the EBAI arm.

DISCUSSION

This trial contributes to implementation science by testing a novel strategy to implement a behavior change intervention in a setting in which clinicians themselves may engage in the behavior. Experiential learning may be useful to address normative and difficult to change lifestyle behaviors that contribute to chronic diseases.

TRIAL REGISTRATION

NCT06358885 (04/10/2024), https://clinicaltrials.gov/study/NCT06358885 .

Implementation of supplemental physiotherapy following hip fracture surgery: a protocol for the process evaluation of a randomised controlled trial

BACKGROUND

Patient outcomes following low-trauma hip fracture are suboptimal resulting in increased healthcare costs and poor functional outcomes at 1 year. Providing early and intensive in-hospital physiotherapy could help improve patient outcomes and reduce costs following hip fracture surgery. The HIP fracture Supplemental Therapy to Enhance Recovery (HIPSTER) trial will compare usual care physiotherapy to intensive in-hospital physiotherapy for patients following hip fracture surgery. The complex environments in which the intervention is implemented present unique contextual challenges that may impact intervention effectiveness. This study aims to complete a process evaluation to identify barriers and facilitators to implementation and explore the patient, carer and clinician experience of intensive therapy following hip fracture surgery.

METHODS AND ANALYSIS

The process evaluation is embedded within a two-arm randomised, controlled, assessor-blinded trial recruiting 620 participants from eight Australian hospitals who have had surgery for a hip fracture sustained via a low-trauma injury. A theory-based mixed method process evaluation will be completed in tandem with the HIPSTER trial. Patient and carer semi-structured interviews will be completed at 6 weeks following hip fracture surgery. The clinician experience will be explored through online surveys completed pre- and post-implementation of intensive therapy and mapped to domains of the Theoretical Domains Framework (TDF). Translation and behaviour change success will be assessed using the Reach Effectiveness-Adoption Implementation Maintenance (RE-AIM) framework and a combination of qualitative and quantitative data collection methods. These data will assist with the development of an Implementation Toolkit aiding future translation into practice.

DISCUSSION

The embedded process evaluation will help understand the interplay between the implementation context and the intensive therapy intervention following surgery for low-trauma hip fracture. Understanding these mechanisms, if effective, will assist with transferability into other contexts and wider translation into practice.

TRIAL REGISTRATION

ACTRN 12622001442796.

Assessing Barriers to Utilization of Premedication for Neonatal Intubation Based on the Theoretical Domains Framework

OBJECTIVE

 This study aimed to identify barriers and facilitators of premedication utilization for nonemergent neonatal intubations (NIs) in a level IV neonatal intensive care unit (NICU).

STUDY DESIGN

 Between November 2018 and January 2019, multidisciplinary providers at a level IV NICU were invited to participate in an anonymous, electronic survey based on Theoretical Domains Framework to identify influences on utilization of evidence-based recommendations for NI premedication.

RESULTS

 Of 186 surveys distributed, 84 (45%) providers responded. Most agreed with premedication use in the following domains: professional role/identity (86%), emotions (79%), skills (72%), optimism (71%), and memory, attention, and decision process (71%). Domains with less agreement include social influences (42%), knowledge (57%), intention (60%), belief about capabilities (63%), and behavior regulation (64%). Additional barriers include environmental context and resources, and beliefs about consequences.

CONCLUSION

 Several factors influence premedication use for nonemergent NI and may serve as facilitators and/or barriers. Efforts to address barriers should incorporate a multidisciplinary approach to improve patient outcomes and decrease procedure-related pain.

KEY POINTS

· Premedication for NIs can optimize conditions and decrease rates of tracheal intubation adverse events but there is significant international and institutional variation for premedication use for NI.. · Guided by implementation science methods, the Theoretical Domains Framework was utilized to construct a novel assessment tool to determine potential barriers to and facilitators of the use of premedication for NI.. · Several factors influence premedication for nonemergent NI..

The Asthma App as a New Way to Promote Responsible Short-Acting Beta2-Agonist Use in People With Asthma: Results of a Mixed Methods Pilot Study

BACKGROUND

Approximately 262 million people worldwide are affected by asthma, and the overuse of reliever medication-specifically, short-acting beta2-agonist (SABA) overuse-is common. This can lead to adverse health effects. A smartphone app, the Asthma app, was developed via a participatory design to help patients gain more insight into their SABA use through monitoring and psychoeducation.

OBJECTIVE

This pilot study aims to evaluate the feasibility and usability of the app. The preliminary effects of using the app after 3 months on decreasing asthma symptoms and improving quality of life were examined.

METHODS

A mixed methods study design was used. Quantitative data were collected using the app. Asthma symptoms (measured using the Control of Allergic Rhinitis and Asthma Test) and the triggers of these symptoms were collected weekly. Quality of life (36-Item Short-Form Health Survey) was assessed at baseline and after 3, 6, and 12 months. User experience (System Usability Scale) was measured at all time points, except for baseline. Furthermore, objective user data were collected, and qualitative interviews, focusing on feasibility and usability, were organized. The interview protocol was based on the Unified Theory of Acceptance and Use of Technology framework. Qualitative data were analyzed using the Framework Method.

RESULTS

The baseline questionnaire was completed by 373 participants. The majority were female (309/373, 82.8%), with a mean age of 46 (SD 15) years, and used, on average, 10 SABA inhalations per week. App usability was rated as good: 82.3 (SD 13.2; N=44) at 3 months. The Control of Allergic Rhinitis and Asthma Test score significantly improved at 3 months (18.5) compared with baseline (14.8; β=.189; SE 0.048; P<.001); however, the obtained score still indicated uncontrolled asthma. At 3 months, there was no significant difference in the quality of life. Owing to the high dropout rate, insufficient data were collected at 6 and 12 months and were, therefore, not further examined. User data showed that 335 users opened the app (250/335, 74.6%, were returning visitors), with an average session time of 1 minute, and SABA registration was most often used (7506/13,081, 57.38%). Qualitative data (from a total of 4 participants; n=2, 50% female) showed that the participants found the app acceptable and clear. Three participants stated that gaining insight into asthma and its triggers was helpful. Two participants no longer used the app because they perceived their asthma as controlled and, therefore, did not use SABA often or only used it regularly based on the advice of the pulmonologist.

CONCLUSIONS

The initial findings regarding the app's feasibility and usability are encouraging. However, the notable dropout rate underscores the need for a cautious interpretation of the results. Subsequent studies, particularly those focusing on implementation, should explore the potential integration of the app into standard treatment practices.

Barriers and facilitators to using an objective risk communication tool during primary care dental consultations: A Theoretical Domains Framework (TDF) informed qualitative study

OBJECTIVES

Objective risk communication tools can supplement clinical judgement and support the understanding of potential health risks. This study used the Theoretical Domains Framework (TDF) to identify barriers and facilitators to implementing a risk communication aid within primary care dental consultations.

METHODS

Dentists (N = 13), recruited via a dental practice database and through professional contacts were interviewed using a TDF-informed semi-structured interview schedule. Data were analysed inductively and deductively coding the themes using the TDF.

RESULTS

Eight theoretical domains (environmental context and resources; beliefs about consequences; goals; memory, attention, and decision processes; optimism; reinforcement; social influences and behavioural regulation) and thirteen sub-themes were identified. Insufficient resources and patient factors were commonly encountered barriers and led to increasing pressure to prioritise other tasks. Whilst dentists had a favourable view towards a risk communication aid and acknowledged its benefits, some were sceptical about its ability to facilitate behaviour change. Self-monitoring strategies and colleague support facilitated tool usage.

CONCLUSIONS

This study identified six barriers and seven facilitators to implementing a risk communication tool within primary care dental settings. Dentists appreciated the value of using a risk communication tool during dental consultations, although some required further support to integrate the tool into practice.

CLINICAL SIGNIFICANCE

Our findings provide a sound theoretical base for interventions aimed at facilitating patient behaviour change through the use of risk communication in dentistry. Further research should apply behavioural science to support the implementation of the tool in clinical practice.

Barriers and enablers to blood culture sampling in Indonesia, Thailand and Viet Nam: a Theoretical Domains Framework-based survey

OBJECTIVE

Blood culture (BC) sampling is recommended for all suspected sepsis patients prior to antibiotic administration. We examine barriers and enablers to BC sampling in three Southeast Asian countries.

DESIGN

A Theoretical Domains Framework (TDF)-based survey, comprising a case scenario of a patient presenting with community-acquired sepsis and all 14 TDF domains of barriers/enablers to BC sampling.

SETTING

Hospitals in Indonesia, Thailand and Viet Nam, December 2021 to 30 April 2022.

PARTICIPANTS

1070 medical doctors and 238 final-year medical students were participated in this study. Half of the respondents were women (n=680, 52%) and most worked in governmental hospitals (n=980, 75.4%).

OUTCOME MEASURES

Barriers and enablers to BC sampling.

RESULTS

The proportion of respondents who answered that they would definitely take BC in the case scenario was highest at 89.8% (273/304) in Thailand, followed by 50.5% (252/499) in Viet Nam and 31.3% (157/501) in Indonesia (p<0.001). Barriers/enablers in nine TDF domains were considered key in influencing BC sampling, including 'priority of BC (TDF-goals)', 'perception about their role to order or initiate an order for BC (TDF-social professional role and identity)', 'perception that BC is helpful (TDF-beliefs about consequences)', 'intention to follow guidelines (TDF-intention)', 'awareness of guidelines (TDF-knowledge)', 'norms of BC sampling (TDF-social influence)', 'consequences that discourage BC sampling (TDF-reinforcement)', 'perceived cost-effectiveness of BC (TDF-environmental context and resources)' and 'regulation on cost reimbursement (TDF-behavioural regulation)'. There was substantial heterogeneity between the countries. In most domains, the lower (higher) proportion of Thai respondents experienced the barriers (enablers) compared with that of Indonesian and Vietnamese respondents. A range of suggested intervention types and policy options was identified.

CONCLUSIONS

Barriers and enablers to BC sampling are varied and heterogenous. Cost-related barriers are more common in more resource-limited countries, while many barriers are not directly related to cost. Context-specific multifaceted interventions at both hospital and policy levels are required to improve diagnostic stewardship practices.

A qualitative study evaluating barriers and enablers to improving antimicrobial use for the management of bacteriuria in hospitalized adults

Objective

The objective of this study was to explore barriers and enablers to improving the management of bacteriuria in hospitalized adults.

Design

Qualitative study.

Setting

Nova Scotia, Canada.

Participants

Nurses, physicians, and pharmacists involved in the assessment, diagnosis, and treatment of bacteriuria in hospitalized patients.

Methods

Focus groups (FGs) were completed between May and July 2019. FG discussions were facilitated using an interview guide that consisted of open-ended questions coded to the theoretical domains framework (TDF) v2. Discussions were transcribed verbatim then independently coded to the TDFv2 by two members of the research team and compared. Thematic analysis was used to identify themes.

Results

Thirty-three healthcare providers from five hospitals participated (15 pharmacists, 11 nurses, and 7 physicians). The use of antibiotics for the treatment of asymptomatic bacteriuria (ASB) was the main issue identified. Subthemes that related to management of ASB included: "diagnostic uncertainty," difficulty "ignoring positive urine cultures," "organizational challenges," and "how people learn." Barriers and/or enablers to improving the management of bacteriuria were mapped to 12 theoretical domains within these subthemes. Barriers and enablers identified by participants that were most extensively discussed related to the domains of environmental context and resources, belief about capabilities, social/professional role and identity, and social influences.

Conclusions

Healthcare providers highlighted barriers and recognized enablers that may improve delivery of care to patients with bacteriuria. A wide range of barriers at the individual and organization level to address diagnostic challenges and improve workload should be considered to improve management of bacteriuria.

The Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) for serious mental illness in community mental health part 3: study protocol to evaluate sustainment in a hybrid type 2 effectiveness-implementation cluster-randomized trial

BACKGROUND

Although research on the implementation of evidence-based psychological treatments (EBPTs) has advanced rapidly, research on the sustainment of implemented EBPTs remains limited. This is concerning, given that EBPT activities and benefits regularly decline post-implementation. To advance research on sustainment, the present protocol focuses on the third and final phase-the Sustainment Phase-of a hybrid type 2 cluster-randomized controlled trial investigating the implementation and sustainment of the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) for patients with serious mental illness and sleep and circadian problems in community mental health centers (CMHCs). Prior to the first two phases of the trial-the Implementation Phase and Train-the-Trainer Phase-TranS-C was adapted to fit the CMHC context. Then, 10 CMHCs were cluster-randomized to implement Standard or Adapted TranS-C via facilitation and train-the-trainer. The primary goal of the Sustainment Phase is to investigate whether adapting TranS-C to fit the CMHC context predicts improved sustainment outcomes.

METHODS

Data collection for the Sustainment Phase will commence at least three months after implementation efforts in partnering CMHCs have ended and may continue for up to one year. CMHC providers will be recruited to complete surveys (N = 154) and a semi-structured interview (N = 40) on sustainment outcomes and mechanisms. Aim 1 is to report the sustainment outcomes of TranS-C. Aim 2 is to evaluate whether manipulating EBPT fit to context (i.e., Standard versus Adapted TranS-C) predicts sustainment outcomes. Aim 3 is to test whether provider perceptions of fit mediate the relation between treatment condition (i.e., Standard versus Adapted TranS-C) and sustainment outcomes. Mixed methods will be used to analyze the data.

DISCUSSION

The present study seeks to advance our understanding of sustainment predictors, mechanisms, and outcomes by investigating (a) whether the implementation strategy of adapting an EBPT (i.e., TranS-C) to the CMHC context predicts improved sustainment outcomes and (b) whether this relation is mediated by improved provider perceptions of treatment fit. Together, the findings may help inform more precise implementation efforts that contribute to lasting change.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT05956678 . Registered on July 21, 2023.

Designing a Behaviour Change Wheel guided implementation strategy for a hypoxaemic respiratory failure and ARDS care pathway that targets barriers

BACKGROUND

A significant gap exists between ideal evidence-based practice and real-world application of evidence-informed therapies for patients with hypoxaemic respiratory failure (HRF) and acute respiratory distress syndrome (ARDS). Pathways can improve the quality of care provided by helping integrate and organise the use of evidence informed practices, but barriers exist that can influence their adoption and successful implementation. We sought to identify barriers to the implementation of a best practice care pathway for HRF and ARDS and design an implementation science-based strategy targeting these barriers that is tailored to the critical care setting.

METHODS

The intervention assessed was a previously described multidisciplinary, evidence-based, stakeholder-informed, integrated care pathway for HRF and ARDS. A survey questionnaire (12 open text questions) was administered to intensive care unit (ICU) clinicians (physicians, nurses, respiratory therapists) in 17 adult ICUs across Alberta. The Behaviour Change Wheel, capability, opportunity, motivation - behaviour components, and Theoretical Domains Framework (TDF) were used to perform qualitative analysis on open text responses to identify barriers to the use of the pathway. Behaviour change technique (BCT) taxonomy, and Affordability, Practicality, Effectiveness and cost-effectiveness, Acceptability, Side effects and safety and Equity (APEASE) criteria were used to design an implementation science-based strategy specific to the critical care context.

RESULTS

Survey responses (692) resulted in 16 belief statements and 9 themes with 9 relevant TDF domains. Differences in responses between clinician professional group and hospital setting were common. Based on intervention functions linked to each belief statement and its relevant TDF domain, 26 candidate BCTs were identified and evaluated using APEASE criteria. 23 BCTs were selected and grouped to form 8 key components of a final strategy: Audit and feedback, education, training, clinical decision support, site champions, reminders, implementation support and empowerment. The final strategy was described using the template for intervention description and replication framework.

CONCLUSIONS

Barriers to a best practice care pathway were identified and were amenable to the design of an implementation science-based mitigation strategy. Future work will evaluate the ability of this strategy to improve quality of care by assessing clinician behaviour change via better adherence to evidence-based care.

Development of a behaviour change intervention to increase the delivery of upper limb constraint-induced movement therapy programs to people with stroke and traumatic brain injury

Purpose: Constraint-induced movement therapy (CIMT) is a recommended intervention for arm recovery after acquired brain injury but is underutilised in practice. The purpose of this study is to describe the development of a behaviour change intervention targeted at therapists, to increase delivery of CIMT.Methods: A theoretically-informed approach for designing behaviour change interventions was used including identification of which behaviours needed to change (Step 1), barriers and enablers that needed to be addressed (Step 2), and intervention components to target those barriers and enablers (Step 3). Data collection methods included file audits and therapist interviews. Quantitative data (file audits) were analysed using descriptive statistics. Qualitative data analysis (interviews) was informed by the Theoretical Domains Framework (TDF) and Behaviour Change Wheel.Results: Fifty two occupational therapists, physiotherapists and allied health assistants participated in focus groups (n = 7) or individual interviews (n = 6). Key barriers (n = 20) and enablers (n = 10) were identified across 11 domains of the TDF and perceived to influence CIMT implementation. The subsequent behaviour change intervention included training workshops, nominated team champions, community of practice meetings, three-monthly file audit feedback cycles, poster reminders and drop-in support during CIMT.Conclusion: This study describes the development of a behaviour change intervention to increase CIMT delivery by clinicians.Trial registration: Australian New Zealand Clinical Trials Registry, Trial ID: ACTRN12617001147370.

Primary Care Providers' Information Needs for Prescribing Adolescents HIV Pre-Exposure Prophylaxis

Although knowledge is a salient determinant in primary care providers (PCPs) prescribing HIV pre-exposure prophylaxis (PrEP) to adolescents, we know little about what information PCPs want about PrEP. We conducted an online mixed-method study to explore the PrEP information needs of a national sample of 351 PCPs. We analyzed data with deductive content analysis and compared themes between respondents who were aware and not aware of PrEP, knowledgeable and not knowledgeable of the prescribing guidelines, and prescribed and never prescribed PrEP to an adolescent. PCPs who were unknowledgeable about PrEP and never prescribed PrEP to an adolescent mentioned manufacturing information, indications and dosing, and contraindications and adverse reactions more so than PCPs who were aware of and prescribed PrEP. A better understanding of the information needs of PCPs could inform provider education interventions. Future research must examine the facilitators and barriers to integrating PrEP information into medical education and clinical settings.

The needs, barriers, and opportunities perceived by health professionals for an online competency-based interprofessional course to enhance the care of older adults with chronic musculoskeletal pain

BACKGROUND

It is recommended that continued education in pain should be supported using information and communication technologies (ICTs), but there are gaps about the previous competencies of health professionals, especially in low- and middle-income countries. This study characterized the competencies of professionals in the Colombian Caribbean, the circumstances that favor and hinder the development of appropriate care, as well as the preferences, expectations and attitudes toward an educational intervention supported by ICTs.

METHODS

We used a qualitative, phenomenological approach, combining documentary review and data obtained through observation, an online survey and two focus groups involving 55 healthcare professionals (physicians, nurses and psychologists) of varying experience. For the analysis and integration of results, the Capacity, Opportunity, Motivation and Behavior model and the Theoretical Domains Framework were used as references. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist guided the reporting of this study.

RESULTS

Competency deficits were found regardless of the profession and experience, which are related to inadequacies in undergraduate and post-graduate training. Structural problems in Colombian society and healthcare service organization were also discovered, which were considered unmodifiable barriers and have been aggravated by the social, economic and health effects of the pandemic. The main modifiable barriers found were as follows: pain underestimation and under-treatment of older adults, as well as stereotypes regarding old age and pain, lack of knowledge of the psychosocial determinants of pain and of techniques for its assessment and treatment, overestimation of pharmacological treatment and failure to update pharmacological and non-pharmacological techniques.

CONCLUSIONS

Recommendations for the design of the educational intervention were established as follows: favoring non-synchronous resources, facilitating synchronous activities of short duration, facilitating permanent access to information and resources and generating incentives for continuing education, such as certification, institutional recognition and encouraging popular recognition.

Implementation of the Richmond Agitation-Sedation Scale (palliative version) on an inpatient palliative care unit

BACKGROUND

The Richmond Agitation-Sedation Scale - Palliative version (RASS-PAL) tool is a brief observational tool to quantify a patient's level of agitation or sedation. The objective of this study was to implement the RASS-PAL tool on an inpatient palliative care unit and evaluate the implementation process.

METHODS

Quality improvement implementation project using a short online RASS-PAL self-learning module and point-of-care tool. Participants were staff working on a 31-bed inpatient palliative care unit who completed the RASS-PAL self-learning module and online evaluation survey.

RESULTS

The self-learning module was completed by 49/50 (98%) of regular palliative care unit staff (nurses, physicians, allied health, and other palliative care unit staff). The completion rate of the self-learning module by both regular and casual palliative care unit staff was 63/77 (82%). The follow-up online evaluation survey was completed by 23/50 (46%) of respondents who regularly worked on the palliative care unit. Respondents agreed (14/26; 54%) or strongly agreed (10/26; 38%) that the self-learning module was implemented successfully, with 100% agreement that it was effective for their educational needs.

CONCLUSION

Using an online self-learning module is an effective method to engage and educate interprofessional staff on the RASS-PAL tool as part of an implementation strategy.

Mechanical insufflation-exsufflation for invasively ventilated critically ill patients-A focus group study

INTRODUCTION

Mechanical Insufflation-Exsufflation (MI-E) is used as an airway clearance intervention in primary care (home ventilation), long-term care (prolonged rehabilitation after intensive care, neuromuscular diseases, and spinal cord injury), and increasingly in acute care in intensive care units (ICU).

AIM

We sought to develop in-depth understanding of factors influencing decision-making processes of health care professionals regarding initiation, escalation, de-escalation, and discontinuation of MI-E for invasively ventilated patients including perceived barriers and facilitators to use.

METHODS

We conducted focus groups (3 in the Netherlands; 1 with participants from four European countries) with clinicians representing the ICU interprofessional team and with variable experience of MI-E. The semi-structured interview guide was informed by the Theoretical Domains Framework (TDF). Two researchers independently coded data for directed content analysis using codes developed from the TDF.

RESULTS

A purposive sample of 35 health care professionals participated. Experience varied from infrequent to several years of frequent MI-E use in different patient populations. We identified four main themes: (1) knowledge; (2) beliefs; (3) clinical decision-making; and (4) future adoption.

CONCLUSION

Interprofessional knowledge and expertise of MI-E in invasively ventilated patients is limited due to minimal available evidence and adoption. Participants believed MI-E a potentially useful intervention for airway clearance and inclusion in weaning protocols when more evidence is available.

RELEVANCE TO CLINICAL PRACTICE

This focus group study provides an overview of current practice, knowledge and expertise, and barriers and facilitators to using MI-E in mechanically ventilated patients. From these data, it is evident there is a need to develop further clinical expertise and evidence of efficacy to further understand the role of MI-E as an airway clearance technique for ventilated patients.

The Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) for serious mental illness in community mental health part 3: Study protocol to evaluate sustainment in a hybrid type 2 effectiveness-implementation cluster-randomized trial

treatments (EBPTs) has advanced rapidly, research on the sustainment of implemented EBPTs remains limited. This is concerning, given that EBPT activities and benefits regularly decline post-implementation. To advance research on sustainment, the present protocol focuses on the third and final phase - the Sustainment Phase - of a hybrid type 2 cluster-randomized controlled trial investigating the implementation and sustainment of the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) for patients with serious mental illness and sleep and circadian problems in community mental health centers (CMHCs). Prior to the first two phases of the trial - the Implementation Phase and Train-the-Trainer Phase - TranS-C was adapted to fit the CMHC context. Then, 10 CMHCs were cluster-randomized to implement Standard or Adapted TranS-C via facilitation and train-the-trainer. The primary goal of the Sustainment Phase is to investigate whether adapting TranS-C to fit the CMHC context predicts improved sustainment outcomes.

Methods

Data collection for the Sustainment Phase will commence at least three months after implementation efforts in partnering CMHCs have ended and may continue for up to one year. CMHC providers will be recruited to complete surveys (N = 154) and a semi-structured interview (N = 40) on sustainment outcomes and mechanisms. Aim 1 is to report the sustainment outcomes of TranS-C. Aim 2 is to evaluate whether manipulating EBPT fit to context (i.e., Standard versus Adapted TranS-C) predicts sustainment outcomes. Aim 3 is to test whether provider perceptions of fit mediate the relation between treatment condition (i.e., Standard versus Adapted TranS-C) and sustainment outcomes. Mixed methods will be used to analyze the data.

Discussion

The present study seeks to advance our understanding of sustainment predictors, mechanisms, and outcomes by investigating (a) whether the implementation strategy of adapting an EBPT (i.e., TranS-C) to the CMHC context predicts improved sustainment outcomes and (b) whether this relation is mediated by improved provider perceptions of treatment fit. Together, the findings may help inform more precise implementation efforts that contribute to lasting change.

Trial Registration

ClinicalTrials.gov identifier: NCT05956678. Registered on July 21, 2023. https://classic.clinicaltrials.gov/ct2/show/NCT05956678?term=NCT05956678&draw=2&rank=1.

Factors perceived by health professionals to be barriers or facilitators to caries prevention in children: a systematic review

BACKGROUND

Considered the most prevalent noncommunicable disease in childhood, dental caries is both an individual and a collective burden. While international guidelines highlight prevention as a major strategy for caries management in children, health professionals still struggle to implement prevention into their clinical practice. Further research is needed to understand the gap between the theoretical significance of dental prevention and its lack of implementation in the clinical setting. This systematic review aims to identify and classify factors perceived by health professionals to be barriers or facilitators to caries prevention in children.

METHOD

A systematic literature search was conducted in three electronic databases (Medline, Web of Science and Cairn). Two researchers independently screened titles, abstracts and texts. To be selected, studies had to focus on barriers or facilitators to caries prevention in children and include health professionals as study participants. Qualitative and quantitative studies were selected. The factors influencing caries prevention in children were sorted into 3 main categories (clinician-related factors, patient-related factors, and organizational-related factors) and then classified according to the 14 domains of the theoretical domains framework (TDF).

RESULTS

A total of 1771 references were found by combining manual and database searches. Among them, 26 studies met the inclusion criteria, of which half were qualitative and half were quantitative studies. Dentists (n = 12), pediatricians (n = 11), nurses (n = 9), and physicians (n = 5) were the most frequently interviewed health professionals in our analysis. Barriers and facilitators to caries prevention in children were categorized into 12 TDF domains. The most frequently reported domains were Environmental Context and Resources, Knowledge and Professional Role and Identity.

CONCLUSION

This systematic review found that a wide range of factors influence caries prevention in children. Our analysis showed that barriers to pediatric oral health promotion affect all stages of the health care system. By highlighting the incompatibility between the health care system's organization and the implementation of caries prevention, this study aims to help researchers and policy-makers design new interventions to improve children's access to caries prevention.

TRIAL REGISTRATION

PROSPERO CRD42022304545.

Knowledge, sex, and region associated with primary care providers prescribing adolescents HIV pre-exposure prophylaxis

Although HIV pre-exposure prophylaxis (PrEP) effectively and safely prevents HIV among adolescents, uptake of PrEP is low. Adolescents must have primary care providers (PCPs) prescribe them PrEP, making PCPs critical actors in PrEP delivery. However, research has primarily investigated determinants of PCPs' intention to prescribe adolescents PrEP rather than the determinants of performing the behavior itself. We examined the demographic, clinical practice, and implementation determinants of PCPs previously prescribing PrEP to adolescents. PCPs were recruited from a national Qualtrics panel of licensed medical providers in the United States from July 15-August 19, 2022. The Theoretical Domains Framework informed the implementation determinants measured. A multivariable logistic regression was used. PCPs who were more knowledgeable of the CDC guidelines (aOR 2.97, 95% CI 2.16-4.10), who were assigned male at birth (aOR 1.64, 95% CI 1.03-2.59), and who practiced in the Western region (aOR 1.85, 95% CI 1.04-3.30) had greater odds of prior prescribing adolescents PrEP. Provider-based educational interventions should be designed, implemented, and tested to encourage PCPs to prescribe PrEP to eligible adolescents.

Using the Theoretical Domain Framework to understand what helps and hinders the use of different sensory approaches in Australian psychiatric units: A survey of mental health clinicians

BACKGROUND/AIM

Although sensory approaches are recommended to relieve distress and agitation and reduce the use of seclusion and restraint, many Australian psychiatric units have struggled to sustain their practice. The aim of this study was to investigate the barriers and enablers influencing the use of different sensory approaches across one health region in Australia and to obtain recommendations for strategies to improve their use.

METHOD

This cross-sectional survey was informed by the Theoretical Domain Framework. Likert scale questions considered barriers and enablers to the use of non-weighted sensory interventions, weighted modalities, sensory rooms, and sensory assessments/plans. Open-ended questions explored participant concerns and recommendations to improve the use of sensory approaches.

RESULTS

Participants (n = 211) were from nursing, allied health, medical, and peer support staff across inpatient psychiatric units. Factors most frequently identified as enablers for using sensory approaches were beliefs of positive benefits to consumers (e.g. decreasing distress and agitation); belief it was within the staff's role; and knowledge of the approaches. Limited time was the most common identified barrier. Factors statistically associated with more frequent use were knowledge, skills, confidence, availability, and easy access to sensory tools/equipment. Only 30% of participants were concerned about potential risks of sensory approaches, with this risk mitigated through adequate supervision and thorough risk assessment. Recommendations to improve practice included improved access to, and maintenance of, equipment, more training, and increased staffing.

CONCLUSION

This study revealed how barriers and enablers vary for different sensory approaches and how these factors impact their frequency of use in psychiatric units. It provides insights into staff recommendations to improve the use of sensory approaches in one health region in Australia. This knowledge will lead to the development of implementation strategies to address identified barriers and improve the use of sensory approaches in psychiatric units.

Perceptions of shared decision making in gastroenterology and inflammatory bowel disease: A qualitative analysis

OBJECTIVE

Shared decision-making (SDM) is the partnership and discussion between clinicians and patients to make an appropriate decision based on scientific evidence and patient preferences. Many benefits are associated with SDM; however, little is known about its awareness or use by inflammatory bowel disease (IBD) clinicians in gastroenterology departments across Israel. This study aims to identify barriers and facilitators in implementing SDM as standard practice to achieve optimal disease management and personalized care for patients with IBD.

METHODS

Sixteen semi-structured interviews were conducted with IBD clinicians across Israel to identify the barriers and facilitators for SDM use. An interview guide was developed, based on the systematic approach of the Theoretical Domain Framework (TDF). Interview transcripts were coded into theoretical domains to identify factors that may impact SDM.

RESULTS

Sixteen gastroenterologists from nine different hospitals were interviewed. Common TDF domains that presented as barriers were: knowledge, skills, social/professional role and identity, environmental context and resources, and reinforcement. Most participants had never heard the precise term "shared decision making" and lacked formal training on SDM.

CONCLUSION

This study identified key barriers and facilitators to SDM in IBD clinics across Israel. Main barriers of SDM include limited or nonexistent training; clinicians were unaware of SDM guidelines or techniques. The main facilitators of SDM were clinicians' social and professional role and identity and their beliefs about the influence of IBD and/or CD.

PRACTICE IMPLICATIONS

These influencing factors and TDF domains identified provide a basis for developing future interventions to improve the implementation of SDM within IBD management.

Barriers to and facilitators of the use of oxygen therapy in people living with an interstitial lung disease: a systematic review of qualitative evidence

BACKGROUND

Oxygen therapy is prescribed to treat hypoxaemia in people with interstitial lung disease (ILD); however, uptake and adherence remain an ongoing challenge. This systematic review aimed to identify the barriers to and facilitators of use of oxygen therapy in people with ILD, caregivers and health professionals.

METHODS

A systematic search for qualitative literature was undertaken using five electronic databases (MEDLINE, CINAHL, Embase, PsycINFO, PubMed). Qualitative analysis identified themes that were mapped to the Theoretical Domains Framework and the Consolidated Framework for Implementation Research and classified as barriers, facilitators or both.

RESULTS

A total of 13 studies were eligible for inclusion. Commonly represented domains were associated with the design of the oxygen delivery system, the associated cost, financing, stigmatisation, the physical environment and the individual needs that acted as barriers to and facilitators of the optimisation of oxygen therapy.

CONCLUSION

Effective implementation of oxygen therapy in ILD requires more robust evidence to strengthen international guidelines, sustainable and equitable funding models, and improved oxygen delivery systems that meet the needs of users. Increased information and support for users will be critical to optimise the uptake and outcomes of this important therapy.

Approaches to tracheoesophageal voice rehabilitation: a survey of the UK and Irish speech and language therapists' current practice and beliefs

BACKGROUND

After total laryngectomy, surgical voice restoration is used to establish communication via tracheoesophageal voice prosthesis. Once voice is established, there is a paucity of information on what speech and language therapists (SLTs) should do to improve tracheoesophageal voice quality to ensure functional communication. No existing surveys or studies investigate this specific question. There is also a disconnect between guidelines, knowledge and clinical practice, whereby clinical guidelines stipulate the requirement for SLT intervention, but do not detail what this entails in the rehabilitation context.

AIMS

(1) To advance understanding of current clinical practice beyond voice prosthesis management and care. (2) To explore what approaches are implemented in clinical practice across the UK and Republic of Ireland to rehabilitate tracheoesophageal voice. (3) To investigate the barriers and facilitators to provision of tracheoesophageal voice therapy.

METHODS & PROCEDURES

A self-administered 10-min online survey was developed using Qualtrics software and piloted before dissemination. Survey development was informed by the Behaviour Change Wheel to identify barriers, facilitators and additional factors contributing to SLTs' provision of voice therapy to tracheoesophageal speakers. The survey was disseminated via social media and professional networks. Eligibility criteria included SLTs with at least one year post-registration experience and with experience of working with laryngectomy in the past 5 years. Descriptive statistics were used to analyse closed answer questions. Open question responses were analysed using content analysis.

OUTCOMES & RESULTS

The survey received 147 responses. Participants were representative of the head and neck cancer SLT workforce. SLTs believe that tracheoesophageal voice therapy is an important aspect of laryngectomy rehabilitation; however, there was a lack of knowledge about therapy approaches and insufficient resources for implementing therapy. SLTs expressed a desire for more training, specific guidelines and a stronger evidence base to inform clinical practice. Some SLTs expressed feelings of frustration and lack of acknowledgement for the specialist skills required to undertake laryngectomy rehabilitation and tracheoesophageal work in general.

CONCLUSIONS & IMPLICATIONS

The survey identifies the need for a robust training approach and detailed clinical guidelines to promote consistent practice across the profession. The evidence base within this clinical area is emergent, hence there is a need for increased research and clinical audit to inform practice. Under-resourcing was highlighted, which should be considered in service planning to ensure that adequate staff, access to expert practitioners or time ring-fenced for therapy are available for tracheoesophageal speakers to receive the support they require.

WHAT THIS PAPER ADDS

What is already known on this subject Total laryngectomy results in life-altering changes to communication. Clinical guidelines advocate for speech and language therapy intervention; however, there is no clear information on what SLTs should do to optimize tracheoesophageal voice and the evidence base to support practice is lacking. What this study adds to existing knowledge This survey identifies what interventions SLTs provide in clinical practice to rehabilitate tracheoesophageal voice; and it explores the barriers and facilitators that influence the provision of tracheoesophageal voice therapy. What are the potential or actual clinical implications of this work? Specific training, clinical guidelines, increased research and audit are required to support clinical practice in laryngectomy rehabilitation. Service planning should address the under-resourcing of staff, expert practitioners and therapy allocated time.

Measuring the determinants of implementation behavior in multiprofessional rehabilitation

BACKGROUND

The Determinants of Implementation Behavior Questionnaire (DIBQ) measures facilitators or barriers of healthcare professionals' implementation behaviors based on the current implementation research on practice and policy. The DIBQ covers 18 domains of the Theoretical Domains Framework and consists of 93 items. A previously tailored version (DIBQ-t) covering 10 domains and 28 items focuses on implementing best-practice low back pain care.

AIM

To tailor a shortened version of DIBQ to multiprofessional rehabilitation context with cross-cultural adaptation to Finnish language.

DESIGN

A two-round Delphi study.

SETTING

National-level online survey.

POPULATION

Purposively recruited experts in multiprofessional rehabilitation (N.=25).

METHODS

Cross-cultural translation of DIBQ to Finnish was followed by a two-round Delphi survey involving diverse experts in rehabilitation (physicians, physiotherapists, occupational therapists, psychologists, nursing scientists, social scientists). In total, 25 experts in Round 1, and 21 in Round 2 evaluated the importance of DIBQ items in changing professionals' implementation behavior by rating on a 5-point Likert Scale (1 = Strongly Disagree, 5 = Strongly Agree) of including each item in the final scale. Consensus to include an item was defined as a mean score of ≥4 by ≥75% of Delphi participants. Open comments were analyzed using inductive content analysis. Items with agreement of ≤74% were either directly excluded or reconsidered and modified depending on qualitative judgements, amended with experts' suggestions. After completing an analogous second-round, a comparison with DIBQ-t was performed. Lastly, the relevance of each item was indexed using content validity index on item-level (I-CVI) and scale-level (S-CVI/Ave).

RESULTS

After Round 1, 17 items were included and 48 excluded by consensus whereas 28 items were reconsidered, and 20 items added for Round 2. The open comments were categorized as: 1) "modifying"; 2) "supportive"; and 3) "critical". After Round 2, consensus was reached regarding all items, to include 21 items. After comparison with DIBQ-t, the final multiprofessional DIBQ (DIBQ-mp) covers 11 TDF domains and 21 items with I-CVIs of ≥0.78 and S-CVI/Ave of 0.93.

CONCLUSIONS

A Delphi study condensed a DIBQ-mp with excellent content validity for multiprofessional rehabilitation context.

CLINICAL REHABILITATION IMPACT

A potential tool for evaluating determinants in implementing evidence-based multiprofessional rehabilitation interventions.

Using a theory-informed approach to guide the initial development of a post-tuberculosis care package in British Columbia, Canada

BACKGROUND

The importance of addressing the long-term needs of tuberculosis (TB) survivors is gaining increasing attention. One promising approach to improving post-TB care is implementing a post-TB care package. With a specific focus on the perspectives of healthcare providers in British Columbia, Canada, this study aimed to (1) determine a set of components to be included in a post-TB care package, (2) explore barriers and facilitators influencing their implementation, and (3) propose potential solutions to overcome identified challenges.

METHODS

Employing a multi-method approach guided by the Theoretical Domains Framework, we first conducted virtual workshops with TB care providers and utilized a modified Delphi process to establish a preliminary list of care package components. Then, we surveyed healthcare providers using closed-ended, Likert-scale questions to identify implementation barriers and enablers. Lastly, we mapped the identified barriers and enablers to establish behaviour change techniques to identify possible solutions to overcome the challenges identified.

RESULTS

Eleven participants attended virtual workshops, and 23 of 51 (45.1%) healthcare providers completed questionnaires. Identified components of the post-TB care package included: 1. Linking people with TB to a primary care provider if they do not have one. 2. Referring people with pulmonary TB for an end-of-treatment chest x-ray and pulmonary function testing. 3. Referring people with TB who smoke to a smoking cessation specialist. 4. Sharing a one-page post-TB information sheet with the patient's primary care provider, including a summary of post-TB health concerns, complications, and recommendations to prioritize age-appropriate screening for cardiovascular disease, lung cancer, and depression. Survey results indicated that domain scores for 'environment, context, and resources' were the lowest, suggesting potential implementation barriers. Care navigation services to help individuals overcome health system barriers while transitioning from TB care, information leaflets, and checklists summarizing key post-TB health concerns for patients and healthcare providers to help facilitate discussions may help overcome the identified barriers.

CONCLUSION

Healthcare providers in British Columbia acknowledge that post-TB care is integral to comprehensive health care but are limited by time and resources. Care navigation services, a post-TB checklist, and patient information leaflets may help resolve some of these barriers.

Implementation Factors Associated With Primary Care Providers' Intention to Prescribe HIV PrEP to Adolescents in the United States

PURPOSE

In the United States, adolescents (those 13-18 years old) are a key age group of those at risk for and affected by HIV. Although HIV pre-exposure prophylaxis (PrEP), one promising HIV prevention tool, is approved for eligible adolescents to use, adolescent access to PrEP is limited by primary care providers' (PCPs) willingness to prescribe it. This study examined which Theoretical Domains Framework factors are associated with PCPs' intention to prescribe PrEP to sexually active adolescents.

METHODS

A total of 770 licensed PCPs practicing family medicine, internal medicine, or pediatrics in the United States completed an online cross-sectional questionnaire. Participants were recruited through a Qualtrics panel. We used a hierarchical regression to assess the association of demographic characteristics, sexual health care practices, and the 10 Theoretical Domains Framework factors with intention to prescribe PrEP to sexually active adolescents aged 13-18 years old.

RESULTS

Although nearly all PCPs had heard about PrEP (90.9%), 30.6% ever prescribed PrEP to an adolescent. Intention to prescribe PrEP to sexually active adolescents was associated with seven out of the 10 Theoretical Domains Framework factors: knowledge, skills, professional role, belief capacity, belief consequence, environmental resource, social influence, and emotion.

DISCUSSION

Our findings demonstrate that the Theoretical Domains Framework can be employed to understand the intrapersonal, interpersonal, and environmental factors associated with PCPs' intention to prescribe sexually active adolescents PrEP. Implementation strategies are needed to implement interventions that improve provider knowledge, attitudes, and skills related to prescribing PrEP to eligible adolescents.

Enhancing doctor-patient relationships in community health care institutions: the Patient Oriented Four Habits Model (POFHM) trial-a stepped wedge cluster randomized trial protocol

BACKGROUND

The poor relationship between doctors and patients is a long-standing, global problem. However, current interventions tend to focus on the training of physicians, while patient-targeted interventions still need to be improved. Considering that patients play a significant role in outpatient consultations, we developed a protocol to assess the effectiveness of the Patient Oriented Four Habits Model (POFHM) in improving doctor-patient relationships.

METHODS

A cross-sectional incomplete stepped-wedge cluster randomized trial design will be conducted in 8 primary healthcare institutions (PHCs). Following phase I of "usual care" as control measures for each PHC, either a patient- or doctor-only intervention will be implemented in phase II. In phase III, both patients and doctors will be involved in the intervention. This study will be conducted simultaneously in Nanling County and West Lake District. The primary outcomes will be evaluated after patients complete their visit: (1) patient literacy, (2) sense of control and (3) quality of doctor-patient communication. Finally, a mixed-effects model and subgroup analysis will be used to evaluate the effectiveness of the interventions.

DISCUSSION

Fostering good consultation habits for the patient is a potentially effective strategy to improve the quality of doctor-patient communication. This study evaluates the implementation process and develops a rigorous quality control manual using a theoretical domain framework under the collective culture of China. The results of this trial will provide substantial evidence of the effectiveness of patient-oriented interventions. The POFHM can benefit the PHCs and provide a reference for countries and regions where medical resources are scarce and collectivist cultures dominate.

TRIAL REGISTRATION

AsPredicted #107,282 on Sep 18, 2022; https://aspredicted.org/QST_MHW.

Facilitators and Barriers to Nurses Screening for Frailty in Acute Care in a Provincial Health-Care System: a Survey Study Guided by the Theoretical Domains Framework

Background

Older adults living with frailty represent the largest population of hospitalized patients in Canada, but they do not always receive the quality of care needed. Nurses are well-positioned to screen for frailty, but current frailty screening practices are poorly understood.

Methods

A cross-sectional survey study was conducted over a six-week period with nurses from Alberta, Canada working in acute care with older adults. Demographics were descriptively reported. Frailty screening methods were quantified on 5-point frequency scales, reported descriptively and compared by practice area using linear regression. The top-five mean scores from a 43-item, 6-point Likert-type questionnaire based on the Theoretical Domains Framework were compared by practice area.

Results

Frailty screening by clinical impression was "usually" used (median = 4, IQR = 4-5), while tools were "rarely" used (median = 2, IQR = 1-3). Medical and/or surgical nursing had higher general frailty screening tool use (β = 0.81, r = .31, p < .001), but no significant (p > .05) differences for using clinical impression, or preference of screening method. The top facilitator was the disbelief that frailty screening negatively impacts relationships with older adults. The top barrier was belief that conducting frailty screening was routine. Nursing practice area influenced frailty screening beliefs.

Conclusions

There is an opportunity to implement frailty screening tools into the nursing practice of Alberta' nurses working in acute care. Frailty screening tools that become routine have greater likelihood for utilization. Nursing practice areas may have unique situations that require tailored approached to tool implementation.

A Proof-of-Concept Evaluation of the 1616 Story-Based Positive Youth Development Program

The 1616 Program is a newly developed and evidence-informed story-based positive youth development (PYD) program for young ice hockey players (10-12 years of age) in North America. The program uses elite ice hockey players as role models-through story-telling-to serve as inspirational figures to engage youth athletes and important social agents (i.e., parents, coaches) with evidence-informed PYD concepts. The objective of this study was to use a Proof-of-Concept evaluation to assess whether the 1616 Program 'worked' in enhancing PYD outcomes and to determine if the concepts were engaging and enjoyable for youth, their parents, and coaches. The 5 week Proof-of-Concept evaluation was conducted with 11 ice hockey teams (n = 160 youths, 93 parents, and 11 coaches), encompassing both qualitative (e.g., focus groups) and quantitative (e.g., retrospective pretest-posttest questionnaires) processes and outcome assessments. Results showed that the program was well received by participants and positively impacted the intended outcomes. Overall, the data presented in this Proof-of-Concept evaluation was deemed to support the development and implementation of the full-scale 1616 Program for a more comprehensive evaluation.

Telemedicine during the COVID-19 pandemic in Germany: Results from three nationally representative surveys on use, attitudes and barriers among adults affected by depression

Introduction

The COVID-19 pandemic has necessitated a reduction in face-to-face consultations, resulting in significant limitations in healthcare for individuals with depression. To ensure safe and adequate care, e-health services, such as telemedicine, gained a more prominent role. Governments have eased restrictions on the use of telemedicine, enabling healthcare professionals to increasingly offer video and telephone consultations.

Objective

This study examines, 1) possible changes over the course of the pandemic in reported use of video and telephone consultations and intended future use of video consultations with healthcare professionals among adults with diagnosed depression; 2) their attitudes towards video and telephone consultations and perceived barriers towards using e-health after prolonged time of the pandemic; and 3) differences in results between subgroups based on sociodemographic and clinical characteristics.

Methods

Three population-representative online surveys were conducted in Germany at different timepoints (t) during the COVID-19 pandemic. Respondents aged 18-69 years with a professionally diagnosed depression were included in the present analyses (t1: June/July 2020 with n = 1094; t2: February 2021 with n = 1038; t3: September 2021 with n = 1255).

Results

The overall proportion of adults with depression who used video or telephone consultations did not change significantly in the time surveyed (t1: 16.51 %, n = 179; t2: 20.23 %, n = 210; t3: 18.47 %, n = 230). However, among users, reported use of video consultations with a psychotherapist increased significantly from t1 (34.83 %, n = 62) to t3 (44.98 %, n = 102, p = .023). Intended future use of VC for healthcare varied depending on the purpose of the consultation. Significant differences over time were only found for the purpose of using VC to discuss clinical findings, laboratory results and diagnostic analyses with a doctor, with higher intentions reported at t2 during lockdown in Germany. At t3, the majority of adults with depression felt that video and telephone consultations were too impersonal and considered them more as a helpful support rather than an alternative to face-to-face psychotherapy. Key barriers to using e-health were found within the societal context and the lacking support from significant others for using e-health, while knowledge and skills represented facilitators for using e-health.

Conclusion

Despite ambivalent attitudes towards video and telephone consultations among adults with depression, reported use of video consultations with a psychotherapist increased during the COVID-19 pandemic.

A sequential, multiple assignment randomized trial comparing web-based education to mobile video interpreter access for improving provider interpreter use in primary care clinics: the mVOCAL hybrid type 3 study protocol

BACKGROUND

Individuals who use a language other than English for medical care are at risk for disparities related to healthcare safety, patient-centered care, and quality. Professional interpreter use decreases these disparities but remains underutilized, despite widespread access and legal mandates. In this study, we compare two discrete implementation strategies for improving interpreter use: (1) enhanced education targeting intrapersonal barriers to use delivered in a scalable format (interactive web-based educational modules) and (2) a strategy targeting system barriers to use in which mobile video interpreting is enabled on providers' own mobile devices.

METHODS

We will conduct a type 3 hybrid implementation-effectiveness study in 3-5 primary care organizations, using a sequential multiple assignment randomized trial (SMART) design. Our primary implementation outcome is interpreter use, calculated by matching clinic visits to interpreter invoices. Our secondary effectiveness outcome is patient comprehension, determined by comparing patient-reported to provider-documented visit diagnosis. Enrolled providers (n = 55) will be randomized to mobile video interpreting or educational modules, plus standard interpreter access. After 9 months, providers with high interpreter use will continue as assigned; those with lower use will be randomized to continue as before or add the alternative strategy. After another 9 months, both strategies will be available to enrolled providers for 9 more months. Providers will complete 2 surveys (beginning and end) and 3 in-depth interviews (beginning, middle, and end) to understand barriers to interpreter use, based on the Theoretical Domains Framework. Patients who use a language other than English will be surveyed (n = 648) and interviewed (n = 75) following visits with enrolled providers to understand their experiences with communication. Visits will be video recorded (n = 100) to assess fidelity to assigned strategies. We will explore strategy mechanism activation to refine causal pathway models using a quantitative plus qualitative approach. We will also determine the incremental cost-effectiveness of each implementation strategy from a healthcare organization perspective, using administrative and provider survey data.

DISCUSSION

Determining how these two scalable strategies, alone and in sequence, perform for improving interpreter use, the mechanisms by which they do so, and at what cost, will provide critical insights for addressing a persistent cause of healthcare disparities.

TRIAL REGISTRATION

NCT05591586.

Exploring enablers and barriers to implementing the Transparency and Openness Promotion Guidelines: a theory-based survey of journal editors

The Transparency and Openness Promotion (TOP) Guidelines provide a framework to help journals develop open science policies. Theories of behaviour change can guide understanding of why journals do (not) implement open science policies and the development of interventions to improve these policies. In this study, we used the Theoretical Domains Framework to survey 88 journal editors on their capability, opportunity and motivation to implement TOP. Likert-scale questions assessed editor support for TOP, and enablers and barriers to implementing TOP. A qualitative question asked editors to provide reflections on their ratings. Most participating editors supported adopting TOP at their journal (71%) and perceived other editors in their discipline to support adopting TOP (57%). Most editors (93%) agreed their roles include maintaining policies that reflect current best practices. However, most editors (74%) did not see implementing TOP as a high priority compared with other editorial responsibilities. Qualitative responses expressed structural barriers to implementing TOP (e.g. lack of time, resources and authority to implement changes) and varying support for TOP depending on study type, open science standard, and level of implementation. We discuss how these findings could inform the development of theoretically guided interventions to increase open science policies, procedures and practices.

Using the Consolidated Framework for Implementation Research to evaluate a nationwide depression prevention project (ImplementIT) from the perspective of health care workers and implementers: Results on the implementation of digital interventions for farmers

Introduction

Depression has a significant impact on individuals and society, which is why preventive measures are important. Farmers represent an occupational group exposed to many risk factors for depression. The potential of guided, tailored internet-based interventions and a personalized telephone coaching is evaluated in a German project of the Social Insurance for Agriculture, Forestry and Horticulture (SVLFG). While user outcomes are promising, not much is known about actual routine care use and implementation of the two digital health interventions. This study evaluates the implementation from the perspective of social insurance employees to understand determinants influencing the uptake and implementation of digital interventions to prevent depression in farmers.

Methods

The data collection and analysis are based on the Consolidated Framework for Implementation Research (CFIR). Health care workers (n = 86) and implementers (n = 7) completed online surveys and/or participated in focus groups. The surveys consisted of validated questionnaires used in implementation research, adapted items from the CFIR guide or from other CFIR studies. In addition, we used reporting data to map implementation based on selected CFIR constructs.

Results

Within the five CFIR dimensions, many facilitating factors emerged in relation to intervention characteristics (e.g., relative advantage compared to existing services, evidence and quality) and the inner setting of the SVLFG (e.g., tension for change, compatibility with values and existing working processes). In addition, barriers to implementation were identified in relation to the outer setting (patient needs and resources), inner setting (e.g., available resources, access to knowledge and information) and characteristics of individuals (e.g., self-efficacy). With regard to the implementation process, facilitating factors (formal implementation leaders) as well as hindering factors (reflecting and evaluating) were identified.

Discussion

The findings shed light on the implementation of two digital prevention services in an agricultural setting. While both offerings seem to be widely accepted by health care workers, the results also point to revealed barriers and contribute to recommendations for further service implementation. For instance, special attention should be given to "patient needs and resources" by raising awareness of mental health issues among the target population as well as barriers regarding the inner setting.

Clinical Trial Registration

German Clinical Trial Registration: [DRKS00017078]. Registered on 18.04.2019.

Barrieren und Förderfaktoren für die Implementierung eines Konzepts zur Förderung evidenzbasierten Arbeitens in der Physiotherapie – Eine Mixed-Methods-Studie

Hintergrund In der Physiotherapie in Deutschland besteht Bedarf an theoretisch und wissenschaftlich fundierten Implementierungsstrategien zur Förderung des evidenzbasierten Arbeitens (EBP). Bei der Entwicklung solcher Strategien ist es notwendig, die Rahmenbedingungen und Einflussfaktoren im individuellen Kontext zu erfassen und zu berücksichtigen. In diesem Zusammenhang wurde das „science4practice“-Konzept mit dem Ziel entwickelt, die Umsetzung von EBP in physiotherapeutischen Einrichtungen zu fördern.

Ziel Erhebung von Barrieren und Förderfaktoren für die Implementierung des „science4practice“-Konzepts.

Methode Im Rahmen einer Mixed-Methods-Studie wurden qualitative, semistrukturierte Interviews sowie eine quantitative Erhebung anhand eines Online- und Papierfragebogens durchgeführt. An den Interviews nahmen Geschäfts- und Therapieleitungen therapeutischer Einrichtungen sowie Physiotherapeut*innen ohne Leitungsverantwortung teil. An der quantitativen Befragung nahmen Physiotherapeut*innen ohne Leitungsverantwortung teil. Die Daten der Interviews wurden mittels thematischer Inhaltsanalyse ausgewertet. Die Daten der quantitativen Erhebung wurden deskriptiv analysiert.

Ergebnisse Aus den 15 durchgeführten Interviews konnten die mangelnden Fähigkeiten zur Literaturrecherche und -bewertung, negative Erfahrungen mit Veränderungsprozessen sowie unzureichende Zugangsmöglichkeiten zu wissenschaftlicher Literatur als Barrieren abgeleitet werden. Als Förderfaktoren wurden die Unterstützung durch Vorgesetzte sowie die Verfügbarkeit von Ressourcen für die Implementierung des Konzepts identifiziert. Die Umfrageergebnisse von 47 Physiotherapeut*innen ohne Leitungsverantwortung zeigen kumulierte Zustimmungswerte („trifft voll zu“ und „trifft eher zu“) von 83–91 % für die Bereitschaft zur Umsetzung des „science4practice“-Konzepts. Durch die Zusammenführung der quantitativen und qualitativen Daten konnte die Bereitschaft des Teams zur Konzeptumsetzung abschließend als Förderfaktor eingeordnet werden.

Schlussfolgerung Die Studie identifiziert Barrieren und Förderfaktoren aus Sicht der Teilnehmenden mit und ohne Leitungsverantwortung. Einerseits unterstreichen die Daten national und international identifizierte Barrieren wie mangelnde wissenschaftliche Kompetenzen oder unzureichende Zugänge zu wissenschaftlicher Literatur. Andererseits zeigen die Ergebnisse das Potential des Konzepts als EBP-Implementierungsvorhaben in der Physiotherapie in Deutschland. Im nächsten Schritt sollten Studien durchgeführt werden, um die Machbarkeit des Konzepts zu überprüfen.

Survivors' perceptions regarding the follow-up of pain complaints after breast cancer treatment: Distinct coping patterns

Introduction

After finishing cancer treatment, breast cancer survivors often experience both physical and psychosocial symptoms such as pain. In some, pain can persist for months or even years. Pain is a complex experience. Its occurrence and maintenance are explained through interactions between multiple factors, which are biological/physiological, psychological, and social in nature. Unaddressed needs related to this problem - such as insufficient pain relief, limited validation of the problem, and minimal physical and psychological support - may cause severe disability and negatively impact well-being and quality of life. This study investigated how breast cancer survivors perceive their (chronic) pain complaints to be addressed during follow-up care. Furthermore, we explored how they coped with the way their trajectories happened to unfold.

Methods

We conducted four focus groups with a total of thirty-one breast cancer survivors. Each focus group consisted of an asynchronous part with an online discussion platform and a synchronous part through video calls. Data analysis was guided by the Qualitative Analysis Guide of Leuven.

Results

Narratives revealed the unmet needs of survivors and showed variability in the lived experiences of having to deal with pain. Some survivors tend to ignore the pain, while others look for solutions to reduce pain. A third coping pattern is accepting pain and its impact. Furthermore, how survivors cope with pain is influenced by intrapersonal, interpersonal, and societal processes. For example, pain-related beliefs and prejudices among healthcare providers, family, friends, colleagues, other cancer survivors, and society could possibly steer a survivor towards a certain way of coping. In these processes, the role of healthcare providers seems pivotal. For instance, when survivors do not feel heard or taken seriously by healthcare providers, their acceptance of pain can be impeded.

Discussion

To conclude, a person's way of coping with pain and the associated needs is dynamic and influenced by factors at multiple levels such as the intrapersonal, interpersonal and societal level. To sufficiently address the problem of pain among cancer survivors, we therefore also need actions that tackle the health care system and its stakeholders, as well as the public debate concerning cancer follow-up care.

Early Years Physical Activity and Motor Skills Intervention-A Feasibility Study to Evaluate an Existing Training Programme for Early Years Educators

A lack of fundamental motor skills (FMS) in the early years can lead to lower engagement with physical activity (PA), and track into adulthood. This study aimed to test the feasibility of an existing intervention for Early Years Educators ("Educators") designed to increase knowledge, confidence and the ability to increase PA and FMS of children in a deprived area of England. Non-randomised design with wait-list control. Sixty-seven settings in Middlesbrough, North East England were invited. Recruitment target: 10 settings, 2 Educators per setting, four children per Educator.

INTERVENTION

one-day training course "Physical Literacy in the Early Years", an age-appropriate theoretical and practical training course to support the development of physical literacy.

PRIMARY OUTCOMES

recruitment, retention, acceptability of intervention and outcome measures.

SECONDARY OUTCOMES

change in Educators' knowledge, intentions and behaviour, and change in children's BMI z-score, PA and FMS. Eight settings were recruited; all Intervention Educators completed the training. Six settings participated at follow-up (four Intervention, two Control). The target for Educator recruitment was met (two per setting, total n = 16). Questionnaires were completed by 80% of Intervention Educators at baseline, 20% at follow-up. Control Educators completed zero questionnaires. No Educators took part in a process evaluation interview. Forty-eight children participated at baseline, 28 at follow-up. The intervention was deemed acceptable. The recruitment, retention and acceptability of measurements were insufficient to recommend proceeding. Additional qualitative work is needed to understand and surmount the challenges posed by the implementation of the trial.

Development, internal reliability and preliminary construct validity of the Dutch Dietary Intention Evaluation Tool for In-patients (DIETI)

BACKGROUND AND AIMS

Diet is important in prevention and management of non-communicable disease and in particular, cardiovascular disease. Recently, more hospitals gear towards healthier dietary policies, however, a tool to assess the effect of these interventions in patient populations is currently lacking. The Theory of Planned Behavior (TPB) is generally used to assess health-related behavior and offers a framework for development of questionnaires. In this study, we aim to evaluate the reliability, internal consistency and preliminary construct validity of the newly developed Dietary Intention Evaluation Tool for In-hospital patients (DIETI) which is based on the TPB.

METHODS AND RESULTS

An expert panel constructed the item list of the DIETI. A total of 312 patients admitted to the cardiology ward filled out the DIETI. Explanatory- and confirmatory factor analysis showed that our tool adequately discerns five TPB-consistent factors regarding a healthy diet in hospitalized patients. (N = 312, for the CFA model χ² = 313.072 (df = 160, p < 0.001, CFI = 0.939, RMSEA = 0.058). Subsequent analysis of reliability showed satisfactory to strong internal consistency of the questionnaire as a whole and all subscales (Cronbach's alpha for the subscales ranging between 0.65 and 0.88).

CONCLUSIONS

We conclude that the DIETI is an internally reliable tool to assess behavioral intentions regarding a healthy diet of in-hospital patients. Thus, this questionnaire can be used to evaluate the effect of dietary interventions aimed at hospitalized patients.

The Concussion Awareness Training Tool for Women's Support Workers Improves Knowledge of Intimate Partner Violence-Caused Brain Injury

Women who experience physical intimate partner violence (IPV) are at high risk of suffering a brain injury (BI) due to head impacts and/or strangulation. Currently, most staff at women's shelters tend not to be aware of IPV-caused BIs. The objective of this study was to address this by developing a new online module within the Concussion Awareness Training Tool (cattonline.com) specifically focused on IPV-caused BI, and measuring its effectiveness in increasing BI awareness and knowledge among staff members at women's shelters. A mixed-methods approach was used which included (i) a survey to measure participant knowledge before and after completing the module; (ii) a 1-on-1 interview 6 months post-training to better understand participants' perceptions of what effect the training had on how they worked with women in their job; and (iii) an evaluation of the content of the module using behavior change techniques. About 81 participants recruited from staff at women's shelters completed the pre/post survey. The average BI knowledge score increased significantly from the pre-survey (M = 8.12/12, SD = 1.05) to the post-survey (M = 9.72/12, SD = 1.62), t(80) = 9.12, P < .001, d = 1.01). Analysis of the interviews with 9 participants highlighted 3 main themes arising from the module: knowledge, mindfulness, and advocacy. All participants felt their knowledge of IPV-caused BIs had increased and said they would recommend the training to their co-workers. Analysis of the module content revealed the most frequent behavior change techniques were related to instructions on how to perform screening and accommodation for IPV-caused BI. The results showed the module was effective in increasing knowledge of IPV-caused BIs amongst women's shelter staff as well as improving how they advocate for, and are mindful of, their clients with BIs. This online training may help improve the care women with IPV-caused BIs receive, and ultimately improve their quality of life.

Implementation of effective blended periconception lifestyle care in a tertiary hospital in the Netherlands: a cross-sectional study on determinants and patient satisfaction

OBJECTIVE

To identify implementation determinants of blended periconception lifestyle care, and to evaluate patient satisfaction.

DESIGN

Cross-sectional study.

SETTING

The outpatient clinic of the department of Obstetrics and Gynaecology of the Erasmus MC.

PARTICIPANTS

Implementation part: counsellors providing blended periconception lifestyle care. Patient satisfaction part: women who received blended periconception lifestyle care.

METHODS

Blended periconception lifestyle care, including face-to-face counselling and 26 weeks of lifestyle coaching via the online platform 'Smarter Pregnancy', was implemented between June-December 2018. The Measurement Instrument for Determinants of Innovations questionnaire was used as input for the consolidated framework for implementation research to assess determinants of implementation. To evaluate patient satisfaction, patients receiving lifestyle care filled out an evaluation questionnaire, including questions on the needs for lifestyle counselling, information provision during counselling, and motivation and lifestyle change after counselling.

PRIMARY AND SECONDARY OUTCOME MEASURES

Identification of implementation determinants and the level of patient satisfaction.

RESULTS

Facilitators were reported in the implementation domains 'characteristics of the intervention' and 'characteristics of the individuals'. Barriers were in the implementation domains 'inner setting' and 'implementation process'. Regarding patient satisfaction on nutrition counselling, 31% of the respondents wanted information prior to the counselling session, 22% received new information after consultation, 51% got motivated to change and 40% changed their nutritional behaviour.

CONCLUSIONS

A considerable number of patients improved lifestyle after counselling, although, a relatively small number wanted lifestyle counselling prior to consultation.This study underlines the importance of implementation science and the information it provides for improving the implementation process.

Development and Psychometric Properties of the Community Implementation Behaviour Questionnaire (CIBQ) in the Context of Supporting Caring Relatives of People with Dementia

The Theoretical Domains Framework (TDF) investigates the determinants influencing the implementation behaviour of actors in healthcare. Caring for people with dementia (PWD) can be burdensome. Therefore, caring relatives (CRs) often rely on support of various actors in their community (CAs). However, the support of this target group is not sufficient, and the implementation of support services needs to be optimised. As it stands, there is no German-language questionnaire to investigate the factors that influence the implementation behaviour of CAs. Therefore, based on the TDF, the Community Implementation Behaviour Questionnaire (CIBQ) was developed in this study. A total of 205 CAs from 16 German communities were surveyed. The 34-item CIBQ asked about their implementation behaviour regarding support services for CRs of PWD. To identify the best model fit, the internal consistency and construct validity were computed. After adaptation, the final CIBQ consisted of ten domains and thirty-one items. The psychometric properties of the questionnaire are as follows: CMIN/DF = 1.63; SRMR = 0.05; RMSEA = 0.07; CFI = 0.92; Cronbach's alpha 0.74-0.89; inter-item correlation 0.38-0.88. The initial results show satisfactory internal consistency and construct validity of the CIBQ. Using the CIBQ enables the health and care optimisation of CRs of PWD.

Barriers and enablers to diabetic retinopathy screening: a cross-sectional survey of young adults with type 1 and type 2 diabetes in the UK

INTRODUCTION

Diabetic retinopathy screening (DRS) attendance in young adults (YAs) is consistently below recommended levels. The aim of this study was to identify barriers and enablers of DRS attendance among YAs in the UK living with type 1 (T1D) and type 2 diabetes (T2D).

RESEARCH DESIGN AND METHODS

YAs (18-34 years) were invited to complete an anonymous online survey in June 2021 assessing agreement with 30 belief statements informed by the Theoretical Domains Framework (TDF) of behavior change describing potential barriers/enablers to DRS.

RESULTS

In total, 102 responses were received. Most had T1D (65.7%) and were regular attenders for DRS (76.5%). The most salient TDF domains for DRS attendance were 'Goals', with 93% agreeing that DRS was a high priority, and 'Knowledge', with 98% being aware that screening can detect eye problems early.Overall, 67.4% indicated that they would like greater appointment flexibility (Environmental context/resources) and 31.3% reported difficulties getting time off work/study to attend appointments (Environmental context/resources). This was more commonly reported by occasional non-attenders versus regular attenders (59.1% vs 23.4%, p=0.002). Most YAs were worried about diabetic retinopathy (74.3%), anxious when receiving screening results (63%) (Emotion) and would like more support after getting their results (66%) (Social influences). Responses for T1D and T2D were broadly similar, although those with T2D were more likely have developed strategies to help them to remember their appointments (63.6% vs 37.9%, p=0.019) (Behavioral regulation).

CONCLUSIONS

Attendance for DRS in YAs is influenced by complex interacting behavioral factors. Identifying modifiable determinants of behavior will provide a basis for designing tailored interventions to improve DRS in YAs and prevent avoidable vision loss.

Exploring nurse-sensitive patient outcomes in Dutch district nursing care: A survey study

There is a lack of evidence to guide district nurses in using nurse-sensitive patient outcomes as it is unclear how these outcomes are currently used in daily district nursing practice. Therefore, we aimed to explore (1) which nurse-sensitive patient outcomes are measured and how these outcomes are measured, (2) how district nurses use the outcomes to learn from and improve current practice and (3) the barriers and facilitators to using outcomes in current district nursing practice. An exploratory cross-sectional survey study was conducted. The survey was distributed online among nurses working for various district nursing care organisations across the Netherlands. The responses from 132 nurses were analysed, demonstrating that different instruments or questionnaires are available and used in district nursing care as outcome measures. The nurse-sensitive patient outcomes most often measured with validated instruments are pain using the Numeric Rating Scale or Visual Analogue Scale, delirium using the Delirium Observation Scale, weight loss using the Short Nutritional Assessment Questionnaire and caregiver burden using the Caregiver Strain Index or a Dutch equivalent. Falls and client satisfaction with delivered care are most often measured using unvalidated outcome measures. The other nurse-sensitive outcomes are measured in different ways. Outcomes are measured, reported and fed back to the nursing team multiple times and in various ways to learn from and improve current practice. In general, nurses have a positive attitude towards using nurse-sensitive outcomes in practice, but there is a lack of facilitation to support them. Because insight into how nurses can and should be supported is still lacking, exploring their needs in further research is desirable. Additionally, due to the high variation in the utilisation of outcomes in current practice, it is recommended to create more uniformity by developing (inter)national guidelines on using nurse-sensitive patient outcomes in district nursing care.

A qualitative study of barriers and facilitators to the implementation of a pilot school-based, toothbrushing programme

Background

While supervised toothbrushing programmes have been established in many countries of the world, little is known about different perspectives on their implementation. The aim of the study was to explore stakeholders' barriers and facilitators to implementation of a school-based toothbrushing programme in Taiwan.

Methods

Focus groups and interviews were used to explore the views of elementary school students, teachers, staff, and nurses in a piloted school-based toothbrushing programme. The topic guides were developed according to the Theoretical Domains Framework (TDF) to cover the behavioural factors systematically and comprehensively. Data were analysed with content analysis.

Results

Overall, 36 students, 29 teachers/staff, and five school nurses (N = 65) were included. The overarching theme was the importance of habit formation for both staff and children to ensure that toothbrushing as part of the programme was embedded into the school schedule and routine. While children did not necessarily appear to retain the dental knowledge which was taught in the programme, the provision of fluoride toothpaste and toothbrush for their use in schools allowing teachers and staff to choose the timing of the brushing and engaging classmates to supervise each other were found to be key factors.

Conclusions

Implementing a school-based toothbrushing programme with the support of staff and active engagement of children can help children to develop a toothbrushing habit. Classmate-supervised toothbrushing may reduce the burden on teachers and staff to implement the programme.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02494-7.

The mechanics of implementation strategies and measures: advancing the study of implementation mechanisms

BACKGROUND

There is a fundamental gap in understanding the causal mechanisms by which strategies for implementing evidence-based practices address local barriers to effective, appropriate service delivery. Until this gap is addressed, scientific knowledge and practical guidance about which implementation strategies to use in which contexts will remain elusive. This research project aims to identify plausible strategy-mechanism linkages, develop causal models for mechanism evaluation, produce measures needed to evaluate such linkages, and make these models, methods, and measures available in a user-friendly website. The specific aims are as follows: (1) build a database of strategy-mechanism linkages and associated causal pathway diagrams, (2) develop psychometrically strong, pragmatic measures of mechanisms, and (3) develop and disseminate a website of implementation mechanisms knowledge for use by diverse stakeholders.

METHODS

For the first aim, a combination of qualitative inquiry, expert panel methods, and causal pathway diagramming will be used to identify and confirm plausible strategy-mechanism linkages and articulate moderators, preconditions, and proximal and distal outcomes associated with those linkages. For the second aim, rapid-cycle measure development and testing methods will be employed to create reliable, valid, pragmatic measures of six mechanisms of common strategies for which no high-quality measures exist. For the third aim, we will develop a user-friendly website and searchable database that incorporates user-centered design, disseminating the final product using social marketing principles.

DISCUSSION

Once strategy-mechanism linkages are identified using this multi-method approach, implementation scientists can use the searchable database to develop tailored implementation strategies and generate more robust evidence about which strategies work best in which contexts. Moreover, practitioners will be better able to select implementation strategies to address their specific implementation problems. New horizons in implementation strategy development, optimization, evaluation, and deployment are expected to be more attainable as a result of this research, which will lead to enhanced implementation of evidence-based interventions for cancer control, and ultimately improvements in patient outcomes.

Effectiveness of a Multi-Strategy Behavioral Intervention to Increase Vegetable Sales in Primary School Canteens: A Randomized Controlled Trial

Children’s vegetable intake remains inadequate and school canteens may provide opportunities to address this public health concern. This study aimed to determine the effectiveness of an 8-week multi-strategy behavioral intervention that included vegetable provisioning and online menu architecture on vegetable sales in primary school canteens. A randomized controlled trial was undertaken in 16 Australian primary schools (n = 4302 students). The control arm kept their regular canteen menu. The primary outcome was vegetable sales measured by assessing vegetable content (in grams) from all menu items and using canteen sales (ordered online and over-the-counter) to calculate vegetable sales (in grams/week) at baseline (3 weeks) and during intervention implementation (8 weeks). Secondary outcomes were vegetable sales in subcategories, intervention acceptability among canteen managers and vegetable waste (four schools). Linear mixed model analysis showed that from baseline to follow-up, the intervention group had significantly higher weekly vegetable sales overall compared with the control group (2707 g/week, 95% CI 1276 to 4137 g/week; p < 0.001), with increased vegetable sales in the subcategories of burgers, hot foods and snacks, but not in sandwiches and pasta/rice dishes. The intervention did not lead to more vegetable waste, nor to a decrease in canteen revenue. The canteen managers found the intervention easy to implement and felt children responded favorably to three of the seven strategies. In conclusion, a multi-strategy behavioral canteen intervention increased vegetable sales amongst primary school students.

Opportunities and Capabilities to Perform Pelvic Floor Muscle Training Are Critical for Participation: A Systematic Review and Qualitative Meta-Synthesis

OBJECTIVE

Pelvic floor muscle training (PFMT) is considered a behavioral task that requires the interaction of physical, social, and cognitive processes. Enablers and barriers to participation in PFMT have been explored primarily in women. This review aimed to identify the barriers and enablers that influence participation in PFMT in all adult populations.

METHODS

A systematic review and meta-synthesis of qualitative literature was conducted. The inclusion criteria comprised qualitative studies with populations of people aged 18 years and older who have been recommended for PFMT. Line-by-line coding and an inductive thematic analysis identified themes that were applied to the Theoretical Domains Framework and Capabilities, Opportunities, and Motivation Behavioral Model to determine behavioral influences on PFMT.

RESULTS

Twenty full-text articles met inclusion criteria. PFMT was mostly influenced by individual opportunities impacted by social determinants and competing demands. Capability of carrying out PFMT was impacted by knowledge, understanding, and appropriate skill acquisition linked to self-efficacy.

CONCLUSION

Increasing opportunities and capabilities for engagement in PFMT are the most important factors in optimizing positive behavior changes. Ways to address these factors include clear patient communication to boost confidence in skill acquisition and using technology to encourage autonomy and improve convenience. Future research should address the impact of health professionals' beliefs about patient participation, assess the role of social values and gender roles, and explore the timing of the implementation of behavioral change strategies to improve PFMT.

IMPACT

This is believed to be the first systematic review and qualitative meta-synthesis to consider the enablers and barriers to participation in PFMT for all adult populations, purposes, and symptom complexes. Patient opportunities and capabilities are the greatest influencers on participation and self-efficacy. Individualized treatment approaches that acknowledge and address social influencers and competing demands will optimize self-efficacy and participation.

LAY SUMMARY

If you have pelvic floor muscle dysfunction, your opportunities and capabilities are the greatest influencers on participation and self-efficacy in PFMT. Your physical therapist can design individualized treatment approaches that acknowledge and address social influencers and competing demands to help you optimize participation.

Identifying barriers to the educational role of midwives in Cyprus and defining determinants in behaviour terms using the Behaviour Change Wheel: a mixed-method formative study

Background

Τhe Baby Buddy Cyprus webapp was co-created with parents and health professionals within a Participatory Action Research framework. While using Baby Buddy in routine consultations can support the educational role of mother–child healthcare providers (HP), antenatal education (AE) may be currently perceived as a formal activity within the physical space of the antenatal class. We aimed to gain an understanding of influences on midwives engaging in an educational role during routine appointments and identify potential interventions using the Behaviour Change Wheel (BCW) framework.

Methods

This is a formative mixed-methods research study, with a convergent parallel design, guided by the COM-B model and related Theoretical Domains Framework (TDF). Complimentary methods were used to collect information from in-training and registered midwives: focus group (N = 11), questionnaire survey (N = 24) and Nominal Group Technique during workshops (N = 40). Deductive content analysis of qualitative data and quantitative survey analysis shaped the behaviour diagnosis along the 6 COM-B and 14 TDF domains, and informed the selection of relevant intervention functions and related Behaviour Change Techniques from the BCW taxonomy.

Results

AE is viewed as a core function of the professional role, yet neither supported nor prioritized by current practices. Problematic areas relate to organizational context, such as weak interprofessional collaboration and lack of policy, protocols and resources. In addition, medicalization of birth and related socio-cultural norms, pertaining to users and providers, are sustaining alienation of the midwife and conditions of power dynamics. AE was perceived as a means to enhance the autonomy of the profession but there might be issues with procedural knowledge and the need for skill development was identified. Several intervention functions were identified as promising, however cognitive re-framing through strategic communication and modelling may also be needed both in terms of providing “credible models” for the role itself as well as re-framing AE through the concept of “making every contact count”.

Conclusions

AE is currently perceived to be a ‘bad fit’ with routine practice. The study identified several barriers to the educational role of midwives, influencing Capacity, Opportunity and Motivation. While digital tools, such as Baby Buddy, can facilitate aspects of the process, a much wider behaviour and system change intervention is needed to enhance midwives’ educational role and professional identity. In addition to proposing a theory-driven research-informed intervention, the process functioned as a participatory learning experience through collective reflection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08599-7.

Evaluating a train-the-trainer model for scaling-up Healthy Conversation Skills training: A pre-post survey using the Theoretical Domains Framework

OBJECTIVES

Healthy Conversation Skills (HCS) training is an established method of upskilling health professionals in person-centred behaviour change communication. A Train-the-Trainer (TtT) model was adopted to scale-up delivery of HCS training. This study examined the impact of the TtT course on new Trainers' perceived barriers and enablers to delivering HCS training using the Theoretical Domains Framework (TDF).

METHODS

The TtT course was delivered in 2019-2020. Pre-training (T1) and post-training (T2) surveys collected data on barriers and enablers to delivering HCS training based on 10 TDF domains. Data were summarised using descriptive statistics, and differences between pre- and post-training scores analysed using paired t-tests.

RESULTS

Forty-six trainees participated, including 43 women and 10 Aboriginal people. Scores for nine domains increased post-training, including knowledge, skills, social and professional role/identity, beliefs about capabilities, intentions, goals, environmental context and resources, social influences, and behavioural regulation. Knowledge, beliefs about consequences and intentions were no longer barriers to delivering HCS training after participating in the TtT course.

CONCLUSIONS

The TtT model supports new Trainers by addressing barriers to delivering HCS training.

PRACTICE IMPLICATIONS

The HCS TtT model builds healthcare workforce capacity for person-centred approaches to behaviour change. The findings facilitate the refinement of the TtT course.

Use of the Theoretical Domains Framework to explore factors influencing paediatric fever management practices and antipyretic use in New Zealand emergency departments

AIM

To explore factors influencing fever management practices and antipyretic use among New Zealand Emergency Department (ED) doctors and nurses using the Theoretical Domains Framework (TDF).

METHODS

Cross-sectional survey of doctors and nurses across 11 New Zealand EDs. The questionnaire examined eight of 12 TDF domains, based on a generic questionnaire validated to assess TDF-based determinants of health-care professional behaviour. Relevant domains were identified by the frequency of beliefs; the presence of conflicting beliefs within a domain; and the likely strength of impact of a belief on paediatric fever management in the ED.

RESULTS

About 602 participants (243 doctors, 353 nurses and 6 unknown) completed the survey (response rate 47.5%). Over half (351/591, 59.6%, 95% confidence interval (CI) 55.5-63.5%) knew the content of clinical practice guidelines regarding antipyretic use in febrile children (TDF Domain Knowledge), or had been trained to ensure antipyretics are given to febrile children only if they appear distressed (347/592, 58.6%, 95% CI 54.5-62.6%) (Skills). Over 40% (246/590, 95% CI 37.7-45.8%) aim to reduce the fever before discharge (Goals). Most (444/591, 75.1%, 95% CI 71.4-78.6%) participants felt capable of explaining appropriate antipyretic use to parents/care givers (Beliefs about Capabilities). Only a minority (155/584, 26.5%, 95% CI 23.0-30.3%) thought that they can ensure antipyretics are given to febrile children only if they appear distressed when the ED is busy (Environmental Context and Resources).

CONCLUSIONS

Using the TDF, we identified factors influencing fever management practices and antipyretic use in the ED. These factors can guide the design of targeted, theory-informed knowledge translation strategies.

A randomized controlled trial in schools aimed at exploring mechanisms of change of a multifaceted implementation strategy for promoting mental health at the workplace

Background

This study will explore implementation mechanisms through which a single implementation strategy and a multifaceted implementation strategy operate to affect the implementation outcome, which is fidelity to the Guideline For The Prevention of Mental Ill Health within schools. The guideline gives recommendations on how workplaces can prevent mental ill health among their personnel by managing social and organizational risks factors in the work environment. Schools are chosen as the setting for the study due to the high prevalence of mental ill health among teachers and other personnel working in schools. The study builds on our previous research, in which we compared the effectiveness of the two strategies on fidelity to the guideline. Small improvements in guideline adherence were observed for the majority of the indicators in the multifaceted strategy group. This study will focus on exploring the underlying mechanisms of change through which the implementation strategies may operate to affect the implementation outcome.

Methods

We will conduct a cluster-randomized-controlled trial among public schools (n=55 schools) in Sweden. Schools are randomized (1:1 ratio) to receive a multifaceted strategy (implementation teams, educational meeting, ongoing training, Plan-Do-Study-Act cycles) or a single strategy (implementation teams, educational meeting). The implementation outcome is fidelity to the guideline. Hypothesized mediators originate from the COM-B model. A mixed-method design will be employed, entailing a qualitative study of implementation process embedded within the cluster-randomized controlled trail examining implementation mechanisms. The methods will be used in a complementary manner to get a full understanding of the implementation mechanisms.

Discussion

This implementation study will provide valuable knowledge on how implementation strategies work (or fail) to affect implementation outcomes. The knowledge gained will aid the selection of effective implementation strategies that fit specific determinants, which is a priority for the field. Despite recent initiatives to advance the understanding of implementation mechanisms, studies testing these mechanisms are still uncommon.

Trial registration

ClinicalTrials.org dr.nr 2020-01214.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01230-7.