Cultural adaptation of a shared decision making tool with Aboriginal women: a qualitative study

Co-production of a systematic review on decision coaching: a mixed methods case study within a review

BACKGROUND

Co-production is a collaborative approach to prepare, plan, conduct, and apply research with those who will use or be impacted by research (knowledge users). Our team of knowledge users and researchers sought to conduct and evaluate co-production of a systematic review on decision coaching.

METHODS

We conducted a mixed-methods case study within a review to describe team co-production of a systematic review. We used the Collaborative Research Framework to support an integrated knowledge translation approach to guide a team through the steps in co-production of a systematic review. The team agreed to conduct self-study as a study within a review to learn from belonging to a co-production research team. A core group that includes a patient partner developed and conducted the study within a review. Data sources were surveys and documents. The study coordinator administered surveys to determine participant preferred and actual levels of engagement, experiences, and perceptions. We included frequency counts, content, and document analysis.

RESULTS

We describe co-production of a systematic review. Of 17 team members, 14 (82%) agreed to study participation and of those 12 (86%) provided data pre- and post-systematic review. Most participants identified as women (n = 9, 75.0%), researchers (n = 7, 58%), trainees (n = 4, 33%), and/or clinicians (n = 2, 17%) with two patient/caregiver partners (17%). The team self-organized study governance with an executive and Steering Committee and agreed on research co-production actions and strategies. Satisfaction for engagement in the 11 systematic review steps ranged from 75 to 92%, with one participant who did not respond to any of the questions (8%) for all. Participants reported positive experiences with team communication processes (n = 12, 100%), collaboration (n = 12, 100%), and negotiation (n = 10-12, 83-100%). Participants perceived the systematic review as co-produced (n = 12, 100%) with collaborative (n = 8, 67%) and engagement activities to characterize co-production (n = 8, 67%). Participants indicated that they would not change the co-production approach (n = 8, 66%). Five participants (42%) reported team logistics challenges and four (33%) were unaware of challenges.

CONCLUSIONS

Our results indicate that it is feasible to use an integrated knowledge translation approach to conduct a systematic review. We demonstrate the importance of a relational approach to research co-production, and that it is essential to plan and actively support team engagement in the research lifecycle.

Finding Your Way - A shared decision making resource developed by and for Aboriginal people in Australia: Perceived acceptability, usability, and feasibility

BACKGROUND

Finding Your Way is a culturally adapted shared decision making (SDM) resource for Aboriginal (First Nations) people of Australia. It integrates the Eight Ways of Aboriginal Learning (8 Ways) and was created by Aboriginal health workers and community members in New South Wales (NSW), Australia.

OBJECTIVE

To explore the perceived acceptability, usability, and feasibility of Finding Your Way as a SDM resource for Aboriginal people making health and wellbeing decisions.

METHODS

The web-based resources were disseminated using social media, professional networks, publications, and the 'Koori grapevine'. Thirteen 'champions' also promoted the resources. An online questionnaire was available on the website for three months. Framework analysis determined early indications of its acceptability, usability, and feasibility. Web and social media analytics were also analysed. Partnership with and leadership by Aboriginal people was integrated at all phases of the project.

RESULTS

The main landing page was accessed 5219 times by 4259 users. 132 users completed the questionnaire. The non-linear and visual aspects of the resources 'speak to mob' and identified with Aboriginal culture. The inclusion of social and emotional well-being, and the holistic approach were well received by the small number of users who opted to provide feedback. They suggested that non-digital formats and guidance on the resources are required to support use in clinical practice.

CONCLUSION

The 8 Ways enabled the development of a culturally safe SDM resource for Aboriginal people, which was well received by users who took the time to provide feedback after a brief dissemination process. Additional accessible formats, practice guides and training are required to support uptake in clinical practice.

PRACTICE IMPLICATIONS

Finding Your Way could be used to help improve experiences, health literacy, decision making quality and outcomes of healthcare for Aboriginal Australians.

Interventions for Indigenous Peoples making health decisions: a systematic review

BACKGROUND

Shared decision-making facilitates collaboration between patients and health care providers for informed health decisions. Our review identified interventions to support Indigenous Peoples making health decisions. The objectives were to synthesize evidence and identify factors that impact the use of shared decision making interventions.

METHODS

An Inuit and non-Inuit team of service providers and academic researchers used an integrated knowledge translation approach with framework synthesis to coproduce a systematic review. We developed a conceptual framework to organize and describe the shared decision making processes and guide identification of studies that describe interventions to support Indigenous Peoples making health decisions. We conducted a comprehensive search of electronic databases from September 2012 to March 2022, with a grey literature search. Two independent team members screened and quality appraised included studies for strengths and relevance of studies' contributions to shared decision making and Indigenous self-determination. Findings were analyzed descriptively in relation to the conceptual framework and reported using guidelines to ensure transparency and completeness in reporting and for equity-oriented systematic reviews.

RESULTS

Of 5068 citations screened, nine studies reported in ten publications were eligible for inclusion. We categorized the studies into clusters identified as: those inclusive of Indigenous knowledges and governance ("Indigenous-oriented")(n = 6); and those based on Western academic knowledge and governance ("Western-oriented")(n = 3). The studies were found to be of variable quality for contributions to shared decision making and self-determination, with Indigenous-oriented studies of higher quality overall than Western-oriented studies. Four themes are reflected in an updated conceptual framework: 1) where shared decision making takes place impacts decision making opportunities, 2) little is known about the characteristics of health care providers who engage in shared decision making processes, 3) community is a partner in shared decision making, 4) the shared decision making process involves trust-building.

CONCLUSIONS

There are few studies that report on and evaluate shared decision making interventions with Indigenous Peoples. Overall, Indigenous-oriented studies sought to make health care systems more amenable to shared decision making for Indigenous Peoples, while Western-oriented studies distanced shared decision making from the health care settings. Further studies that are solutions-focused and support Indigenous self-determination are needed.

How culture influences patient preferences for patient-centered care with their doctors

BACKGROUND

Patient-centered care (PCC) is the prevailing model of care globally. However, most research on PCC has been conducted in Westernized countries or has focused on only two facets of PCC: decision-making and information exchange. Our study examined how culture influences patients' preferences for five facets of PCC, including communication, decision-making, empathy, individualized focus, and relationship.

METHODS

Participants (N = 2071) from Hong Kong, the Philippines, Australia, and the U.S.A. completed an online survey assessing their preferences for exchange of information, autonomy in decision-making, expression and validation of their emotions, focus on them as an individual, and the doctor-patient relationship.

RESULTS

Participants from all four countries had similar preferences for empathy and shared decision-making. For other facets of PCC, participants in the Philippines and Australia expressed somewhat similar preferences, as did those in the U.S.A. and Hong Kong, challenging East-West stereotypes. Participants in the Philippines placed greater value on relationships, whereas Australians valued more autonomy. Participants in Hong Kong more commonly preferred doctor-directed care, with less importance placed on the relationship. Responses from U.S.A. participants were surprising, as they ranked the need for individualized care and two-way flow of information as least important.

CONCLUSIONS

Empathy, information exchange, and shared decision-making are values shared across countries, while preferences for how the information is shared, and the importance of the doctor-patient relationship differ.

Optimizing healthcare system by amalgamation of text processing and deep learning: a systematic review

The explosion of clinical textual data has drawn the attention of researchers. Owing to the abundance of clinical data, it is becoming difficult for healthcare professionals to take real-time measures. The tools and methods are lacking when compared to the amount of clinical data generated every day. This review aims to survey the text processing pipeline with deep learning methods such as CNN, RNN, LSTM, and GRU in the healthcare domain and discuss various applications such as clinical concept detection and extraction, medically aware dialogue systems, sentiment analysis of drug reviews shared online, clinical trial matching, and pharmacovigilance. In addition, we highlighted the major challenges in deploying text processing with deep learning to clinical textual data and identified the scope of research in this domain. Furthermore, we have discussed various resources that can be used in the future to optimize the healthcare domain by amalgamating text processing and deep learning.

The Aspects of Running Artificial Intelligence in Emergency Care; a Scoping Review

Introduction

Artificial Inteligence (AI) application in emergency medicine is subject to ethical and legal inconsistencies. The purposes of this study were to map the extent of AI applications in emergency medicine, to identify ethical issues related to the use of AI, and to propose an ethical framework for its use.

Methods

A comprehensive literature collection was compiled through electronic databases/internet search engines (PubMed, Web of Science Platform, MEDLINE, Scopus, Google Scholar/Academia, and ERIC) and reference lists. We considered studies published between 1 January 2014 and 6 October 2022. Articles that did not self-classify as studies of an AI intervention, those that were not relevant to Emergency Departments (EDs), and articles that did not report outcomes or evaluations were excluded. Descriptive and thematic analyses of data extracted from the included articles were conducted.

Results

A total of 137 out of the 2175 citations in the original database were eligible for full-text evaluation. Of these articles, 47 were included in the scoping review and considered for theme extraction. This review covers seven main areas of AI techniques in emergency medicine: Machine Learning (ML) Algorithms (10.64%), prehospital emergency management (12.76%), triage, patient acuity and disposition of patients (19.15%), disease and condition prediction (23.40%), emergency department management (17.03%), the future impact of AI on Emergency Medical Services (EMS) (8.51%), and ethical issues (8.51%).

Conclusion

There has been a rapid increase in AI research in emergency medicine in recent years. Several studies have demonstrated the potential of AI in diverse contexts, particularly when improving patient outcomes through predictive modelling. According to the synthesis of studies in our review, AI-based decision-making lacks transparency. This feature makes AI decision-making opaque.

Information extraction from German radiological reports for general clinical text and language understanding

Recent advances in deep learning and natural language processing (NLP) have opened many new opportunities for automatic text understanding and text processing in the medical field. This is of great benefit as many clinical downstream tasks rely on information from unstructured clinical documents. However, for low-resource languages like German, the use of modern text processing applications that require a large amount of training data proves to be difficult, as only few data sets are available mainly due to legal restrictions. In this study, we present an information extraction framework that was initially pre-trained on real-world computed tomographic (CT) reports of head examinations, followed by domain adaptive fine-tuning on reports from different imaging examinations. We show that in the pre-training phase, the semantic and contextual meaning of one clinical reporting domain can be captured and effectively transferred to foreign clinical imaging examinations. Moreover, we introduce an active learning approach with an intrinsic strategic sampling method to generate highly informative training data with low human annotation cost. We see that the model performance can be significantly improved by an appropriate selection of the data to be annotated, without the need to train the model on a specific downstream task. With a general annotation scheme that can be used not only in the radiology field but also in a broader clinical setting, we contribute to a more consistent labeling and annotation process that also facilitates the verification and evaluation of language models in the German clinical setting.

Construction and case study of a novel lung cancer risk index

PURPOSE

This study constructs a lung cancer risk index (LCRI) that incorporates many modifiable risk factors using an easily reproducible and adaptable method that relies on publicly available data.

METHODS

We used meta-analysis followed by Analytic Hierarchy Process (AHP) to generate a lung cancer risk index (LCRI) that incorporates seven modifiable risk factors (active smoking, indoor air pollution, occupational exposure, alcohol consumption, secondhand smoke exposure, outdoor air pollution, and radon exposure) for lung cancer. Using county-level population data, we then performed a case study in which we tailored the LCRI for use in the state of Illinois (LCRI_IL).

RESULTS

For both the LCRI and the LCRI_IL, active smoking had the highest weights (46.1% and 70%, respectively), whereas radon had the lowest weights (3.0% and 5.7%, respectively). The weights for alcohol consumption were 7.8% and 14.7% for the LCRI and the LCRI_IL, respectively, and were 3.8% and 0.95% for outdoor air pollution. Three variables were only included in the LCRI: indoor air pollution (18.5%), occupational exposure (13.2%), and secondhand smoke exposure (7.6%). The Consistency Ratio (CR) was well below the 0.1 cut point. The LCRI_IL was moderate though significantly correlated with age-adjusted lung cancer incidence (r = 0.449, P < 0.05) and mortality rates (r = 0.495, P < 0.05).

CONCLUSION

This study presents an index that incorporates multiple modifiable risk factors for lung cancer into one composite score. Since the LCRI allows data comprising the composite score to vary based on the location of interest, this measurement tool can be used for any geographic location where population-based data for individual risk factors exist. Researchers, policymakers, and public health professionals may utilize this framework to determine areas that are most in need of lung cancer-related interventions and resources.

Understanding how and under what circumstances decision coaching works for people making healthcare decisions: a realist review

Background

Decision coaching is non-directive support delivered by a trained healthcare provider to help people prepare to actively participate in making healthcare decisions. This study aimed to understand how and under what circumstances decision coaching works for people making healthcare decisions.

Methods

We followed the realist review methodology for this study. This study was built on a Cochrane systematic review of the effectiveness of decision coaching interventions for people facing healthcare decisions. It involved six iterative steps: (1) develop the initial program theory; (2) search for evidence; (3) select, appraise, and prioritize studies; (4) extract and organize data; (5) synthesize evidence; and (6) consult stakeholders and draw conclusions.

Results

We developed an initial program theory based on decision coaching theories and stakeholder feedback. Of the 2594 citations screened, we prioritized 27 papers for synthesis based on their relevance rating. To refine the program theory, we identified 12 context-mechanism-outcome (CMO) configurations. Essential mechanisms for decision coaching to be initiated include decision coaches’, patients’, and clinicians’ commitments to patients’ involvement in decision making and decision coaches’ knowledge and skills (four CMOs). CMOs during decision coaching are related to the patient (i.e., willing to confide, perceiving their decisional needs are recognized, acquiring knowledge, feeling supported), and the patient-decision coach interaction (i.e., exchanging information, sharing a common understanding of patient’s values) (five CMOs). After decision coaching, the patient’s progress in making or implementing a values-based preferred decision can be facilitated by the decision coach’s advocacy for the patient, and the patient’s deliberation upon options (two CMOs). Leadership support enables decision coaches to have access to essential resources to fulfill their role (one CMOs).

Discussion

In the refined program theory, decision coaching works when there is strong leadership support and commitment from decision coaches, clinicians, and patients. Decision coaches need to be capable in coaching, encourage patients’ participation, build a trusting relationship with patients, and act as a liaison between patients and clinicians to facilitate patients’ progress in making or implementing an informed values-based preferred option. More empirical studies, especially qualitative and process evaluation studies, are needed to further refine the program theory.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-02007-0.

Health professionals knowledge of telemedicine and its associated factors working at private hospitals in resource-limited settings

Introduction

The appropriate implementation of telemedicine in the healthcare system has the potential to overcome global problems such as accessibility and quality healthcare services. Thus assessing the knowledge of health professionals before the actual adoption of telemedicine is considered a prominent solution to the problems.

Objective

This study aimed to assess healthcare professionals' knowledge of telemedicine and its associated factors at private hospitals in low-resource settings.

Method

An institution-based cross-sectional study was conducted among 423 health professionals at private hospitals in low-income settings in Ethiopia, from March to April 2021. Data collection was performed by pretested and self-administered questionnaires. This study employed statistical packages for social sciences software. This study employed multivariable logistic regression to determine dependent and independent variables associated with adjusted odd ratio and 95% CI.

Result

in this study about 65.8% of health professionals have good knowledge on Telemedicine .Computer literacy (AOR = 2.9; 95% CI: 1.8, 4.6), computer training (AOR = 2.0; 95% CI: 1.2, 3.3), Internet availability at workplace (AOR = 2.1; 95%CI: 1.3, 3.4), had private laptop (AOR = 1.7; 95% CI: 1.1, 2.9) were significantly associated with knowledge.

Conclusion and recommendation

In general health professionals had good knowledge of Telemedicine. Inclusive packages of capacity by training among health providers are fundamental for the successful implementation of telemedicine.

Decision aids for home and community care: a systematic review

OBJECTIVES

Decision aids (DAs) for clients in home and community care can support shared decision-making (SDM) with patients, healthcare teams and informal caregivers. We aimed to identify DAs developed for home and community care, verify their adherence to international DA criteria and explore the involvement of interprofessional teams in their development and use.

DESIGN

Systematic review reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

Six electronic bibliographic databases (MEDLINE, Embase, CINAHL Plus, Web of Science, PsycINFO and the Cochrane Library) from inception to November 2019, social media and grey literature websites up to January 2021.

ELIGIBILITY CRITERIA

DAs designed for home and community care settings or including home care or community services as options.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently reviewed citations. Analysis consisted of a narrative synthesis of outcomes and a thematic analysis. DAs were appraised using the International Patient Decision Aid Standards (IPDAS). We collected information on the involvement of interprofessional teams, including nurses, in their development and use.

RESULTS

After reviewing 10 337 database citations and 924 grey literature citations, we extracted characteristics of 33 included DAs. DAs addressed a variety of decision points. Nearly half (42%) were relevant to older adults. Several DAs did not meet IPDAS criteria. Involvement of nurses and interprofessional teams in the development and use of DAs was minimal (33.3% of DAs).

CONCLUSION

DAs concerned a variety of decisions, especially those related to older people. This reflects the complexity of decisions and need for better support in this sector. There is little evidence about the involvement of interprofessional teams in the development and use of DAs in home and community care settings. An interprofessional approach to designing DAs for home care could facilitate SDM with people being cared for by teams.

PROSPERO REGISTRATION NUMBER

CRD42020169450.

sPLINK: a hybrid federated tool as a robust alternative to meta-analysis in genome-wide association studies

Meta-analysis has been established as an effective approach to combining summary statistics of several genome-wide association studies (GWAS). However, the accuracy of meta-analysis can be attenuated in the presence of cross-study heterogeneity. We present sPLINK, a hybrid federated and user-friendly tool, which performs privacy-aware GWAS on distributed datasets while preserving the accuracy of the results. sPLINK is robust against heterogeneous distributions of data across cohorts while meta-analysis considerably loses accuracy in such scenarios. sPLINK achieves practical runtime and acceptable network usage for chi-square and linear/logistic regression tests. sPLINK is available at https://exbio.wzw.tum.de/splink .

Multimorbidity and adverse events of special interest associated with Covid-19 vaccines in Hong Kong

Prior research using electronic health records for Covid-19 vaccine safety monitoring typically focuses on specific disease groups and excludes individuals with multimorbidity, defined as ≥2 chronic conditions. We examine the potential additional risk of adverse events 28 days after the first dose of CoronaVac or Comirnaty imposed by multimorbidity. Using a territory-wide public healthcare database with population-based vaccination records in Hong Kong, we analyze a retrospective cohort of patients with chronic conditions. Thirty adverse events of special interest according to the World Health Organization are examined. In total, 883,416 patients are included and 2,807 (0.3%) develop adverse events. Results suggest vaccinated patients have lower risks of adverse events than unvaccinated individuals, multimorbidity is associated with increased risks regardless of vaccination, and the association of vaccination with adverse events is not modified by multimorbidity. To conclude, we find no evidence that multimorbidity imposes extra risks of adverse events following Covid-19 vaccination.

Polypharmacy Exposure, Aging Populations, and COVID-19: Considerations for Healthcare Providers and Public Health Practitioners in Africa

Given the continent's growing aging population and expanding prevalence of multimorbidity, polypharmacy is an increasingly dire threat to the health of persons living in Africa. The COVID-19 pandemic has only exacerbated these issues. Widespread misinformation, lack of vaccine access, and attempts to avoid being infected have resulted in increases in Africans' willingness to take multiple prescription and nonprescription medications and supplements. Issues with counterfeit pharmaceuticals and the relatively new recognition of emergency medicine as a specialty across the continent also create unique challenges for addressing this urgent public health need. Experts have called for more robust pharmaceutical regulation and healthcare/public health infrastructure investments across the continent. However, these changes take time, and more near-term strategies are needed to mitigate current health needs. In this commentary, we present a nonexhaustive set of immediately implementable recommendations that can serve as local strategies to address current polypharmacy-related health needs of Africans. Importantly, our recommendations take into consideration that not all healthcare providers are emergency medicine trained and that local trends related to polypharmacy will change over time and require ever-evolving public health initiatives. Still, by bolstering training to safeguard against provider availability biases, practicing evidence-based prescribing and shared decision making, and tracking and sharing local trends related to polypharmacy, African healthcare providers and public health practitioners can better position themselves to meet population needs. Furthermore, although these recommendations are tailored to Africans, they may also prove useful to providers and practitioners in other regions facing similar challenges.

Adaptation of a Shared Decision-Making Tool for Early Rheumatoid Arthritis Treatment Decisions with Indigenous Patients

Background

Patient decision aids (PtDAs) enable shared decision-making between patients and healthcare providers. Adaptations to PtDAs for use with populations facing inequities in healthcare can improve the relevancy of information presented, incorporate appropriate cultural context, and address health literacy concerns. Our objective was to adapt the Early RA (rheumatoid arthritis) PtDA for use with Canadian Indigenous patients.

Methods

The Early RA PtDA was modified through an iterative process using data obtained from semi-structured interviews of two sequential cohorts of Indigenous patients with RA. Interview data were analyzed using thematic analysis.

Results

Seven participants provided initial feedback on the existing PtDA. The modifications they suggested were made and shared with another nine participants to confirm acceptability and provide further feedback. The first cohort suggested revisions to clarify medical and cost coverage information, include Indigenous traditional healing practice options, simplify text, and include Indigenous images and colors aligned with Canadian Indigenous community representation. Additional revisions were suggested by the second cohort to increase the legibility of the text, insert more Indigenous imagery, address formulary coverage for non-status First Nations patients, and include information about lifestyle factors in managing RA.

Conclusion

Incorporating Indigenous-specific adaptations in the design of PtDAs may increase use and relevancy to support engagement in treatment decisions, thereby supporting health-equity oriented health service interventions. Indigenous patient-specific evidence and translation of key words into the end-users’ Indigenous languages should be included for implementation of the PtDA.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40271-021-00546-8.

Collaborative Relationship-Focused Occupational Therapy: Evolving Lexicon and Practice

BACKGROUND.

Client-centred practice has been part of occupational therapists' identity for several decades. However, therapists have begun to question whether the term obstructs critical relational aspects of therapy.

PURPOSE.

The purpose of this article is to summarize critiques of the use of the term client-centred and propose an expanded descriptor and a fundamental shift in how occupational therapists engage with individuals, families, groups, communities, and populations.

KEY ISSUES.

Three themes summarize critiques of how client-centred practice has been envisioned: (a) the language of client-centred, (b) insufficient appreciation of how the therapist affects the relationship, and (c) inadequate consideration of the relational context of occupation. We propose collaborative relationship-focused practice that has key relational elements of being contextually relevant, nuanced, and safe, and promotes rights-based self-determination.

CONCLUSION.

We argue that these essential relational elements, along with a focus on occupations, are required to promote occupational participation, equity, and justice.

Towards attainment of Indigenous health through empowerment: resetting health systems, services and provider approaches

Colonial policies and practices have introduced significant health challenges for Indigenous populations in commonwealth countries. Health systems and models of care were shaped for dominant society, and were not contextualised for Indigenous communities nor with provision of Indigenous cultural approaches to maintain health and wellness. Shifts to support Indigenous health outcomes have been challenged by debate on identifying which system and service components are to be included, implementation approaches, the lack of contextualised evaluation of implemented models to justify financial investments, but most importantly lack of effort in ensuring equity and participation by affected communities to uphold Indigenous rights to health. Prioritising the involvement, collaboration and empowerment of Indigenous communities and leadership are critical to successful transformation of healthcare in Indigenous communities. Locally determined priorities and solutions can be enacted to meet community and individual needs, and advance health attainment. In this paper, existing successful and sustainable models that demonstrate the empowerment of Indigenous peoples and communities in advocating for, designing, delivering and leading health and wellness supports are shared.

Participatory design and qualitative evaluation of a decision guide for workplace human immunodeficiency virus self-disclosure: The importance of a socio-ecological perspective

Background

Disclosure of human immunodeficiency virus (HIV)‐positive status in a workplace can be a complex social decision for a person living with HIV.

Objective

To design a Decision Guide to support people living with HIV in assessing contexts, risks and benefits of workplace disclosure in choosing whether or not, or to what extent, to disclose. In this report, we review the participatory design of a Decision Guide prototype and focus on its evaluation.

Methods

We began with stakeholder input through an environmental scan and community consultation that informed the development of an online Decision Guide prototype. To evaluate the comprehensiveness, acceptability and usability of the prototype, we used qualitative methodology involving individual interviews and the think‐aloud technique. Interviews were transcribed and analysed qualitatively.

Results

Fourteen people, including people living with HIV and service providers, participated. We identified benefits of the Decision Guide related to comprehensiveness, acceptability and usability. Additional interview themes focused on disclosure concerns, mitigating risks associated with disclosure and additional considerations for the Decision Guide.

Conclusions

The Decision Guide was perceived to be acceptable, comprehensive and useful. The findings endorse the application of a socio‐ecological perspective when designing decision support aids for complex social decisions.

Patient or public contribution

People with lived experience of HIV were involved in the prototype design phases as research team members. They, along with community leaders and service providers, also participated in a community forum and were key informants for the evaluation of the Workplace Disclosure Decision Guide prototype.

Experiences of Inuit in Canada who travel from remote settings for cancer care and impacts on decision making

BACKGROUND

Inuit experience the highest cancer mortality rates from lung cancer in the world with increasing rates of other cancers in addition to other significant health burdens. Inuit who live in remote areas must often travel thousands of kilometers to large urban centres in southern Canada and negotiate complex and sometimes unwelcoming health care systems. There is an urgent need to improve Inuit access to and use of health care. Our study objective was to understand the experiences of Inuit in Canada who travel from a remote to an urban setting for cancer care, and the impacts on their opportunities to participate in decisions during their journey to receive cancer care.

METHODS

We are an interdisciplinary team of Steering Committee and researcher partners ("the team") from Inuit-led and/or -specific organizations that span Nunavut and the Ontario cancer health systems. Guided by Inuit societal values, we used an integrated knowledge translation (KT) approach with qualitative methods. We conducted semi-structured interviews with Inuit participants and used process mapping and thematic analysis.

RESULTS

We mapped the journey to receive cancer care and related the findings of client (n = 8) and medical escort (n = 6) ("participant") interviews in four themes: 1) It is hard to take part in decisions about getting health care; 2) No one explains the decisions you will need to make; 3) There is a duty to make decisions that support family and community; 4) The lack of knowledge impacts opportunities to engage in decision making. Participants described themselves as directed, with little or no support, and seeking opportunities to collaborate with others on the journey to receive cancer care.

CONCLUSIONS

We describe the journey to receive cancer care as a "decision chain" which can be described as a series of events that lead to receiving cancer care. We identify points in the decision chain that could better prepare Inuit to participate in decisions related to their cancer care. We propose that there are opportunities to build further health care system capacity to support Inuit and enable their participation in decisions related to their cancer care while upholding and incorporating Inuit knowledge.

Development of a Decision Aid for Patients and Families Considering Hospice

Background: Hospice is underutilized. Miscommunication, decisional complexity, and misunderstanding around engaging hospice may contribute. Shared decision making (SDM), aided by patient decision aids (PtDAs), can improve knowledge and decision quality. Currently, there are no freely available hospice-specific PtDA to facilitate conversions between patients and providers about hospice care. Objective: To develop a theory-based and unbiased hospice specific PtDA. Design: Guided by the Ottawa Decision Support Framework and International Patient Decision Aid Standards, we used a theory-driven, eight-step, iterative, user-centered approach with multistakeholder input to develop a hospice-specific PtDA for anyone facing end-of-life decisions. Subjects: Feedback was obtained from a 10-member Patient Advisory Panel composed of lay patient advisors; focus groups of hospice providers, family caregivers, and patients; and the Palliative Care Research Group at University of Colorado Hospital consisting of palliative care physicians, midlevel providers, nurses, social workers, chaplains, and researchers. Results: There are many challenges in developing an unbiased hospice decision aid, including (1) balancing the provision of education (eligibility, payment) with decisional support, (2) clarifying values and incorporating emotion, (3) ideally representing the potential downsides of hospice, and (4) adequately capturing and describing care alternatives to hospice. Within this context, we developed a 12-page article and 17-minute video PtDAs. The PtDA openly acknowledges the emotional complexity of the decision and incorporates values clarification techniques to help decision makers reflect and evaluate their goals and preferences for end-of-life care. Conclusions: Hospice decision making is complex and emotional, demanding high-quality SDM aided by a formal PtDA. This work resulted in a freely available article and video PtDA for patients considering hospice. The effectiveness and implementation of these tools will be studied in future research. Clinical Trials Registration (NCT03794700 & NCT04458090).

Development of a novel gout treatment patient decision aid by patient and physician: A qualitative research study

BACKGROUND

Gout treatment is not optimized globally, often due to therapeutic inertia by physicians or poor adherence to urate-lowering medications by patients. A patient decision aid (PDA) to facilitate shared decision making (SDM) in gout treatment may overcome these physician-patient barriers.

OBJECTIVE

The study explored the views of physicians and patients on a novel locally designed gout treatment PDA prototype.

DESIGN

Qualitative descriptive design was used to gather data from in-depth-interviews (IDI) and focus group discussions (FGD). Data analysis was via thematic analysis. Emergent themes shaped a revised version of the PDA.

SETTING AND PARTICIPANTS

Adult Asian patients with recent acute gout exacerbations and local Primary Care Physicians (PCP) in Singapore were purposefully chosen. 15 patients with gout and 11 PCPs participated across three IDIs and six FGDs, with the investigators exploring their views of a prototype gout treatment PDA.

RESULTS

Patients and physicians generally concurred with the content and design of the PDA prototype. However, while patients preferred fewer treatment details, the PCPs desired more information. Patients preferred the display of statistics, while PCPs felt that numbers were not relevant to patients. The latter were hesitant to include treatment options that were unavailable in primary care. Both stakeholders indicated that they would use the PDA during a consultation. PCPs would need further training in SDM, given a lack of understanding of it.

CONCLUSION AND PATIENT CONTRIBUTION

Patients will be the prime users of the PDA. While their views differed partially from the physicians, both have jointly developed the novel gout treatment PDA.

Decision Needs and Preferred Strategies for Shared Decision Making in Rheumatoid Arthritis: Perspectives of Canadian Urban Indigenous Women

OBJECTIVE

Decision making for treatment of rheumatoid arthritis (RA) is complex, with multiple beneficial medication options available, but with the potential for treatment-related adverse effects and significant economic considerations. Indigenous patients make treatment decisions informed by an interplay of clinical, family, and societal factors. Shared decision-making (SDM) may represent an approach to support treatment decisions in a culturally congruent manner. The study identified aspects of arthritis care that Indigenous participants found relevant for SDM and explored preferences for SDM strategies.

METHODS

A purposive sampling from rheumatology clinics that provide services to Indigenous patients in a Canadian urban centre was used to recruit participants for interviews. Seven participants were recruited to reach content saturation. Interview content was coded by two individuals, including an Indigenous patient with RA, and the data were analyzed via thematic analysis.

RESULTS

Participants were all women aged 37-61 years living with RA. Participants supported that SDM would be beneficial, primarily to support decisions around treatment plans and medication changes. SDM approaches would need to reflect Indigenous-specific content areas, such as benefits and risks of therapy informed by data from Indigenous patient populations and inclusion of traditional modes of healing. All participants were interested in having a decision coach and preferred that decision aids be in both paper and electronic formats for accessibility.

CONCLUSIONS

This study advances knowledge in the priority areas and specific content needed in the SDM process, and the preferences of SDM strategies relevant and appropriate for urban Indigenous women living with RA in Canada.

Factors Influencing Pregnant Women's Use of Patient Decision Aids and Decision Making on Prenatal Screening: A Qualitative Study

Objective: We aimed to identify factors influencing pregnant women’s use of patient decision aids (PtDA) and decision making on prenatal screening.

Materials and methods: This qualitative study was conducted between July 2019 and June 2020 in Tehran, Iran. The sample included 26 pregnant women selected by purposive sampling. The participants used a prenatal screening PtDA, then interviewed about factors that would influence their decision making and use of decision aids. The data were analyzed by conventional content analysis.

Results: Three categories were identified for the process of and factors influencing decision making, including the current decision making process, expected decision making process, and factors influencing decision making. Also, five categories were identified as factors affecting the use of PtDAs, including the content of decision aids, the appearance of decision aids, the decision aid platform, the provision of decision aids, and the sub features of decision aids.

Conclusion: To design, develop, and implementation of PtDAs for pregnant women, one should identify the factors affecting pregnant women’s decision making and the use of decision aids. This study helped to the identification of these factors, which is the first step towards the use of PtDAs by pregnant women and their participation in decision making.

Barriers to eHealth adoption in routine antenatal care practices: Perspectives of expectant mothers in Uganda - A qualitative study using the unified theory of acceptance and use of technology model

Current empirical evidence suggests that successful adoption of eHealth systems improves maternal health outcomes, yet there are still existing gaps in adopting such systems in Uganda. Service delivery in maternal health is operating in a spectrum of inadequacy, hence eHealth adoption cannot ensue. This study set out to explore the challenges that impede eHealth adoption in women's routine antenatal care practices in Uganda. A qualitative approach using semi-structured interviews was employed to document challenges. These challenges were classified based on a unified theory of acceptance and use of technology constructs. One hundred and fifteen expectant mothers, aged between 18 and 49 years, who spoke either English or Luganda were included in the study that took place between January to May 2019. Thematic analysis using template analysis was adopted to analyse qualitative responses. Challenges were categorised based on five principal unified theories of acceptance and use of technology constructs namely: performance expectancy, effort expectancy, social influence, facilitating conditions and behavioural intention. Facilitating conditions had more influence on technology acceptance and adoption than the other four constructs. Specifically, the lack of training prior to using the system, technical support, computers and smart phones had a downhill effect on adoption. Subsequently, the cost of data services, internet intermittency, and the lack of systems that bridge the gap between mothers and health providers further hindered technology uptake. In conclusion, strategies such as co-development, training end-users, garnering support at the national and hospital levels should be advocated to improve user acceptance of technology.

A Survey of Potentially Modifiable Patient-Level Factors Associated with Self-Report and Objectively Measured Adherence to Adjuvant Endocrine Therapies After Breast Cancer

PURPOSE

Despite the efficacy of adjuvant endocrine therapy (AET) in reducing breast cancer recurrence and mortality, suboptimal AET adherence is common and hence an important clinical issue among breast cancer survivors. Delineating potentially modifiable patient-level factors associated with AET adherence may support the development of successful adherence-enhancing interventions.

PATIENTS AND METHODS

The present study included 133 breast cancer survivors prescribed AET recruited from a cancer pharmacy. Women completed a baseline questionnaire examining psychosocial factors and self-reported adherence and consented to their prescription records being monitored for the proceeding 12 months to ascertain proportion of days covered (PDC), an objective measure of adherence. Regression analyses were used to identify the factors most strongly associated with both self-reported and objective adherence. Exploratory moderation analyses examined whether factors were differentially associated with adherence based on AET type (aromatase inhibitors or tamoxifen).

RESULTS

Adherence was high in this sample (PDC over 12 months was 95%). Side effect severity was most strongly associated with self-reported adherence, followed by self-efficacy, and medication/healthcare system-related barriers. Medication/healthcare system-related barriers was the only factor that uniquely predicted objective adherence. Within medication/healthcare system-related barriers, fear of side effects was most strongly associated with both measures of adherence. There were no significant interactions between AET type and potentially modifiable factors in predicting self-reported or objective adherence.

CONCLUSION

Side effects, reactions to side effects, and self-efficacy may represent modifiable targets through which AET adherence can be improved. Associations between potentially modifiable factors and adherence did not vary by AET type, despite distinct side-effect profiles.

What older adults and their caregivers need for making better health-related decisions at home: a participatory mixed methods protocol

INTRODUCTION

Shared decision making is an interpersonal process whereby healthcare providers collaborate with and support patients in decision-making. Older adults receiving home care need support with decision-making. We will explore what older adults receiving home care and their caregivers need for making better health-related decisions.

METHODS AND ANALYSIS

This two-phase sequential exploratory mixed methods study will be conducted in a pan-Canadian healthcare organisation, SE Health. First, we will create a participant advisory group to advise us throughout the research process. In phase 1 (qualitative), we will recruit a convenience sample of 15-30 older adults and caregivers receiving home care to participate in open-ended semi-structured interviews. Phase 1 participants will be invited to share what health-related decisions they face at home and what they need for making better decisions. In phase 2 (quantitative), interdisciplinary health and social care providers will be invited to answer a web-based survey to share their views on the decisional needs of older adults and their caregivers. The survey will include questions informed by findings from qualitative interviews in phase 1, and a workbook for assessing decisional needs based on the Ottawa Decision Support Framework. Finally, qualitative and quantitative results will be triangulated (by methods, investigator, theory and source) to develop a comprehensive understanding of decision-making needs from the perspective of older adults, caregivers and health and social care providers. We will use the quality of mixed methods studies in health services research guidelines and the Checklist for Reporting the Results of Internet E-Surveys checklist.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the research ethics boards at Southlake Regional Health Centre and Université Laval. This study will inform the design of decision support interventions. Further dissemination plans include summary briefs for study participants, tailored reports for home care decision makers and policy makers, and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT04327830.

Qualitative Study of Treatment Preferences for Rheumatoid Arthritis and Pharmacotherapy Acceptance: Indigenous Patient Perspectives

Objective

To explore patient preferences that influence decision‐making in the management of rheumatoid arthritis (RA) by indigenous patients living in southern Alberta, Canada.

Methods

We conducted a qualitative narrative‐based study within a social constructivist framework. Thirteen in‐depth interviews with indigenous patients with RA who had attended 1 of 3 rheumatology practices in southern Alberta (1 rural and 2 urban) were completed. Codes generated through 2 phases of analysis were condensed into main themes, triangulated, and used to produce theoretical statements.

Results

Patients preferred to use a combination of nonpharmacologic and pharmacologic treatments to manage their RA. Nonpharmacologic treatments included physical, mental, emotional, and spiritual strategies. Patients’ preferences for taking medications varied and were influenced by factors that were clinical (i.e., trust in health providers and understanding drugs’ mechanisms of action, benefits, harms, and administration burden), familial (i.e., support), and societal (i.e., access to medications and stigmatization of drug dependency).

Conclusion

Indigenous patients apply a holistic approach to the nonpharmacologic management of RA. Increases in preferences for RA medications could be supported through enhanced communication strategies to increase patient understanding of medication effects and health provider recognition of societal and familial influences on patient decisions. A patient–provider relationship based on trust was fundamental to reaching mutual understanding and should be fostered by models of practice that promote cultural safety, empathy, compassion, openness, acknowledgment, and respect of cultural differences.

Trust and world view in shared decision making with indigenous patients: A realist synthesis

INTRODUCTION

How shared decision making (SDM) works with indigenous patient values and preferences is not well understood. Colonization has affected indigenous peoples' levels of trust with institutions, and their world view tends to be distinct from that of nonindigenous people. Building on a programme theory for SDM, the present research aims to refine the original programme theory to understand how the mechanisms of trust and world view might work differently for indigenous patients.

DESIGN

We used a six-step iterative process for realist synthesis: preliminary programme theory development, search strategy development, selection and appraisal of literature, data extraction, data analysis and synthesis, and formation of a revised programme theory.

DATA SOURCES

Searches were through Medline, CINAHL, and the University of Saskatchewan iPortal for grey literature. Medline and CINAHL searches included the University of Alberta Canada-wide indigenous peoples search filters.

DATA SYNTHESIS

Following screening 731 references, 90 documents were included for data extraction (53 peer reviewed and 37 grey literature). Documents from countries with similar colonization experiences were included.

RESULTS

A total of 518 context-mechanism-outcome (CMO) configurations were identified and synthesized into 21 CMOs for a revised programme theory. Demographics, indigenous world view, system and institutional support, language barriers, and the macro-context of discrimination and historical abuse provided the main contexts for the programme theory. These inspired mechanisms of reciprocal respect, perception of world view acceptance, and culturally appropriate knowledge translation. In turn, these mechanisms influenced the level of trust and anxiety experienced by indigenous patients. Trust and anxiety were both mechanisms and intermediate outcomes and determined the level of engagement in SDM.

CONCLUSION

This realist synthesis provides clinicians and policymakers a deeper understanding of the complex configurations that influence indigenous patient engagement in SDM and offers possible avenues for improvement.

Health worker acceptability of an mHealth platform to facilitate the prevention of mother-to-child transmission of HIV in Tanzania

Objectives

Health workers (HWs) are increasingly using mobile health (mHealth) technologies in low-resource settings. Understanding HW acceptability of mHealth is critical to increasing the scale of mHealth solutions. We examined pre- and post-pilot clinical knowledge and acceptability of a tablet-based platform, the Tanzania Health Information System (T-HIT), targeting HWs delivering prevention of mother-to-child transmission (PMTCT) of HIV services in seven health facilities in Misungwi District, Tanzania.

Methods

We developed a survey based on the diffusion of innovation theory and administered it to 27 HWs before and after a 3-month pilot of T-HIT. Using a Wilcoxon signed-rank test, we analyzed changes in acceptability defined as attitudes towards and self-efficacy for system use comparing pre- and post-test assessment scores and changes in knowledge of clinical care. Using analysis of variance, we explored these changes, stratifying health facilities by level of care and by distance from the district hospital.

Results

Post-pilot scores showed statistically significant improvement from pre-test for the total survey (Z = −2.67, p < 0.008) and for questions concerning system attitude (Z = −2.63, p < 0.008). HWs in hospitals and health centers exhibited a lower initial level of system acceptability in attitude than those in dispensaries and a significant improvement in overall mean acceptability over the pilot (95% CI 0.004–0.0187). HWs working more than 20 km from the hospital had a lower initial level of both system knowledge and acceptability than their less remote counterparts, but demonstrated larger improvements in knowledge and acceptability over time, although this change was not statistically significant.

Conclusions

The pilot demonstrates that HWs in PMTCT in Misungwi have a high acceptability of mHealth solutions. Using an mHealth solution can facilitate HW delivery of PMTCT care in rural and remote settings. Consideration of acceptability is important for fostering mHealth scale and program sustainability.

The "Preparation for Shared Decision-Making" Tool for Women With Advanced Breast Cancer: Qualitative Validation Study

Background

The range of decisions and considerations that women with advanced breast cancer (ABC) face can be overwhelming and difficult to manage. Research shows that most patients prefer a shared decision-making (SDM) approach as it provides them with the opportunity to be actively involved in their treatment decisions. The current engagement of these patients in their clinical decisions is suboptimal. Moreover, implementing SDM into routine clinical care can be challenging as patients may not always feel adequately prepared or may not expect to be involved in the decision-making process.

Objective

Avalere Health developed the Preparation for Shared Decision-Making (PFSDM) tool to help patients with ABC feel prepared to communicate with their clinicians and engage in decision making aligned with their preferences. The goal of this study was to validate the tool for its acceptability and usability among this patient population.

Methods

We interviewed a diverse group of women with ABC (N=30). Interviews were audiorecorded, transcribed, and double coded by using NVivo. We assessed 8 themes to understand the acceptability and usability of the tool.

Results

Interviewees expressed that the tool was acceptable for preparing patients for decision making and would be useful for helping patients know what to expect in their care journey. Interviewees also provided useful comments to improve the tool.

Conclusions

This validation study confirms the acceptability and usability of the PFSDM tool for women with ABC. Future research should assess the feasibility of the tool’s implementation in the clinical workflow and its impact on patient outcomes.

Early Rheumatoid Arthritis Presentation, Treatment, and Outcomes in Aboriginal Patients in Canada: A Canadian Early Arthritis Cohort Study Analysis

OBJECTIVE

Health inequities exist in chronic diseases for Aboriginal people. This study compared early rheumatoid arthritis (RA) presentation, treatment, and outcomes between Aboriginal and white patients in a large Canadian cohort study.

METHODS

Longitudinal data from the Canadian Early Arthritis Cohort, a prospective multicenter early RA study, were analyzed for participants who self-identified as Aboriginal or white ethnicity. Disease characteristics at presentation, prognostic factors, frequency of remission, and disease-modifying therapy strategies were contrasted between population groups. Linear mixed models were used to estimate rates of change for disease activity measures over a 5-year period.

RESULTS

At baseline, 2,173 participants (100 Aboriginal and 2,073 white) had similar mean ± SD symptom duration (179 ± 91 days), 28-joint Disease Activity Scores (DAS28; 4.87 ± 1.48), and Health Assessment Questionnaire (0.88 ± 0.68) scores. Factors associated with poor prognosis were more frequently present in Aboriginal participants, but disease-modifying therapy selection and frequency of therapy escalation was similar between the 2 groups. DAS28 remission was achieved less frequently in Aboriginal than in white participants (adjusted odds ratio 0.39 [95% confidence interval 0.25-0.62]). Results were primarily driven by slower improvement in swollen joint counts and nonsignificant improvement in patient global scores in Aboriginal participants. Pain levels remained higher in Aboriginal patients.

CONCLUSION

Aboriginal early RA patients experienced worse disease outcomes than their white counterparts. This may reflect unmeasured biologic differences and/or disparities in prognostic factors informed by inequities in determinants of health. The appropriateness of current treatment strategies applied in different contexts should be considered.

An integrated knowledge translation approach to develop a shared decision-making strategy for use by Inuit in cancer care: a qualitative study

Background

In relation to the general Canadian population, Inuit face increased cancer risks and barriers to health services use. In shared decision-making (sdm), health care providers and patients make health care decisions together. Enhanced participation in cancer care decisions is a need for Inuit. Integrated knowledge translation (kt) supports the development of research evidence that is likely to be patient-centred and applied in practice.

Objective

Using an integrated kt approach, we set out to promote the use of sdm by Inuit in cancer care.

Methods

An integrated kt study involving researchers with a Steering Committee of cancer care system partners who support Inuit in cancer care ("the team") consisted of 2 theory-driven phases:■ using consensus-building methods to tailor a previously developed sdm strategy and developing training in the sdm strategy; and■ training community support workers (csws) in the sdm strategy and testing the sdm strategy with community members.

Results

The team developed a sdm strategy that included a workshop and a booklet with 6 questions for use by csws with patients. The sdm strategy (training and booklet) was finalized based on feedback from 5 urban-based Inuit csws who were recruited and trained in using the strategy. Trained csws were matched with 8 community members, and use of the sdm strategy was assessed during interviews, reported as 6 themes. Participants found the sdm strategy to be useful and feasible for use.

Conclusions

An integrated kt approach of structured research processes with partners developed a sdm strategy for use by Inuit in cancer care. Further work is needed to test the sdm strategy.

Personalised Warfarin Dosing in Children Post-cardiac Surgery

Warfarin dosing is challenging due to a multitude of factors affecting its pharmacokinetics (PK) and pharmacodynamics (PD). A novel personalised dosing algorithm predicated on a warfarin PK/PD model and incorporating CYP2C9 and VKORC1 genotype information has been developed for children. The present prospective, observational study aimed to compare the model with conventional weight-based dosing. The study involved two groups of children post-cardiac surgery: Group 1 were warfarin naïve, in whom loading and maintenance doses were estimated using the model over a 6-month duration and compared to historical case-matched controls. Group 2 were already established on maintenance therapy and randomised into a crossover study comparing the model with conventional maintenance dosing, over a 12-month period. Five patients enrolled in Group 1. Compared to the control group, the median time to achieve the first therapeutic INR was longer (5 vs. 2 days), to stable anticoagulation was shorter (29.0 vs. 96.5 days), to over-anticoagulation was longer (15.0 vs. 4.0 days). In addition, median percentage of INRs within the target range (%ITR) and percentage of time in therapeutic range (%TTR) was higher; 70% versus 47.4% and 83.4% versus 62.3%, respectively. Group 2 included 26 patients. No significant differences in INR control were found between model and conventional dosing phases; mean %ITR was 68.82% versus 67.9% (p = 0.84) and mean %TTR was 85.47% versus 80.2% (p = 0.09), respectively. The results suggest model-based dosing can improve anticoagulation control, particularly when initiating and stabilising warfarin dosing. Larger studies are needed to confirm these findings.

Fostering the conduct of ethical and equitable research practices: the imperative for integrated knowledge translation in research conducted by and with indigenous community members

PLAIN ENGLISH SUMMARY

Integrated knowledge translation is a research approach in which researchers work as partners with the people for whom the research is meant to be of use. A partnered approach can support the use of Indigenous ways of knowing in health research that may then be used in health care. This is important as current health care models do not often support Indigenous values, ways of knowing, and care practices. We describe 1) why it is necessary to co-create knowledge that includes the voices of Indigenous community members, 2) how integrated knowledge translation is a way of doing research that includes many views and 3) how integrated knowledge translation can help those involved in research to agree upon and uphold ethical ways of doing research. Integrated knowledge translation may be used to include Indigenous ways of knowing into mainstream health research and to improve health systems. The use of an integrated knowledge translation approach in research may guide researchers to be research partners with Indigenous people and groups. Integrated knowledge translation may be a way to do research that is respectful and to ensure that Indigenous ways of knowing are included in both health research and health care systems.

ABSTRACT

Background Indigenous people are affected by major health issues at much higher rates than for general populations, and Western health care models do not respond or align with Indigenous values, knowledge systems, and care practices. Knowledge translation (KT) describes ways of moving knowledge from theory into health systems' applications, although there are limitations and concerns related to the effectiveness and contributions of Western-informed approaches to research and KT practices that promote health with Indigenous groups. Integrated KT is an approach to research that engages researchers with the people for whom the research is ultimately meant to be of use ("knowledge users") throughout the entire research process. Integrated KT is done in ways that knowledge users may define as useful, relevant, and applicable in practice, and may also be viewed as complementary to Indigenous health research principles. Main In this paper, we raise and discuss questions posed to researchers by Indigenous knowledge-users about perspectives on health research, researchers, and research institutions, and focus on the role and ethical imperative for integrated KT in Indigenous health research. We describe: 1) why it is necessary to co-create knowledge that includes the voices of Indigenous community members within institutional academic spaces such as universities; 2) how integrated KT accommodates Indigenous and Western-informed perspectives in community-research partnerships throughout the research process; and 3) how an integrated KT approach can help those involved in research to define, agree upon and uphold ethical practices. We argue that integrated KT as a collaborative research practice can create opportunities and space within institutional academic settings for different knowledges to coexist and improve health systems. Most importantly, we argue that integrated KT in Indigenous research contexts includes Indigenous KT. Conclusion The use of integrated KT facilitates opportunities to further define and develop understandings about collaborative approaches to research with Indigenous research partners and that may contribute to respectful inclusion of Indigenous KT practices and processes within institutional academic settings. In the pursuit of useful, relevant and applicable knowledge, those within Western research and health systems must examine and expand upon collaborative approaches to KT.

Engaging knowledge users in development of the CONSORT-Equity 2017 reporting guideline: a qualitative study using in-depth interviews

BACKGROUND

Randomized controlled trials ("randomized trials") can provide evidence to assess the equity impact of an intervention. Decision makers need to know about equity impacts of healthcare interventions so that people get healthcare that is best for them. To better understand the equity impacts of healthcare interventions, a range of people who were potentially the ultimate users of research results were involved in a six-phase project to extend the CONsolidated Standards Of Reporting Trials Statement for health equity ("CONSORT-Equity 2017"). We identified these "knowledge users" as: patients and healthcare researchers, decision makers and providers. This paper reports on one project phase: specifically, a qualitative study designed to integrate the expertise of knowledge users. The experiences and perspectives of knowledge users provided many insights about the reporting of health equity issues in randomized trials. This paper describes key informant interviews with knowledge users that contribute to a better understanding of the effects of an intervention on health equity. Additionally, the paper shows how these insights were used to develop CONSORT-Equity 2017.

METHODS

A qualitative study that used the framework analysis method was conducted in collaboration with an international study executive and advisory board team. In-depth semi-structured interviews were conducted with a purposive sample of key informants who: consider the research ethics of, fund, conduct, participate in, publish, or use research evidence generated in randomized trials. Transcripts were coded and analyzed using the seven-stage framework analysis method, and data reported to reflect knowledge user suggestions to develop CONSORT-Equity 2017.

RESULTS

Thirteen key informants, of which three were patients, chose to participate in interviews. Seven themes emerged: "Differentiate the type of trial", "Prompts for health equity", "Ethics matter", "Describe unique research strategies", "Clarity of reporting", "Implications of equity for sampling and analysis", "Think beyond the immediate trial". The interviews provided direction for the extension of 16 CONSORT-Equity 2017 items.

CONCLUSIONS

Key informant interviews were used to identify new concepts that were not generated in our other studies and to develop CONSORT-Equity 2017. We encourage the use of key informant interviews in guideline development to obtain and include the real-life expertise of knowledge users.

Effectiveness, Complications, and Costs of Rheumatoid Arthritis Treatment with Biologics in Alberta: Experience of Indigenous and Non-indigenous Patients

OBJECTIVE

To examine clinical effectiveness, treatment complications, and healthcare costs for indigenous and non-indigenous Albertans with rheumatoid arthritis (RA) participating in the Alberta Biologics Pharmacosurveillance program.

METHODS

Patients initiating biologic therapy in Alberta (2004-2012) were characterized for disease severity and treatment response. Provincial hospitalization separations, physician claims, outpatient department data, and emergency department data were used to estimate treatment complication event rates and healthcare costs.

RESULTS

Indigenous patients (n = 90) presented with higher disease activity [mean 28-joint count Disease Activity Score (DAS28) 6.11] than non-indigenous patients (n = 1400, mean DAS28 5.19, p < 0.0001). Improvements in DAS28, function, swollen joint count, CRP, and patient and physician global evaluation scores were comparable to non-indigenous patients, but indigenous patients did not have a significant improvement in erythrocyte sedimentation rate (-0.31 per month, 95% CI -0.79 to 0.16, p = 0.199). At the end of study followup, 13% (12/90) of indigenous and 33% (455/1400) of non-indigenous patients were in DAS28 remission (p < 0.001). Indigenous patients had a 40% increased risk of all-cause hospitalization [adjusted incidence rate ratio (IRR) 1.4, 95% CI 1.1-1.8, p = 0.01] and a 4-fold increase in serious infection rate (adjusted IRR 4.0, 95% CI 2.3-7.0, p < 0.001). Non-indigenous patients incurred higher costs for RA-related hospitalizations (difference $896, 95% CI 520-1273, p < 0.001), and outpatient department visits (difference $128, 95% CI 2-255, p = 0.047).

CONCLUSION

We identified disparities in treatment outcomes, safety profiles, and patient-experienced effects of RA for the indigenous population in Alberta. These disparities are critical to address to facilitate and achieve desired RA outcomes from individual and population perspectives.

Evaluating the Quality of Patient Decision-Making Regarding Post-Acute Care

BACKGROUND

Despite a national focus on post-acute care brought about by recent payment reforms, relatively little is known about how hospitalized older adults and their caregivers decide whether to go to a skilled nursing facility (SNF) after hospitalization.

OBJECTIVE

We sought to understand to what extent hospitalized older adults and their caregivers are empowered to make a high-quality decision about utilizing an SNF for post-acute care and what contextual or process elements led to satisfaction with the outcome of their decision once in SNF.

DESIGN

Qualitative inquiry using the Ottawa Decision Support Framework (ODSF), a conceptual framework that describes key components of high-quality decision-making.

PARTICIPANTS

Thirty-two previously community-dwelling older adults (≥ 65 years old) and 22 caregivers interviewed at three different hospitals and three skilled nursing facilities.

MAIN MEASURES

We used key components of the ODSF to identify elements of context and process that affected decision-making and to what extent the outcome was characteristic of a high-quality decision: informed, values based, and not associated with regret or blame.

KEY RESULTS

The most important contextual themes were the presence of active medical conditions in the hospital that made decision-making difficult, prior experiences with hospital readmission or SNF, relative level of caregiver support, and pressure to make a decision quickly for which participants felt unprepared. Patients described playing a passive role in the decision-making process and largely relying on recommendations from the medical team. Patients commonly expressed resignation and a perceived lack of choice or autonomy, leading to dissatisfaction with the outcome.

CONCLUSIONS

Understanding and intervening to improve the quality of decision-making regarding post-acute care supports is essential for improving outcomes of hospitalized older adults. Our results suggest that simply providing information is not sufficient; rather, incorporating key contextual factors and improving the decision-making process for both patients and clinicians are also essential.

Tailoring and field-testing the use of a knowledge translation peer support shared decision making strategy with First Nations, Inuit and Métis people making decisions about their cancer care: a study protocol

PLAIN ENGLISH SUMMARY

Tailoring and testing a peer support decision making strategy with First Nations, Inuit and Métis people making decisions about their cancer care: A study protocol.First Nations, Inuit and Métis (FNIM) people face higher risks for cancer compared to non-FNIM populations. They also face cultural barriers to health service use. Within non-FNIM populations an approach to health decision making, called shared decision making (SDM), has been found to improve the participation of people in their healthcare. Peer support with SDM further improves these benefits. The purpose of this study is to tailor and test a peer support SDM strategy with community support workers to increase FNIM people's participation in their cancer care.This project has two phases that will be designed and conducted with a Steering Committee that includes members of the FNIM and cancer care communities. First, a peer support SDM strategy will be tailored to meet the needs of cancer system users who are receiving care in urban settings, and training in the SDM strategy developed for community support workers. Three communities will be supported for participation in the study and community support workers who are peers from each community will be trained to use the SDM strategy.Next, each community support worker will work with a community member who has a diagnosis of cancer or who has supported a family member with cancer. Each community support worker and community member pair will use the SDM strategy. The participation and experience of the community support worker and community member will be evaluated.The research will be used to develop strategies to support people who are making decisions about their health.

ABSTRACT

Tailoring and field-testing the use of a knowledge translation peer support shared decision making strategy with First Nations, Inuit and Métis people making decisions about their cancer care: A study protocol Background First Nations, Inuit and Métis ("FNIM") people face increased cancer risks in relation to general populations and experience barriers to health service use. Shared decision making (SDM) has been found to improve peoples' participation and outcomes in healthcare and peer support with SDM further improves these benefits. The purpose of this study is to tailor and then field test, by and with FNIM communities, a peer support SDM strategy for use in cancer care. Methods This project has 2 theory-driven phases and 5 stages (a-e). A core research team that includes members of the Aboriginal Cancer Control Unit of Cancer Care Ontario communities and academic researchers, will work with a Steering Committee. In phase 1, (stage a) a peer support SDM strategy will be tailored to meet the needs of cancer system users who are receiving care in urban settings and (stage b), training developed that will i) introduce participant communities to SDM, and ii) train community support workers (CSWs) within these communities. Next (stage c), three communities will be approached for voluntary participation in the study. These communities will be introduced to SDM in community meetings, and if in agreement then CSWs from each community will be recruited to participate in the study. One volunteer CSW from each community will be trained to use the peer support SDM strategy to enable phase 2 (field test of the peer support SDM strategy).During phase 2 (stage d), each CSW will be matched to a volunteer community member who has had a diagnosis of cancer or has supported a family member with cancer and is familiar with Ontario cancer systems. Each CSW-community member pair (3 to 4 pairs/community) will use the tailored peer support SDM strategy; their interaction will be audio-recorded and their participation and experience evaluated (total of 9 to 12 interviews). As well (stage e), data will be collected on health systems' factors related to the use of the peer support SDM strategy. Discussion Findings will develop peer support SDM strategies to enhance participation of FNIM people in cancer care decisions, advance knowledge translation science, and support a proposal to conduct a multi-site implementation trial.

Cultural adaptation and validation of patient decision aids: a scoping review

In order to promote self-determination, patients have to be actively involved with their care providers in health-care decision making, especially when such decisions involve personal preferences. Decision aids (DAs) are tools that can contribute to patient-centered decision-making processes. To benefit from previous fieldwork and avoid duplicating developmental efforts and producing many similar DAs, the adaptation of existing DAs to new cultural contexts is a resource-saving option. However, there are no guidelines on how to culturally adapt and validate DAs. This study aimed to identify and document existing procedures for the cultural adaptation and validation of patient DAs. A scoping review examined studies conducting cultural adaptation and/or validation of patient DAs. The following databases were searched in February 2016: CINAHL, EMBASE, Medline (Ovid), PASCAL, PsychINFO, and PubMed. From the 13 studies selected, 11 main procedures were identified: appraisal of the original DA, assessment of the new cultural context, translation, linguistic adaptation, cultural adaptation, usability testing, exploration of DA acceptability, test-retest reliability, content validity, construct validity, and criterion validity. A conceptual synthesis of these studies suggests there are four phases in the adaptation/validation process of DAs aimed at: 1) exploring the original DA and the new cultural context, 2) adapting the original DA to the new cultural context, 3) lab testing the preliminary version of the adapted DA, and 4) field testing the adapted DA in a real use context. By facilitating the adaptation and broader implementation of DAs, patients may ultimately be empowered in decision-making processes.

Community-based participatory research and integrated knowledge translation: advancing the co-creation of knowledge

BACKGROUND

Better use of research evidence (one form of "knowledge") in health systems requires partnerships between researchers and those who contend with the real-world needs and constraints of health systems. Community-based participatory research (CBPR) and integrated knowledge translation (IKT) are research approaches that emphasize the importance of creating partnerships between researchers and the people for whom the research is ultimately meant to be of use ("knowledge users"). There exist poor understandings of the ways in which these approaches converge and diverge. Better understanding of the similarities and differences between CBPR and IKT will enable researchers to use these approaches appropriately and to leverage best practices and knowledge from each. The co-creation of knowledge conveys promise of significant social impacts, and further understandings of how to engage and involve knowledge users in research are needed.

MAIN TEXT

We examine the histories and traditions of CBPR and IKT, as well as their points of convergence and divergence. We critically evaluate the ways in which both have the potential to contribute to the development and integration of knowledge in health systems. As distinct research traditions, the underlying drivers and rationale for CBPR and IKT have similarities and differences across the areas of motivation, social location, and ethics; nevertheless, the practices of CBPR and IKT converge upon a common aim: the co-creation of knowledge that is the result of knowledge user and researcher expertise. We argue that while CBPR and IKT both have the potential to contribute evidence to implementation science and practices for collaborative research, clarity for the purpose of the research-social change or application-is a critical feature in the selection of an appropriate collaborative approach to build knowledge.

CONCLUSION

CBPR and IKT bring distinct strengths to a common aim: to foster democratic processes in the co-creation of knowledge. As research approaches, they create opportunities to challenge assumptions about for whom, how, and what is defined as knowledge, and to develop and integrate research findings into health systems. When used appropriately, CBPR and IKT both have the potential to contribute to and advance implementation science about the conduct of collaborative health systems research.

Milestones, barriers and beacons: Shared decision making in Canada inches ahead

Canada's approach to shared decision making (SDM) remains as disparate as its healthcare system; a conglomerate of 14 public plans - ten provincial, three territorial and one federal. The healthcare research funding environment has been largely positive for SDM because there was funding for knowledge translation research which also encompassed SDM. The funding climate currently places new emphasis on patient involvement in research and on patient empowerment in healthcare. SDM fields have expanded from primary care to elder care, paediatrics, emergency and critical care medicine, cardiology, nutrition, occupational therapy and workplace rehabilitation. Also, SDM has reached out to embrace other health-related decisions including about home care and social care and has been adapted to Aboriginal decision making needs. Canadian researchers have developed new interprofessional SDM models that are being used worldwide. Professional interest in SDM in Canada is not yet widespread, but there are provincial initiatives in Alberta, British Columbia, Ontario, Quebec and Saskatchewan. Decision aids are routinely used in some areas, for example for prostate cancer in Saskatchewan, and many others are available for online consultation. The Patient Decision Aids Research Group in Ottawa, Ontario maintains an international inventory of decision aids appraised with the International Patient Decision Aid Standards. The Canada Research Chair in SDM and Knowledge Translation in Quebec City maintains a website of SDM training programs available worldwide. These initiatives are positive, but the future of SDM in Canada depends on whether health policies, health professionals and the public culture fully embrace it.

Gender and leadership for health literacy to combat the epidemic rise of noncommunicable diseases

Until recently, the noncommunicable diseases (NCDs) epidemic has been considered only a significant burden to men in high-income countries. However, latest figures indicate that half of all NCD-related deaths affect women, especially in low- and middle-income countries (LMICs), with global responses to the NCD epidemic overlooking the significance of women and girls in their approaches and programs. This case study highlights the burden of disease challenging South Africa that disproportionately affects women in the country and suggests that the country, along with other LMICs internationally, requires a shift in the gender-based leadership of health literacy and self-empowerment.

Conception and Implementation of an Austrian Biobank Directory Integration Framework

INTRODUCTION

Sample collections and data are hosted within different biobanks at diverse institutions across Europe. Our data integration framework aims at incorporating data about sample collections from different biobanks into a common research infrastructure, facilitating researchers' abilities to obtain high-quality samples to conduct their research. The resulting information must be locally gathered and distributed to searchable higher level information biobank directories to maximize the visibility on the national and European levels. Therefore, biobanks and sample collections must be clearly described and unambiguously identified. We describe how to tackle the challenges of integrating biobank-related data between biobank directories using heterogeneous data schemas and different technical environments.

METHODS

To establish a data exchange infrastructure between all biobank directories involved, we propose the following steps: (A) identification of core entities, terminology, and semantic relationships, (B) harmonization of heterogeneous data schemas of different Biobanking and Biomolecular Resources Research Infrastructure (BBMRI) directories, and (C) formulation of technical core principles for biobank data exchange between directories.

RESULTS

(A) We identified the major core elements to describe biobanks in biobank directories. Since all directory data models were partially based on Minimum Information About BIobank Data Sharing (MIABIS) 2.0, the MIABIS 2.0 core model was used for compatibility. (B) Different projection scenarios were elaborated in collaboration with all BBMRI.at partners. A minimum set of mandatory and optional core entities and data items was defined for mapping across all directory levels. (C) Major core data exchange principles were formulated and data interfaces implemented by all biobank directories involved.

DISCUSSION

We agreed on a MIABIS 2.0-based core set of harmonized biobank attributes and established a list of data exchange core principles for integrating biobank directories on different levels. This generic approach and the data exchange core principles proposed herein can also be applied in related tasks like integration and harmonization of biobank data on the individual sample and patient levels.