Redesigning printed educational materials for primary care physicians: design improvements increase usability

Women with ovarian cancer's information seeking and avoidance behaviors: an interview study

Objectives

Despite the importance of using information for ovarian cancer (OvCa) disease management and decision-making, some women with OvCa do not actively seek out information. The purpose of this study is to investigate factors that influence information seeking behaviors and information avoidance behaviors and information resources among women with OvCa and their caregivers.

Materials and methods

We conducted in-depth interviews with OvCa patients or caregivers of OvCa (n = 20) and employed deductive and inductive coding methodologies for analysis.

Results

Our analysis revealed 5 emerging themes associated with active information seeking behavior, 5 themes of passive information acquisition, and 4 themes of information avoidance behavior. Additionally, we identified participants' preferred information sources for OvCa management, such as health organization or government operated resources and web-based social groups.

Discussion

To enhance information access, strategies should be developed to motivate people with OvCa to seek rather than avoid information. The study emphasizes the significance of promoting patient-provider communication and leveraging strong social support networks for effective information acquisition.

Conclusion

Our findings provide valuable implications for clinical practice and policymaking, emphasizing the need to improve access to information for individuals with OvCa. By addressing the identified factors influencing information seeking behaviors, healthcare professionals and policymakers can better support patients and caregivers in their information-seeking journey, ultimately enhancing disease management and decision-making outcomes.

In what ways does user experience design improve printed educational materials?

We report on a series of four studies that investigated how user experience design (UXD) can improve printed educational materials (PEMs). We examined the perceived usability of an existing PEM for breast cancer screening and observed the usability problems associated with it (Study 1). We then compared a breast cancer screening PEM created by user experience designers with two other breast cancer screening PEMS, finding that the PEM based on UXD had higher perceived usability, and lower mentions of usability problems, than the other two PEMs (Study 2). We next examined the impact of individual differences in design expertise on perceived usability, this time including a PEM on cervical cancer screening as well as one on breast cancer screening (Study 3). Our concluding study (Study 4) then examined the impacts of UXD on learnability of PEM content as defined by answers to a knowledge questionnaire about screening administered before and after reading the PEM, and by intention to screen for cancer after reading the PEM. The first three studies showed that the involvement of UXD improved the perceived usability of PEMs, and Study 3 showed that designers differ in their ability to create useable PEMs. Study 4 failed to find a corresponding improvement in learnability or intention to screen when UXD was used to improve perceived usability. We conclude that a user experience design approach that incorporates graphic design can improve the perceived usability of PEMs in some situations (e.g., when the PEM material is not too lengthy or complex, and when the graphic designer is sufficiently skilled). However, we found no evidence that lack of perceived usability accounted for the failure of PEMS (found in previous research) to improve knowledge or intention to screen.

Patient- and Team-Level Characteristics Associated with Handoff Protocol Fidelity in a Hybrid Implementation Study: Results from a Qualitative Comparative Analysis

BACKGROUND

Standardization is an evidence-based approach to improve handoffs. The factors underpinning fidelity (that is, adherence) to standardized handoff protocols are not well specified, which hampers implementation and sustainability efforts.

METHODS

The Handoffs and Transitions in Critical Care (HATRICC) study (2014-2017) involved the creation and implementation of a standardized protocol for operating room (OR)-to-ICU handoffs in two mixed surgical ICUs. The present study used fuzzy-set qualitative comparative analysis (fsQCA) to characterize combinations of conditions associated with fidelity to the HATRICC protocol. Conditions were derived from postintervention handoff observations yielding quantitative and qualitative data.

RESULTS

Sixty handoffs had complete fidelity data. Four conditions from the SEIPS 2.0 model were used to explain fidelity: (1) whether the patient was newly admitted to the ICU; (2) presence of an ICU provider; (3) observer ratings of attention-paying by the handoff team; and (4) whether the handoff took place in a quiet environment. None of the conditions were singly necessary or sufficient for high fidelity. Three combinations of conditions were sufficient for fidelity: (1) presence of the ICU provider and high attention ratings; (2) a newly admitted patient, presence of the ICU provider, and quiet environment; and (3) a newly admitted patient, high attention ratings, and quiet environment. These three combinations explained 93.5% of the cases demonstrating high fidelity.

CONCLUSION

In a study of OR-to-ICU handoff standardization, multiple combinations of contextual factors were associated with handoff protocol fidelity. Handoff implementation efforts should consider multiple fidelity-promoting strategies that support these combinations of conditions.

How to improve the dissemination of clinical practice guidelines in the Brazilian Unified Health System? Report of a pilot project

In Brazil, there have been some initiatives to improve the development of Ministry of Health clinical protocols and therapeutic guidelines (PCDTs in Portuguese, and clinical practice guidelines-CPGs, in English) and their implementation so that best practices can be disseminated and adopted at multiple levels of health systems. One of the initiatives was to conduct a pilot project to improve the format of these CPGs. The objective of this article is to present the processes and results of the pilot project, including the development of a new standardized format for CPGs to promote national dissemination and uptake. The pilot project was designed in three phases: identification and selection of strategies to effectively implement clinical practice guidelines, definition of the ideal characteristics for the format of CPGs, and development and implementation of the new format. Initially, an overview of systematic reviews was conducted to map the global evidence on the effectiveness of dissemination and implementation strategies of CPGs. Among the most effective interventions, a low-cost strategy was selected to improve the format of CPGs, namely a full format and a short format. The two formats were evaluated for usefulness and acceptability by professionals who use or develop CPGs, and after several reiterations, the formats were finalized, considering the progression of care (from diagnosis of the disease to treatment, including specific technologies indicated in each stage of the disease). Related to the technical aspects, the visual presentation of the CPGs was improved, ensuring that key information was easily identified for decision-making by end users. The initial phase of implementation involved 33 clinical conditions, equating to approximately 20% of published CPGs. It is anticipated that disseminating the CPGs in the new formats will promote the accessibility of information and implementation of standardized CPGs by health professionals in the public health sector (servicing more than 210 million Brazilians). Further research should be considered to determine the impact of the use of the new CPGs formats, contributing to the knowledge base related to the implementation of guidelines in Brazil and internationally.

Acceptability Assessment in HIV Prevention and Treatment Intervention and Service Delivery Research: A Systematic Review and Qualitative Analysis

We reviewed the literature on the assessment of acceptability of HIV prevention and treatment interventions and service delivery strategies. Following PRISMA guidelines, we screened 601 studies published from 2015 to 2020 and included 217 in our review. Of 384 excluded studies, 21% were excluded because they relied on retention as the sole acceptability indicator. Of 217 included studies, only 16% were rated at our highest tier of methodological rigor. Operational definitions of acceptability varied widely and failed to comprehensively represent the suggested constructs in current acceptability frameworks. Overall, 25 studies used formal quantitative assessments (including four adapted measures used in prior studies) and six incorporated frameworks of acceptability. Findings suggest acceptability assessment in recent HIV intervention and service delivery research lacks harmonization and rigor. We offer guidelines for best practices and future research, which are timely and critical in this era of informed choice and novel options for HIV prevention and treatment.

Reporting unit context data to stakeholders in long-term care: a practical approach

Background

The importance of reporting research evidence to stakeholders in ways that balance complexity and usability is well-documented. However, guidance for how to accomplish this is less clear. We describe a method of developing and visualising dimension-specific scores for organisational context (context rank method). We explore perspectives of leaders in long-term care nursing homes (NHs) on two methods for reporting organisational context data: context rank method and our traditionally presented binary method—more/less favourable context.

Methods

We used a multimethod design. First, we used survey data from 4065 healthcare aides on 290 care units from 91 NHs to calculate quartiles for each of the 10 Alberta Context Tool (ACT) dimension scores, aggregated at the care unit level based on the overall sample distribution of these scores. This ordinal variable was then summed across ACT scores. Context rank scores were assessed for associations with outcomes for NH staff and for quality of care (healthcare aides’ instrumental and conceptual research use, job satisfaction, rushed care, care left undone) using regression analyses. Second, we used a qualitative descriptive approach to elicit NH leaders’ perspectives on whether the methods were understandable, meaningful, relevant, and useful. With 16 leaders, we conducted focus groups between December 2017 and June 2018: one in Nova Scotia, one in Prince Edward Island, and one in Ontario, Canada. Data were analysed using content analysis.

Results

Composite scores generated using the context rank method had positive associations with healthcare aides’ instrumental research use (p < .0067) and conceptual research use and job satisfaction (p < .0001). Associations were negative between context rank summary scores and rushed care and care left undone (p < .0001). Overall, leaders indicated that data presented by both methods had value. They liked the binary method as a starting point but appreciated the greater level of detail in the context rank method.

Conclusions

We recommend careful selection of either the binary or context rank method based on purpose and audience. If a simple, high-level overview is the goal, the binary method has value. If improvement is the goal, the context rank method will give leaders more actionable details.

Comparison of the validity, perceived usefulness and usability of I-MeDeSA and TEMAS, two tools to evaluate alert system usability: a study protocol

INTRODUCTION

Research has shown that improvements to the usability of medication alert systems are needed. For designers and decisions-makers to assess usability of their alert systems, two paper-based tools are currently available: the instrument for evaluating human-factors principles in medication-related decision support alerts (I-MeDeSA) and the tool for evaluating medication alerting systems (TEMAS). This study aims to compare the validity, usability and usefulness of both tools to identify their strengths and limitations and assist designers and decision-makers in making an informed decision about which tool is most suitable for assessing their current or prospective system.

METHODS AND ANALYSIS

First, TEMAS and I-MeDeSA will be translated into French. This translation will be validated by three experts in human factors. Then, in 12 French hospitals with a medication alert system in place, staff with expertise in the system will evaluate their alert system using the two tools successively. After the use of each tool, participants will be asked to fill in the System Usability Scale (SUS) and complete a survey on the understandability and perceived usefulness of each tool. Following the completion of both assessments, participants will be asked to nominate their preferred tool and relay their opinions on the tools. The design philosophy of TEMAS and I-MeDeSA differs on the calculation of a score, impacting the way the comparison between the tools can be performed. Convergent validity will be evaluated by matching the items of the two tools with respect to the usability dimensions they assess. SUS scores and answers to the survey will be statistically compared for I-MeDeSA and TEMAS to identify differences. Free-text responses in surveys will be analysed using an inductive approach.

ETHICS AND DISSEMINATION

Ethical approval is not required in France for a study of this nature. The results will be published in a peer-reviewed journal.

Pharmacists' perception of educational material to improve patient safety: A cross-sectional study on practices and awareness in Germany

ABSTRACT

Educational material (EM) addresses particular safety information of medicinal products to healthcare professionals and patients. Since 2016, German national competent authorities label approved EM with a Blue Hand symbol. However, data is scarce regarding its usability as a safety communication tool in pharmacies to improve patient safety. The purpose of this study is to investigate for the first time pharmacists' awareness and perception of EM in the setting of community and hospital pharmacies in Germany.The Drug Commission of German Pharmacists surveyed its nationwide network of 677 community and 51 hospital reference pharmacies, to investigate their awareness and perception of EM. The survey was conducted between January 16 and February 10, 2020 using SurveyMonkey. Data were analyzed using Microsoft Excel.A total of 373 community and 32 hospital pharmacists participated; response rates were 55.1% and 62.8%, respectively. Overall, 320 (85.8%) community and all hospital pharmacists confirmed awareness of EM. Community and hospital pharmacists fully (n = 172, 46.9% and n = 9, 28.1%) or rather (n = 109, 29.7% and n = 10, 31.3%) agreed that EM for healthcare professionals is suitable to reduce risks of medicinal products. Moreover, 237 (64.7%) community and 17 (53.1%) hospital pharmacists confirmed to inform patients or care facilities about EM. Asking pharmacists on their personal perception of EM, the refinement of readability and accessibility was indicated.Pharmacists confirm awareness of EM and its suitability as a safety communication tool. However, from a pharmacists' perspective, the applicability and readability of EM still needs further adjustment to improve patient safety.

Opening the 'Black Box': An Overview of Methods to Investigate the Decision-Making Process in Choice-Based Surveys

The desire to understand the preferences of patients, healthcare professionals and the public continues to grow. Health valuation studies, often in the form of discrete choice experiments, a choice based survey approach, proliferate as a result. A variety of methods of pre-choice process analysis have been developed to investigate how and why people make their decisions in such experiments and surveys. These techniques have been developed to investigate how people acquire and process information and make choices. These techniques offer the potential to test and improve theories of choice and/or associated empirical models. This paper provides an overview of such methods, with the focus on their use in stated choice-based healthcare studies. The methods reviewed are eye tracking, mouse tracing, brain imaging, deliberation time analysis and think aloud. For each method, we summarise the rationale, implementation, type of results generated and associated challenges, along with a discussion of possible future developments.

Determinants of usefulness in professional behaviour change interventions: observational study of a 15-year national program

OBJECTIVE

Educational, and audit and feedback interventions are effective in promoting health professional behaviour change and evidence adoption. However, we lack evidence to pinpoint which particular features make them most effective. Our objective is to identify determinants of quality in professional behaviour change interventions, as perceived by participants.

DESIGN

We performed a comparative observational study using data from the Veterans' Medicines Advice and Therapeutics Education Services program, a nation-wide Australian Government Department of Veterans' Affairs funded program that provides medicines advice and promotes physician adoption of best practices by use of a multifaceted intervention (educational material and a feedback document containing individual patient information).

SETTING

Primary care practices providing care to Australian veterans.

PARTICIPANTS

General practitioners (GPs) targeted by 51 distinct behaviour change interventions, implemented between November 2004 and June 2018.

PRIMARY AND SECONDARY OUTCOME MEASURES

We extracted features related to presentation (number of images, tables and characters), content (polarity and subjectivity using sentiment analysis, number of external links and medicine mentions) and the use of five behaviour change techniques (prompt/cues, goal setting, discrepancy between current behaviour and goal, information about health consequences, feedback on behaviour). The main outcome was perceived usefulness, extracted from postintervention survey.

RESULTS

On average, each intervention was delivered to 9667 GPs. Prompt and goal setting strategies in the audit and feedback were independently correlated to perceived usefulness (p=0.030 and p=0.005, respectively). The number of distinct behaviour change techniques in the audit and feedback was correlated with improved usefulness (Pearson's coefficient 0.45 (0.19, 0.65), p=0.001). No presentation or content features in the educational material were correlated with perceived usefulness.

CONCLUSIONS

The finding provides additional evidence encouraging the use of behaviour change techniques, in particular prompt and goal setting, in audit and feedback interventions.

Development of consumer information leaflets for deprescribing in older hospital inpatients: a mixed-methods study

OBJECTIVE

To develop information leaflets for older inpatients and/or their carers to support deprescribing of antipsychotics, benzodiazepines/Z-drugs and proton pump inhibitors (PPIs).

DESIGN

An iterative mixed-methods approach involving face-to-face user testing and semi-structured interviews was performed over three rounds with consumers and hospital health professionals.

SETTING

Sydney, New South Wales, Australia.

PARTICIPANTS

Thirty-seven consumers (or their carers) aged 65 years or older admitted to hospital in the previous 5 years and taking at least one regular medicine (not the medicine tested) completed user testing. Health professionals included a convenience sample of seven pharmacists and five doctors.

METHODS

The antipsychotic leaflet was tested in round 1 (consumers, n=10) and revised and retested in round 2 (consumers, n=9; health professionals, n=5). Findings from rounds 1 and 2 informed the design of the benzodiazepine/Z-drug and PPI leaflets tested in round 3 (benzodiazepine/Z-drug consumers, n=9; health professionals, n=7; PPI consumers, n=9). Findings from round 3 informed the final design of all leaflets. Consumer user testing involved 12-13 questions to evaluate consumers' ability to locate and understand information in the leaflet. Usability by health professionals was assessed using the System Usability Scale (SUS).

RESULTS

At least 80% of consumers correctly found and understood the deprescribing information in the leaflets (9 of 12 information points in round 1 (antipsychotic); 10 of 12 in round 2; 12 of 13 (benzodiazepine/Z-drug) and 11 of 12 (PPI) in round 3). Consumers perceived the leaflets to be informative, well-designed and useful aids for ongoing medication management. The SUS scores obtained from health professionals were 91.0±3.8 for the antipsychotic leaflet and 86.4±6.6 for the benzodiazepine/Z-drug leaflet, indicating excellent usability.

CONCLUSIONS

Understandable and easy-to-use consumer information leaflets were developed and tested by consumers and health professionals. The feasibility and utility of these leaflets to support deprescribing at transitions of care should be explored in clinical practice.

Role of social marketing in promoting primary care to succeed in current era

Social marketing has expanded its purview in the modern era aiming at a behavioral change of target audience on a large scale. Public health practitioners now admit the value of community-based approaches to social change. Three main patterns of health education materials are social marketing communication material, information and education communication (IEC) material, and behavior change communication (BCC) material. Social marketing is a strategy based on marketing principles of selling products. The communication material suggests that the healthcare option for a particular disease is the best solution, and therefore choice or critical thinking is not necessary. IEC strategy attempts at informing people and increasing their knowledge about a disease, having them use it as a basis for action. BCC strategy promotes individual change leading to healthy community behavior. Social marketing communication material for communities should be creative, innovative, original, with clear messages in English and other local languages, reproducible, acceptable, and reflective. Primary care requires customizing health education material using translatable strategies based on social marketing to change health-care patient behavior for wellbeing. The concept of social marketing should be emphasized in early medical education. In the present times, doctors and medical students should be informed about different communication strategies to transform communication material into program tools to achieve health.

Construção e validação de conteúdo de cartilha educativa para prevenção de quedas no hospital

Resumo Objetivo Construir e validar cartilha educativa para prevenção de quedas no hospital. Métodos Estudo metodológico desenvolvido a partir da construção, validação e avaliação da cartilha por 22 enfermeiros e 22 pacientes internados em clínica médica. Para a validação com juízes, avaliou-se objetivo, estrutura/apresentação e relevância do material e, na avaliação com pacientes, aplicou-se o instrumento Suitability Assesment of Materials (SAM). Utilizou-se o Índice de Validade de Conteúdo (IVC) para análise de cada etapa da validação, considerando válido os iguais ou superiores a 0,80. Resultados A cartilha intitulada “Cuidados para não cair nessa” é composta por 20 páginas. Na validação de conteúdo, os profissionais atribuíram o IVC global de 1,0 para objetivo, estrutura/apresentação e relevância do material. Na avaliação dos pacientes, o IVC global da cartilha foi de 0,98. Conclusão A cartilha educativa é considerada válida quanto ao conteúdo e compreensível pelos pacientes de forma que possui utilização viável na educação em saúde para prevenção de quedas no hospital.

Elaboração e validação de cartilha para prevenção da diarreia infantil

Resumo Objetivo Elaborar, validar e avaliar uma cartilha educativa para a promoção da autoeficácia materna na prevenção da diarreia infantil. Método Estudo metodológico, desenvolvido a partir da elaboração, validação e avaliação do material educativo por 30 juízes de conteúdo e três técnicos. Para validação, avaliou-se clareza da linguagem, pertinência prática e relevância teórica, calculando-se o Índice de Validade de Conteúdo para cada item; e aplicou-se o instrumento Suitability Assesment of Materials (SAM) para avaliação da cartilha. Resultados A cartilha teve como título “Você é capaz de prevenir a diarreia no seu filho!” e foi elaborada tendo como referencial a Teoria da Autoeficácia. Os juízes de conteúdo atribuíram Índice de Validade de Conteúdo (IVC) global de 0,88 para clareza da linguagem, 0,91 para pertinência prática e 0,92 para relevância teórica; e os juízes técnicos atribuíram IVC de 0,96, 1,00 e 1,00 para os mesmos itens avaliados, respectivamente. A avaliação dos juízes de conteúdo e técnicos a partir do SAM classificou o material como “superior”, com média de 88,7% e 90,1%, respectivamente. Conclusão A cartilha apresenta conteúdo e aparência adequados para a promoção da autoeficácia materna na prevenção da diarreia infantil.

Communication on Safety of Medicines in Europe: Current Practices and General Practitioners' Awareness and Preferences

Introduction

National competent authorities (NCAs) for medicines coordinate communication relating to the safety of medicines in Europe. The effectiveness of current communication practices has been questioned, particularly with regard to reaching general practitioners (GPs).

Objective

The aim of this study was to assess current European NCA safety communication practices and to investigate European GPs’ awareness of and preferences for safety communications on medicines.

Methods

Web-based surveys were distributed among European NCAs and healthcare professionals (HCPs). The survey among regulators was emailed to a representative of each of the 27 European countries participating in the Strengthening Collaboration for Operating Pharmacovigilance in Europe (SCOPE) Joint Action. HCPs from nine European countries (Denmark, Spain, Croatia, Ireland, Italy, The Netherlands, Norway, Sweden, and the UK) were asked about their preferences through a link to the survey on websites, in newsletters, and/or in a direct email. From this survey, data from GPs were used and descriptive analyses were conducted.

Results

Current NCA practices were reported for 26 countries. In 23 countries (88%), NCAs published direct healthcare professional communications (DHPCs, i.e. urgent communication letters for serious safety issues) on their website in addition to distribution to individual HCPs. Educational materials were available on the NCA’s website in 10 countries (40%), and 21 NCAs (81%) indicated they had their own bulletin/newsletter, which is often presented on the NCA’s website (15 countries; 60%). More than 90% of the 1766 GPs who completed the survey were aware of DHPCs. The most preferred senders of safety information were NCAs and professional bodies, while the preferred channels for keeping up to date with safety information were medicines reference books and clinical guidelines. GPs found the repetition of safety issues useful (range of 80% in the UK to 97% in Italy). Preference for an electronic copy rather than a hardcopy varied per country (36% in Sweden to 72% in Spain).

Conclusions

NCAs use similar methods for safety communications on medicines. Most GPs were aware of urgent communications and preferred similar senders of safety communications; however, their preferences towards the format differed per country.

Electronic supplementary material

The online version of this article (doi:10.1007/s40264-017-0535-0) contains supplementary material, which is available to authorized users.

Application of discrete choice experiments to enhance stakeholder engagement as a strategy for advancing implementation: a systematic review

Background

One of the key strategies to successful implementation of effective health-related interventions is targeting improvements in stakeholder engagement. The discrete choice experiment (DCE) is a stated preference technique for eliciting individual preferences over hypothetical alternative scenarios that is increasingly being used in health-related applications. DCEs are a dynamic approach to systematically measure health preferences which can be applied in enhancing stakeholder engagement. However, a knowledge gap exists in characterizing the extent to which DCEs are used in implementation science.

Methods

We conducted a systematic literature search (up to December 2016) of the English literature to identify and describe the use of DCEs in engaging stakeholders as an implementation strategy. We searched the following electronic databases: MEDLINE, Econlit, PsychINFO, and the CINAHL using mesh terms. Studies were categorized according to application type, stakeholder(s), healthcare setting, and implementation outcome.

Results

Seventy-five publications were selected for analysis in this systematic review. Studies were categorized by application type: (1) characterizing demand for therapies and treatment technologies (n = 32), (2) comparing implementation strategies (n = 22), (3) incentivizing workforce participation (n = 11), and (4) prioritizing interventions (n = 10). Stakeholders included providers (n = 27), patients (n = 25), caregivers (n = 5), and administrators (n = 2). The remaining studies (n = 16) engaged multiple stakeholders (i.e., combination of patients, caregivers, providers, and/or administrators). The following implementation outcomes were discussed: acceptability (n = 75), appropriateness (n = 34), adoption (n = 19), feasibility (n = 16), and fidelity (n = 3).

Conclusions

The number of DCE studies engaging stakeholders as an implementation strategy has been increasing over the past decade. As DCEs are more widely used as a healthcare assessment tool, there is a wide range of applications for them in stakeholder engagement. The DCE approach could serve as a tool for engaging stakeholders in implementation science.

Electronic supplementary material

The online version of this article (10.1186/s13012-017-0675-8) contains supplementary material, which is available to authorized users.

Reviewer training to assess knowledge translation in funding applications is long overdue

Background

Health research funding agencies are placing a growing focus on knowledge translation (KT) plans, also known as dissemination and implementation (D&I) plans, in grant applications to decrease the gap between what we know from research and what we do in practice, policy, and further research. Historically, review panels have focused on the scientific excellence of applications to determine which should be funded; however, relevance to societal health priorities, the facilitation of evidence-informed practice and policy, or realizing commercialization opportunities all require a different lens.

Discussion

While experts in their respective fields, grant reviewers may lack the competencies to rigorously assess the KT components of applications. Funders of health research—including health charities, non-profit agencies, governments, and foundations—have an obligation to ensure that these components of funding applications are as rigorously evaluated as the scientific components. In this paper, we discuss the need for a more rigorous evaluation of knowledge translation potential by review panels and propose how this may be addressed.

Conclusion

We propose that reviewer training supported in various ways including guidelines and KT expertise on review panels and modalities such as online and face-to-face training will result in the rigorous assessment of all components of funding applications, thus increasing the relevance and use of funded research evidence. An unintended but highly welcome consequence of such training could be higher quality D&I or KT plans in subsequent funding applications from trained reviewers.

Negotiating Tensions Between Theory and Design in the Development of Mailings for People Recovering From Acute Coronary Syndrome

Background

Taking all recommended secondary prevention cardiac medications and fully participating in a formal cardiac rehabilitation program significantly reduces mortality and morbidity in the year following a heart attack. However, many people who have had a heart attack stop taking some or all of their recommended medications prematurely and many do not complete a formal cardiac rehabilitation program.

Objective

The objective of our study was to develop a user-centered, theory-based, scalable intervention of printed educational materials to encourage and support people who have had a heart attack to use recommended secondary prevention cardiac treatments.

Methods

Prior to the design process, we conducted theory-based interviews and surveys with patients who had had a heart attack to identify key determinants of secondary prevention behaviors. Our interdisciplinary research team then partnered with a patient advisor and design firm to undertake an iterative, theory-informed, user-centered design process to operationalize techniques to address these determinants. User-centered design requires considering users’ needs, goals, strengths, limitations, context, and intuitive processes; designing prototypes adapted to users accordingly; observing how potential users respond to the prototype; and using those data to refine the design. To accomplish these tasks, we conducted user research to develop personas (archetypes of potential users), developed a preliminary prototype using behavior change theory to map behavior change techniques to identified determinants of medication adherence, and conducted 2 design cycles, testing materials via think-aloud and semistructured interviews with a total of 11 users (10 patients who had experienced a heart attack and 1 caregiver). We recruited participants at a single cardiac clinic using purposive sampling informed by our personas. We recorded sessions with users and extracted key themes from transcripts. We held interdisciplinary team discussions to interpret findings in the context of relevant theory-based evidence and iteratively adapted the intervention accordingly.

Results

Through our iterative development and testing, we identified 3 key tensions: (1) evidence from theory-based studies versus users’ feelings, (2) informative versus persuasive communication, and (3) logistical constraints for the intervention versus users’ desires or preferences. We addressed these by (1) identifying root causes for users’ feelings and addressing those to better incorporate theory- and evidence-based features, (2) accepting that our intervention was ethically justified in being persuasive, and (3) making changes to the intervention where possible, such as attempting to match imagery in the materials to patients’ self-images.

Conclusions

Theory-informed interventions must be operationalized in ways that fit with user needs. Tensions between users’ desires or preferences and health care system goals and constraints must be identified and addressed to the greatest extent possible. A cluster randomized controlled trial of the final intervention is currently underway.

Virtual Patient Technology: Engaging Primary Care in Quality Improvement Innovations

BACKGROUND

Engaging health care staff in new quality improvement programs is challenging.

OBJECTIVE

We developed 2 virtual patient (VP) avatars in the context of a clinic-level quality improvement program. We sought to determine differences in preferences for VPs and the perceived influence of interacting with the VP on clinical staff engagement with the quality improvement program.

METHODS

Using a participatory design approach, we developed an older male smoker VP and a younger female smoker VP. The older male smoker was described as a patient with cardiovascular disease and was ethnically ambiguous. The female patient was younger and was worried about the impact of smoking on her pregnancy. Clinical staff were allowed to choose the VP they preferred, and the more they engaged with the VP, the more likely the VP was to quit smoking and become healthier. We deployed the VP within the context of a quality improvement program designed to encourage clinical staff to refer their patients who smoke to a patient-centered Web-assisted tobacco intervention. To evaluate the VPs, we used quantitative analyses using multivariate models of provider and practice characteristics and VP characteristic preference and analyses of a brief survey of positive deviants (clinical staff in practices with high rates of encouraging patients to use the quit smoking innovation).

RESULTS

A total of 146 clinical staff from 76 primary care practices interacted with the VPs. Clinic staff included medical providers (35/146, 24.0%), nurse professionals (19/146, 13.0%), primary care technicians (5/146, 3.4%), managerial staff (67/146, 45.9%), and receptionists (20/146, 13.7%). Medical staff were mostly male, and other roles were mostly female. Medical providers (OR 0.031; CI 0.003-0.281; P=.002) and younger staff (OR 0.411; CI 0.177-0.952; P=.038) were less likely to choose the younger, female VP when controlling for all other characteristics. VP preference did not influence online patient referrals by staff. In high-performing practices that referred 20 or more smokers to the ePortal (13/76), the majority of clinic staff were motivated by or liked the virtual patient (20/26, 77%).

CONCLUSIONS

Medical providers are more likely motivated by VPs that are similar to their patient population, while nurses and other staff may prefer avatars that are more similar to them.

Program evaluation of neuroscience competency programs to implement evidence-based practices

RATIONALE

Program evaluation is essential to help determine the success of an evidence-based practice program and assist with translating these processes across settings.

AIMS

The purpose of this study was to evaluate the usefulness of 2 competency programs that sought to improve neurocritical care nurses' knowledge of and adherence to evidence-based stroke and spinal cord injury guidelines. These programs consisted of 3 specific implementation strategies, including local opinion leaders, printed educational materials, and educational outreach.

METHODS

A qualitative study using one-on-one interviews with 10 neurocritical care nurses was used. Semi-structured interview questions examined the nurses' perceptions of the competency programs and the implementation strategies used; themes were identified through first-level coding. The transcripts were deductively analyzed and categorized using a predetermined implementation outcomes framework, including the concepts of acceptability, appropriateness, adoption, and sustainability.

RESULTS

Nurses reported that the 3 implementation strategies used for the competency programs were acceptable and appropriate. Further, the nurses perceived that the evidence-based practices reviewed during the programs were being adopted into practice and provided suggestions for sustaining improvements in nursing knowledge of and adherence to these evidence-based practices.

CONCLUSIONS

Findings from this study support the success of the Stroke and Spinal Cord Injury Competency Programs, as well as the usefulness of the 3 implementation strategies used. This study provides insight for improvements for subsequent studies focused on implementing evidence-based practices.

Interactive Dissemination: Engaging Stakeholders in the Use of Aggregated Quality Improvement Data for System-Wide Change in Australian Indigenous Primary Health Care

Background

Integrating theory when developing complex quality improvement interventions can help to explain clinical and organizational behavior, inform strategy selection, and understand effects. This paper describes a theory-informed interactive dissemination strategy. Using aggregated quality improvement data, the strategy seeks to engage stakeholders in wide-scale data interpretation and knowledge sharing focused on achieving wide-scale improvement in primary health-care quality.

Methods

An iterative process involving diverse stakeholders in Australian Aboriginal and Torres Strait Islander health-care delivery uses aggregated audit data collected across key areas of care. Phases of reporting and online feedback are used to identify: (1) priority areas for improvement; (2) health center, system, and staff attributes that may be important in addressing the identified priority evidence-practice gaps; and (3) strategies that could be introduced or strengthened to enable improvement. A developmental evaluation is being used to refine engagement processes and reports as the project progresses.

Discussion

This innovative dissemination approach is being used to encourage wide-scale interpretation and use of service performance data by policy-makers, managers, and other stakeholders, and to document knowledge about how to address barriers to achieving change. Through the developmental evaluation, the project provides opportunities to learn about stakeholders’ needs in relation to the way data and findings are described and distributed, and elements of the dissemination strategy and report design that impact on the useability and uptake of findings.

Conclusion

The project can contribute to knowledge about how to facilitate interactive wide-scale dissemination and about using data to co-produce knowledge to improve health-care quality.

Development of a patient decision aid on inhaled corticosteroids use for adults with asthma

BACKGROUND

Patient decision aids (PDAs) are used in shared decision making to improve practitioner-patient communication and help patients decide about treatment options. To develop a PDA for adults with asthma considering inhaled corticosteroids, with or without long-acting beta2-agonists, to optimize asthma control.

METHODS

The PDA was developed based on the International Patient Decision Aid Standards. Step 1: PDA was drafted. Step 2: PDA acceptability was assessed among target users, certified asthma educators (CAEs) and adults with asthma, following an iterative process. a) Participants read the PDA, b) rated its presentation, length, balance, and perceived usefulness, indicated what they liked/disliked about it, and made suggestions for improvement. c) Based on results from (b), PDA was refined. This process was repeated with new participants until no suggestions were made. Step 3: The PDA was field tested with target users. Interviews with CAEs were conducted to identify areas of improvement. Step 4: Final PDA version was written.

RESULTS

A color-printed, 4-page, letter-sized PDA was drafted. Acceptability testing involved 11 CAEs (women, n = 10) and 20 adults with asthma (women, n = 13; age 22-61 years). Five successive refined versions were produced. Major changes were made to PDA terminology, instructions, paper size, and visual presentation. Two CAEs (women, n = 2) and 26 adults with asthma (women, n = 19; age 20-65 years) field tested PDA. Minor changes were made to language and instructions to ensure usability. The final version was a color-printed, 12-page, A3-sized booklet.

CONCLUSION

Our newly developed PDA was found acceptable and usable in target users.