Aligning intuition and theory: a novel approach to identifying the determinants of behaviours necessary to support implementation of evidence into practice

Investigating processes to support and improve informed financial consent in Australian cancer services: an implementation process mapping study and analysis

OBJECTIVES

Through implementation process mapping and thematic analysis, this study aimed to understand existing pathways of established informed financial consent (IFC) processes to develop general recommendations for implementing IFC in various cancer care settings.

DESIGN

Implementation science-based process mapping qualitative study. The Consolidated Framework for Implementation Research (CFIR) informed the development of interview questions and a process map outlining a normative process or workflow for patient consults was used during the interviews.

SETTING

Australian cancer care provider health services.

PARTICIPANTS

Australian healthcare professionals who provide services to cancer patients and indicated having an IFC process or activities in their service were approached through existing networks to participate in a semistructured interview.

RESULTS

Ten healthcare professionals who regularly worked with cancer patients were interviewed. IFC processes varied by professional specialty (ie, general practice, surgery, radiation oncology and medical oncology) and healthcare settings (eg, public and private). An aggregated process map that highlights the key components of IFC processes discussed was created and includes strategies such as centralised points of contact, consolidated information delivery, reiteration of information by others or at various time-points and the use of follow-up appointments to revisit the financial impact of treatment. Interview themes identified barriers and facilitators such as training, resources and templates that to support or hinder IFC in accordance with CFIR domains.

CONCLUSIONS

The themes and aggregated process map provide timely recommendations for healthcare professionals who provide services to cancer patients to facilitate IFC with their patients prior to treatment or as treatment changes. These practical actions will assist healthcare professionals and services providing cancer care to integrate IFC practices and processes into their routine patient interactions. Further work should identify implementation strategies to integrate and scale-up these evidence-based IFC processes and practices across the healthcare system.

The co-design of a digitally supported intervention for selecting implementation tools and actions for standards (SITAS)

BACKGROUND

Health and social care standards are multi-faceted interventions that promote quality and safe care in health systems. There is a need to apply evidence-based, rigorous and transparent methods when selecting strategies to support the implementation of standards. We aimed to develop an evidence- and theory-informed intervention to guide researchers in identifying appropriate implementation strategies and then selecting tailored support tools and actions for use when implementing a set of standards.

METHODS

Our intervention is a digital tool entitled 'Selecting Implementation Tools and Actions for Standards (SITAS).' The Medical Research Council Framework for Developing and Evaluating Complex Interventions guided the design of SITAS. Co-design of SITAS, using a multi-stage and multi-methods approach included developing programme theory; identifying and prioritising enablers and barriers to implementing standards; identifying the best fit implementation framework using the Theory Comparison and Selection Tool; mapping enablers and barriers to the Consolidated Framework for Implementation Research (CFIR); identifying matching implementation strategies using the CFIR-ERIC (Expert Recommendations for Implementing Change) matching tool; mapping enablers and barriers to the Behaviour Change Wheel (BCW). The enablers and barriers, outputs from the CFIR-ERIC matching tool and the BCW were used to develop a prototype of the content and interactive logic within a digital tool. The prototype was refined following feedback from intended users (n = 7) at three design workshops.

RESULTS

Programme theory was developed and refined following feedback from intended users of SITAS. Twenty-three enablers and barriers were prioritised. CFIR was identified as the best fit framework with the majority of enablers and barriers (n = 15) mapped to the 'Inner Setting' domain. 'Conduct educational meetings' was the most common strategy retrieved using the CFIR-ERIC matching tool. 'Physical opportunity' was the component of the BCW with the most enablers and barriers (n = 8). A prototype of SITAS was designed in Microsoft Excel based on the aforementioned steps. Workshops with intended users provided key insights about the content, functionality and user experience for SITAS which resulted in refinements to SITAS.

CONCLUSION

We developed a practical intervention enhanced by user involvement. SITAS guides users through the process of selecting and tailoring implementation strategies to specific contexts, using core concepts of implementation science. SITAS will need to undergo formal piloting before spread and scale-up.

Exploring how researchers consider nutrition trial design and participant adherence: a theory-based analysis

Introduction

Nutrition trials are important for informing dietary and clinical guidelines. Central to the success of these trials is participant adherence to dietary behaviors. However, trials commonly experience poor adherence. This study seeks to understand if and how researchers consider supporting participant adherence to dietary behaviors and their relationship to using behavior change science when designing trials.

Methods

A mapping exercise was undertaken to create matrices that describe the landscape of current nutrition trials. A total of 12 researchers participated in semi-structured, one-on-one interviews. Transcripts were analyzed using (i) the theoretical domains framework (TDF) to identify themes in current practice and beliefs, and (ii) the capability, opportunity, motivation, and behavior model to identify barriers and enablers to using behavior change science in the design of nutrition trials.

Results

Twenty-two belief statements were identified across all 14 TDF domains and were conceptualized as 5 key themes with respect to designing nutrition trials to improve participant adherence: (i) what was done, (ii) how it was done, (iii) why it was done, (iv) adherence challenges, and (v) conflicting beliefs. Regarding using behavior change science when designing trials, some researchers felt this would be beneficial but lacked the knowledge and skills to do so, while others were skeptical of its value over the current experience-based practice.

Discussion

Researchers are motivated to encourage participant adherence to dietary behaviors, and, consciously and subconsciously, implement a range of strategies through non-systematic methods in their trials. Future publications would benefit from the explicit documentation of levels of adherence to dietary behaviors and strategies implemented to improve adherence.

Improving Lynch syndrome detection: a mixed-methods process evaluation of a hybrid type III effectiveness-implementation trial

INTRODUCTION

Translating evidence-based practices into real-world healthcare settings is challenging, particularly in the rapidly evolving field of genomics. A pragmatic two-arm cluster-randomized clinical trial (Hide and Seek Project - HaSP) tested two implementation approaches for improving hereditary cancer referral practices with one key distinction: implementation strategies that were designed 1) explicitly using psychological theory, or 2) using healthcare professional intuition. This mixed-methods process evaluation aimed to provide insights into how and why change occurred by examining contextual determinants, identifying mechanisms of action, and exploring the role of theory.

METHODS

Post-implementation interviews were conducted with Implementation Leads and clinicians from participating HaSP sites. Transcripts were analysed using a mixed inductive and deductive approach, guided by the updated Consolidated Framework for Implementation Research (2.0). Findings were triangulated with other HaSP process evaluation data sources, including HaSP focus group observations, HaSP research team focus groups, MDT observations, and Implementation Lead project logs. Logic models and case studies were developed to articulate causal processes underlying strategy effectiveness and conditions necessary for implementation success.

RESULTS

Eighteen participants from seven HaSP sites were interviewed. Qualitative analysis identified themes related to Lynch syndrome complexity, pandemic disruptions, operational challenges, information technology constraints, multidisciplinary collaboration, cultural determinants, attitudes towards change, the value of theory, adaptations, and implementation support. Within these themes, a total of 39 contextual determinants were identified, with barriers and facilitators spanning 18 CFIR constructs across five domains. Logic models and case studies highlighted a number of mechanisms of action, producing variable clinical outcomes. Process evaluation findings, interpreted together with HaSP trial outcomes, indicate that theory-based implementation strategies may better support Lynch syndrome detection practices compared to intuition-based strategies.

CONCLUSIONS

The information gained from this process evaluation deepens understanding of the factors influencing the success of hospital-specific implementation strategies within the HaSP framework. Potential pathways for optimising the effectiveness of the overall HaSP implementation approach have been identified.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12618001072202. Registered 27 June 2018, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375348&isReview=true .

Bridging the Gap between Intuition and Theory: A Comparison of Different Approaches to Implementation Strategy Development for Improving Lynch Syndrome Detection

INTRODUCTION

Despite growing calls for the explicit application of theory when designing behaviour change interventions, limited empirical evidence exists regarding the effectiveness of these methods compared to non-theoretical approaches. A cluster randomized controlled trial (Hide and Seek Project - HaSP) tested two implementation approaches for improving hereditary cancer referral practices with one key distinction: implementation strategies were designed based explicitly on psychological theory or based on stakeholder intuition. This study presents the detailed methods and resources used to facilitate this comparison, whilst examining the strategies generated through both approaches.

METHODS

Across seven Australian hospitals, clinical stakeholders attended focus groups to co-design site-specific strategies for improving Lynch syndrome referral. Co-design methods differed according to trial arm. Implementation strategy content was examined, with intuitively derived strategies retrospectively coded to determine theoretical alignment.

RESULTS

Fifty-one strategies were proposed across all sites (theory-based arm = 32, intuition-based arm = 19). Overall, nine behaviour change technique (BCT) categories were used on 77 occasions. In the theory-based trial arm, eight BCT categories were identified on 53 occasions; and five BCT categories on 24 occasions in the intuition-based arm. BCT categories were largely similar across both arms. After retrospectively coding intuitively derived strategies, 42% contained mechanistic links, thereby demonstrating theoretical alignment.

CONCLUSION

Methods facilitated robust comparison of theoretical and intuitive approaches to implementation strategy design. Recognizing the known benefits of theory for enhancing scientific learning, applying these methods on a larger scale may provide definitive evidence about the comparative effectiveness of theoretical approaches.

Using Implementation Science Frameworks to Guide the Use of Electronic Patient-Reported Outcome Symptom Monitoring in Routine Cancer Care

PURPOSE

Electronic patient-reported outcomes (ePROs) are an evidence-based means of detecting symptoms earlier and improving patient outcomes. However, there are few examples of successful implementation in routine cancer care. We conducted a qualitative study to identify barriers and facilitators to implementing ePRO symptom monitoring in routine cancer care using the Consolidated Framework for Implementation Research (CFIR).

METHODS

Participants were adult patients with cancer, their caregivers, or health care professionals involved in ePRO monitoring or processes. Focus groups or individual interviews were conducted using a semistructured approach informed by the CFIR. Data were analyzed deductively using the CFIR. Barriers were matched to theory-informed implementation strategies using the CFIR-Expert Recommendations for Implementing Change (ERIC) matching tool.

RESULTS

Thirty participants were interviewed: 22 females (73%), aged 31-70 years (28, 94%), comprising patients (n = 8), caregivers (n = 2), medical oncologists (n = 4), nurses (n = 4), hospital leaders (n = 6), clinic administrators (n = 2), pharmacists (n = 2), and information technology specialists (n = 2). Barriers pertaining to four CFIR domains were identified and several were novel, including the challenge of adapting ePROs for different anticancer treatments. Facilitators pertaining to all CFIR domains were identified, such as leveraging acceptability of remote care post-COVID-19 to drive implementation. Conducting consensus discussions with stakeholders to tailor ePROs to the local setting, identifying/preparing individual and group-level champions, and assessing readiness for change (including leveraging technological advances and increased confidence in using remote monitoring post-COVID-19) were the most frequently recommended implementation strategies.

CONCLUSION

The CFIR facilitated identification of known and novel barriers and facilitators to implementing ePRO symptom monitoring in routine cancer care. Implementation strategies summarized in a conceptual framework will be used to codesign an ePRO symptom monitoring system for immunotherapy side effects.