Ten recommendations for using implementation frameworks in research and practice

Teaching and interconnecting research and evidence-based practice in midwifery and nursing education: A mixed methods systematic review

OBJECTIVE

To examine current approaches in research, teaching, and Evidence Based Practice (EBP) in midwifery and nursing education and how they interconnect.

DESIGN

A mixed-methods systematic review.

DATA SOURCES

Seven databases were used: Academic Search Complete, ASSIA, CINAHL, Cochrane Library, Education Source, Medline, and Scopus. Grey literature was searched from GreyNet International, The Society for Research on Educational Effectiveness, Virginia Henderson Global Nursing e-Repository, The National Institutes for Health Library, and the DART-Europe E-theses Portal.

METHODS

This review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. It includes studies conducted in higher and professional practice education in midwifery and nursing between 2013 and 2024. Included studies were published in English, reported the design, development, implementation, and/or evaluation of research or EBP intervention with primary data as part of their research, regardless of study design. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool (MMAT). Extracted data were analysed using reflective thematic analysis and descriptive statistics.

RESULTS

A total of 59 studies, and 7214 participants were included. Four themes representing the interconnections between teaching, research and EBP were identified: 1) Pedagogical approaches employed in teaching and learning interventions 2) Theories, models, and frameworks to bridge the theory-practice gap 3) Collaborative approaches and partnerships as a conduit for the acquisition of knowledge and transferable skills 4) Capabilities developed in research and EBP.

CONCLUSIONS

This review is the first to demonstrate how different educational interventions, models and findings relate to teaching research and EBP and their application in midwifery and nursing. Despite numerous educational strategies for integrating research into teaching, there is no conclusive evidence on the best methods for teaching EBP. The field needs clear guidelines, educational toolkits, and comprehensive materials to effectively bridge the gap between knowledge and practice and to address the challenges of EBP education and its clinical application.

Developing a framework for MyDispense implementation using the nominal group technique: Perspectives across student progression levels

INTRODUCTION

MyDispense is an online dispensing pharmacy simulation with features such as electronic health records and clinical decision-making. This study aims to develop a framework for integrating MyDispense into pharmacy education programs, and to identify key considerations around its implementation.

METHODS

A nominal group technique with faculty staff and students was employed to gather opinions and experiences with MyDispense, factors to consider during implementation, and perceptions of an ideal framework. A framework for MyDispense implementation was developed based on the input gathered, and common themes from content analysis and considerations for effective integration were identified.

RESULTS

An analysis of discussions on the role of MyDispense in pharmacy student learning revealed that its role depends on how far along students are in their degree and their level of pharmacy knowledge as they progress through their degree. The proposed framework for implementing MyDispense in novice pharmacy education emphasizes the development of fundamental skills, while for students in intermediate year levels, MyDispense can be used in clinical notes. For near-entry to practice students, the focus shifts to refining advanced clinical decision-making skills through authentic virtual training exercises. Valuable insights from former users contributed to shaping a proposed implementation framework, indicating the need for tailored approaches at different student proficiency levels.

CONCLUSION

Our study highlights the versatility of MyDispense as a tool for enhancing pharmacy education. The MyDispense framework, shaped by diverse participant insights, emphasizes the need for tailored implementation based on student proficiency level. The findings offer practical guidance for educators to optimize MyDispense use in fostering clinical skills in pharmacy students.

The science behind the lifesum app: an intervention design analysis

Wellness is an increasingly important part of public health and can prevent both disease and death. Diet and nutrition are important factors that contribute to wellness and predict health outcomes. Adhering to healthy diets is notoriously difficult for many, and some support is often required. Increasingly, that support may be found in the shape of an app in a smartphone. One such app is Lifesum, with some 65 million users worldwide. Lifesum adopts a more holistic approach to nutrition and well-being, and adopted an evidence-based approach to its development. The aim of this study was to describe the scientific, theoretical basis for the Lifesum app and contribute to advancing science in the field of wellness app development. This was an intervention design analysis, designed to describe the theoretical model and intervention theory used to create the Lifesum app in its current embodiment. A pragmatic theoretical model describing behaviour change in the context of healthy eating was devised based on findings in literature. Factors that drive unhealthy eating behaviours, but that were malleable and whose mechanisms of change were feasible to implement, were identified and used to form an intervention theory. The theoretical model and the intervention theory could then guide the implementation of the Lifesum app, illustrated by a logic model. The theoretical model emphasizes personal goal-attainment and motivation as keys to establishing and maintaining healthy eating behaviours, with proximal outcomes being nutrition knowledge, mindfulness about eating and macro-nutrient balance. Nutrition knowledge is achieved through the provision of nutrition information from a vast database on food items, easily available. Continuous feedback on food choices made will enhance this knowledge and a greater awareness of the impact of nutrition on health remains desirable. A more mindful disposition regarding foods is achieved through support in terms of tracking food intake continuously, as well as recommending meals or recipes. After collecting user preferences on health status, biometrics and goals, these meal plans and recipes can be made to offer the optimal macro-nutrient distribution for each individual user. A theoretical model for diet-related behavior change was developed and key dietary issues were identified, outlining mechanisms for positive impact. These insights informed a mechanistic description of the Lifesum app, providing a foundation for future research on intervention outcomes.

Exploring the efficacy and safety of lecanemab in the management of early Alzheimer's disease: A systematic review of clinical evidence

BackgroundAlzheimer's disease (AD) is a growing neurodegenerative disorder causing cognitive decline, memory loss, and functional impairment. Lecanemab has shown safety and efficacy in clinical trials.ObjectiveThis review aims to understand the clinical evidence of lecanemab's effectiveness and safety in managing early AD.MethodsA systematic search was conducted using the Scopus database and ClinicalTrials.gov. Studies from 2014 to 2024 on lecanemab's safety, efficacy, and clinical outcomes for AD were included. Data extraction involved two independent reviewers, with synthesis using qualitative methodology.ResultsFindings from 13 studies and 13 ongoing clinical trials were reported, showing that lecanemab substantially reduces amyloid plaque load in the brains of AD patients. The therapeutic regimens vary across reported studies and trials, ranging from 2.5 mg/kg biweekly, 5 mg/kg monthly, 5 mg/kg biweekly, 10 mg/kg monthly, and 10 mg/kg intravenously biweekly. The Clarity AD phase 3 trial, the AHEAD study, and the DIAN-TU-001 trials have reported positive study outcomes with robust efficacy and safety outcomes with minimal side effects. Completed and ongoing trials report on the onset of amyloid-related imaging abnormalities (ARIA) and the continuation of care status following the onset of ARIA in these patients. The common infusion-related reactions were observed in 26.4% of the lecanemab group compared to 7% in the placebo group.ConclusionsThe management of AD has evolved over the years with the introduction of novel therapeutic agents like lecanemab. While its safety profile is generally favorable, careful monitoring is essential.

The road to successful implementation of innovation in radiotherapy: A research-based implementation protocol

BACKGROUND AND PURPOSE

Radiotherapy (RT) is rapidly advancing, yet only 50 % of innovations are implemented promptly. Despite the availability of Implementation Science (ImpSci) theories, models, and frameworks (TMFs), a theory-practice gap persists in effectively applying these insights in RT clinical practice. This study aims to develop a consensus-based implementation protocol for RT innovations using validated ImpSci knowledge.

MATERIAL AND METHODS

A literature review of TMFs (May-August 2023) and 20 semi-structured interviews with Dutch RT professionals (August-December 2023) identified key RT components for implementation. These insights informed a draft RT implementation protocol, which was refined through a three-round international Delphi study (March-September 2024) involving 11 RT and 5 ImpSci experts. Consensus was determined using a 5-point Likert scale, analysing medians, interquartile ranges (IQRs), and percentage scoring.

RESULTS

The Knowledge-to-Action (KTA) Framework and input from expert interviews were used to draft the protocol. Delphi response rates were 100 %, 93.8 %, and 88.9 % across rounds. In round 1, 88.9 % of elements achieved consensus (median = 4.0, IQR = 0.0-1.3); only the application of a prediction model for timely implementation (step 3c) needed revision after rounds 1 and 2. In round 3, also for step 3c consensus was reached (median = 4.0, IQR = 0.3). The protocol includes defining innovation types, stakeholder analysis, tailored implementation strategies, and a phased evaluation plan to ensure sustainability.

CONCLUSION

This is the first consensus-based RT innovation implementation protocol, addressing the theory-practice gap with a structured clinical approach. Future research should validate the protocol and assess the impact of preparation on implementation success.

Theory-based and Person-centered Approach to Design a Digital Tool for Improving Lifelong Congenital Heart Disease Care

There is a critical need to support patients with congenital heart disease (CHD), especially during their young adulthood, to help maintain lifelong care with adult CHD specialists. The near ubiquitous use of digital tools, especially among the young adults, offers potential solutions to develop effective, scalable, accessible, and sustainable strategies to support these patients. This study describes the development of a digital tool using the combination of theory-based behavioral analysis, semi-structured interviews with 54 patients and clinicians, and community-based participatory research approaches. Four hopes for the digital tool emerged: easy access to credible resources, uplifting of patient voices, customizing to patient needs, and centering positivity and joy. The digital tool, named by community partners as Empower My Congenital Heart (EmpowerMyCH), is web- and mobile-based, Apple- and Android-compatible. Key intervention components include a digital medical passport, expert and peer advice, and peer support. EmpowerMyCH redefines how we support patients to be actively involved in their care and could potentially reduce some care gaps.

Obstetrics and gynecology devices designed for low- and middle-income countries: A narrative review

There are many barriers contributing to poor health outcomes for women in low- and middle-income countries (LMICs), one of which is the lack of necessary medical devices. Presently, the development of various kinds of devices intended to improve women's health outcomes specifically in LMICs remains underrepresented in the literature; therefore, we performed a narrative review to understand this current state of literature. A literature search was conducted in Scopus and Overton between December 2023 to February 2024, and PubMed in October 2024 to broadly explore peer-reviewed publications focusing on understanding the development of devices used specifically in obstetrics and gynecology (OBGYN) care in LMICs. The initial search identified 132 published manuscripts: 114 non-duplicates from 1993 to 2024. After a two-research team member independent review, 22 manuscripts from 2011 to 2023 were included, and 18 devices identified. Nine devices focus on postpartum hemorrhage, four on general obstetrics, one on fetal monitoring, one on vaginal deliveries, one on gynecology hemorrhage, one on gynecology screening, and one on OBGYN anesthesia. This review provides recommendations for areas of improvement of key gaps affecting the development and implementation of OBGYN devices for use in LMICs. Recommendations are provided for various stages of the development to early commercialization phases. We believe future incorporation of these recommendations can aid in equitable and implementable medical device design for OBGYN care in LMICs.

Using Implementation Science in Surgical Care: A Scoping Review

OBJECTIVE

Improvement of surgical care is dependent upon evidence-based practices (EBPs), policies, procedures, and innovations. The objective of this study was to understand and synthesize the use of implementation science (IS) in surgical care.

BACKGROUND

This article summarizes the existing literature to identify the frequency and types of EBPs selected for surgical care, IS frameworks that guided the published research, and prominent facilitators and barriers.

METHODS

A modified version of the Arksey and O'Malley framework and the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews Checklist were used to provide the guidance and standards to conduct this scoping review. We queried Ovid MEDLINE, American Psychological Association PsycINFO, Embase, Cumulated Index to Nursing and Allied Health Literature, Web of Science, and Google Scholar for manuscripts published January 2001-June 2023.

RESULTS

The initial search found 3674 citations, of which 129 met the inclusion criteria. The heterogeneity and volume of innovations within the surgical IS field were vast. The most frequent innovations were in perioperative care, safety in surgery, and Enhanced Recovery After Surgery. Six constructs were identified as both major facilitators and barriers: support from leadership, surgeon and staff knowledge regarding EBPs, relationship/team building, environmental context, data, and resources.

CONCLUSION

Identifying these implementation factors used in the surgical field enables us to determine variables that support and inhibit the adoption and implementation of new practices, support practice change, enhance quality and equity of surgical care, and identify research gaps for future IS in surgical care.

Providers' Perspectives on Implementation of Low-threshold HCV Treatment in New York State: A Qualitative Study

Background

Global study data show injection drug use is driving upwards of 79% of all new hepatitis C virus (HCV) cases in high-income countries. Low-threshold models can engage vulnerable populations in treatment to achieve HCV elimination targets. We examined the implementation of low-threshold models for HCV care in New York State, which has a robust HCV elimination program.

Methods

We conducted semi-structured interviews with 16 healthcare providers in 2022. Included providers either self-described as "low-threshold," had a clinical focus on marginalized populations, or practiced in non-traditional settings. Interviews focused on the implementation of low-threshold HCV care. Transcripts were analyzed using thematic analysis and were categorized into themes guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework.

Results

Providers implemented low-threshold HCV care by facilitating access (e.g., having walk-in or telemedicine HCV services). Point-of-care testing and peer support were other important features. The inner context was driven by provider and organization values and involved providing low-threshold HCV care within health systems that were not themselves "low-threshold." Adequate staffing was crucial for the extensive care coordination and outreach activities needed to engage persons who inject drugs (PWID). The outer context was characterized by a limited funding environment, restrictive insurance policies, and the high impact of patients' unmet social needs. Providers relied on care coordination and integrated care models to overcome these barriers.

Conclusions

Low-threshold HCV care incorporates operational flexibility and patient navigation but is challenged by patients' unmet social needs. Jurisdictions can support implementation by providing adequate funding for substantial outreach activities needed to engage vulnerable populations.

Barriers and Facilitators to Physical Activity Participation Among Colorectal Cancer Survivors: A Mixed-Method Systematic Review

OBJECTIVES

Physical activity (PA) is essential in cancer rehabilitation. Worryingly, PA compliance among colorectal cancer (CRC) survivors is relatively poor, and the barriers and facilitators of PA participation in this population are poorly understood. This review aimed to identify the barriers and facilitators of PA participation among CRC survivors and apply the Capability-Opportunity-Motivation-Behavior (COM-B) model to analyze and categorize these factors.

METHODS

A mixed-method systematic review was conducted using six electronic databases (Embase, Medline, PubMed, Scopus, Web of Science, and Chinese National Knowledge Infrastructure) to conduct literature search. The searches were conducted from the inception of databases till May 2024, and eligible studies were limited to English or Chinese. The mixed methods appraisal tool (MMAT) was utilized to perform quality assessment, and the convergent integrated approach and descriptive analysis were used for data synthesis and analysis.

RESULTS

This review included 32 studies (seven qualitative, 24 quantitative, and one mixed-method), and no studies were eliminated due to quality. According to the COM-B model, cancer-related symptoms, time constraints, and lack of motivation or interest were the main barriers to PA participation among CRC survivors. The main facilitators of PA participation for CRC survivors included improvement in cancer-related symptoms, enough social support from family and friends, and perceived benefits of PA.

CONCLUSIONS

This review comprehensively identified the unique barriers and facilitators to PA participation among CRC survivors based on the COM-B model. Future research should consider these barriers and facilitators and develop effective PA interventions to increase PA compliance among CRC survivors.

Development and testing of an interactive evaluation tool: the Evaluating QUality and ImPlementation (EQUIP) Tool

BACKGROUND

Evaluating implementation outcomes is gaining momentum in health service delivery organizations. Teams are increasingly recognizing the importance of capturing and learning from their implementation efforts, and Implementation Scientists have published extensively on implementation outcomes. However, Quality Improvement approaches and tools are more widely recognized and routinely used in healthcare to improve processes and outcomes. This article describes the development of an interactive online tool designed to help researchers and practitioners effectively design and develop appropriate evaluation plans that support the understanding of successful implementation.

METHODS

There were two main development phases. Phase 1, from January to October 2020, involved several design sessions with a small group of professionals leading implementation initiatives within the provincial health delivery system. This resulted in a testable prototype. Phase 2, from November 2020 to June 2021, focused on usability testing and interviews with a broader group of researchers and professionals leading implementation initiatives across the province.

RESULTS

The result is the EQUIP (Evaluating QUality and ImPlementation) Tool, an interactive online tool that integrates quality measures from the Alberta Quality Matrix for Health and implementation measures from widely used outcomes frameworks, such as the one developed by Proctor and colleagues and the RE-AIM planning and evaluation framework. The tool encourages users to explore implementation outcomes and quality dimensions from different perspectives and select questions and indicators relevant to their project.

CONCLUSION

The EQUIP tool was designed and refined in collaboration with end users to create an accessible and practical online tool. This work addresses the call for greater integration of Quality Improvement and Implementation Science by combining approaches from both fields to strengthen evaluation processes within the health system.

Evaluating the implementation of adult smoking cessation programs in community settings: a scoping review

Introduction

Tobacco smoking is a leading contributor to preventable morbidity and premature mortality globally. Although evidence-based smoking cessation programs have been implemented, there is limited evidence on the application of theories, models, and frameworks (TMFs), and implementation strategies to support such programs. This scoping review mapped the evidence for interventions, TMFs, and implementation strategies used for smoking cessation programs in the community.

Methods

We searched four electronic databases in addition to grey literature and conducted hand-searching between February and December 2023. Original studies of qualitative, quantitative, or mixed methods were considered for inclusion. Studies reporting prospectively planned and/or delivered implementation of smoking cessation interventions or programs, incorporating contextual factors, use of implementation TMF, implementation strategies, or other factors influencing implementation were considered for inclusion. Intervention components were categorized using the Template for Intervention Description and Replication (TIDieR) checklist. Implementation strategies were mapped to the Expert Recommendations for Implementing Change (ERIC) Strategy Clusters.

Results

A total of 31 studies were included. We identified 12 discrete interventions, commonly included as part of multicomponent interventions. Most studies reported tailoring or modifying interventions at the population or individual level. We identified 19 distinct implementation TMFs used to prospectively guide or evaluate implementation in 26 out of 31 included studies. Studies reported diverse implementation strategies. Three studies embedded culturally appropriate TMFs or local cultural guidance into the implementation process. These studies took a collaborative approach with the communities through partnership, participation, cultural tailoring, and community-directed implementation.

Discussion

Our findings highlight the methods by which the implementation of smoking cessation may be supported within the community. Whilst there is debate surrounding their necessity, there are practical benefits to applying TMFs for implementing, evaluating, and disseminating findings. We determined that whilst ERIC was well-suited as a framework for guiding the implementation of future smoking cessation programs, there was inconsistent use of implementation strategies across the ERIC domains. Our findings highlight a lack of harmonization in the literature to culturally tailor implementation processes for local communities.

Bridging the gap: translating and simplifying CFIR 2.0 for French practitioners in implementation science

BACKGROUND

The Consolidated Framework for Implementation Research (CFIR) 2.0 is widely used in implementation projects but can be difficult for non-researchers to apply due to its complexity. While a French version of the original CFIR exists, CFIR 2.0 had not yet been translated. This study aimed to translate and simplify CFIR 2.0 for healthcare practitioners in French-speaking Switzerland to improve its accessibility and utility.

METHOD

Using the Principles of Good Practice for Translation and Cultural Adaptation, the process included: (1) four independent forward translations, (2) reconciliation of simplified definitions, (3) online survey with 16 clinical nurse specialists to assess the content validity of the simplified definitions, (4) back translation, and (5) harmonization to finalize the French version. The content validity of each construct was assessed using the Content Validity Index (CVI), with further revisions based on feedback.

RESULTS

Most participants found the simplified definitions understandable, with an average score of 1.46 (where 1 is "very easy to understand" and 2 is "easy to understand"). Thirteen items with lower I-CVI scores (≤ 0.78) were revised. The overall S-CVI was 0.87, indicating high content validity. Minor discrepancies in the back translation were resolved.

CONCLUSIONS

This study produced a French translation of CFIR 2.0 with simplified definitions tailored for healthcare practitioners. The high content validity and feedback underscore the need for contextually relevant adaptations to enhance the practical use of the CFIR framework. Further testing in diverse French-speaking contexts is necessary to refine the tool and broaden its applicability in real-world settings.

Theory-informed process evaluation protocol to assess a rapid-access outpatient model of care in South East Queensland, Australia

INTRODUCTION

Chronic diseases place a large burden on health systems globally. While long-term planned care is essential for their management, episodes of deterioration are common. The emergence of rapid access to outpatient care has proliferated in response to increased resource pressures on acute health services. It is anticipated that these new models of care may prevent hospitalisations and reduce the burden on emergency departments. While some evidence supports the clinical effectiveness of these models, little is known about the core components and key attributes of these services. This paper outlines the protocol of a theory-driven, pragmatic process evaluation embedded within a new rapid-access outpatient service for chronic disease in South East Queensland, Australia.

METHODS AND ANALYSIS

This mixed-methods process evaluation will be conducted across three phases: (1) context assessment to identify programme characteristics and core components; (2) evaluation of key service processes and development of service improvement strategies and (3) sustainability assessment, with a focus on programme embedding and the resources associated with service evaluation. Each phase will be guided using implementation science frameworks and/or theory. Participants will include service consumers, service delivery staff, implementation leaders and decision-makers and wider system referrers. Professional stakeholders will be recruited through a direct invitation to participate (using purposeful sampling methods) and will be engaged in interviews at 1-3 data collection time points. Service consumers will be recruited through direct advertisement to participate in interviews. Administrative and clinical data collections will be retrospectively analysed with descriptive and inferential methods and triangulated with qualitative data to yield primary and secondary outcomes.

ETHICS AND DISSEMINATION

Ethical clearance has been obtained from the West Moreton Hospital and Health Service Human Research Ethics Committee. The planned dissemination of results will occur through conferences, abstracts and publications.

TRIAL REGISTRATION NUMBER

Australia and New Zealand Clinical Trials Registry (ANZCTR Trial ID: ACTRN12624000757516).

Integrated specialty care for amyloidosis: a scoping review using the Consolidated Framework for Implementation Research

BACKGROUND

Amyloidosis is a complex and rare disease requiring specialized, multidisciplinary care to effectively manage its diverse manifestations. Existing evidence underscores the benefits of such care, linked to improved patient outcomes and clinician satisfaction. With the rising incidence of amyloidosis diagnoses and rapid advancements in treatment, the need for coordinated, expert-led care is increasing. However, implementing these centers is challenging due to resource allocation and inter-specialty collaboration. While resource allocation is a known hurdle, there has not been a comprehensive review of all the barriers and facilitators to establishing these clinics. This scoping review aims to identify the barriers and facilitators related to the implementation of coordinated, multidisciplinary specialty care clinics in amyloidosis management.

METHODS

An electronic search was conducted in Medline, Embase, and CINAHL for studies published in English from 2013 to 2023, supplemented by a grey literature search. The inclusion criteria focused on studies discussing multidisciplinary clinical environments for amyloidosis care, particularly light-chain (AL) and transthyretin amyloidosis (TTR). Exclusion criteria included books, opinion pieces, dissertations, and conference abstracts. Data were analyzed and synthesized using a narrative synthesis approach, guided by the Consolidated Framework for Implementation Research (CFIR), and reported according to PRISMA-ScR guidelines.

RESULTS

The search resulted in 1547 findings. After screening with Covidence, 7 papers were included in the final review. Independent reviewers screened and extracted the papers. Key facilitators identified include access to experts, adequate staffing, secure funding, partnerships with patient advocacy groups, and robust processes for multidisciplinary communication. Barriers primarily relate to the complexity of care, a lack of standardized protocols, difficulties in communication and coordination between providers, and challenges in training and maintaining knowledgeable care providers. The review also revealed significant gaps in existing research.

CONCLUSIONS

This review enhances understanding of the barriers and facilitators in establishing amyloidosis specialty clinics. Addressing these barriers and leveraging facilitators are crucial for shaping the future of amyloidosis care. These insights support a model for implementing integrated care for this growing patient population and highlight the need for further research to support policy development and effective implementation of these specialized clinics.

The design and implementation of an innovative indicated suicide prevention service in Melbourne

BACKGROUND

Suicide prevention strategies are targeted at three levels: the general population (Universal), persons at risk (Selected), and persons who have attempted suicide or have suicidal ideation (Indicated). This study describes the implementation of an innovative indicated suicide prevention service that prioritizes peer and psychosocial support at one of Australia's largest mental health services. The purpose of this paper is threefold. (1) To describe the process of designing and implementing an innovative indicated suicide prevention service in Melbourne (2) To compare the implementation framework developed around it with other relevant frameworks and (3) To describe its stages of care.

RESULTS

Based on the activities undertaken by the 'project champion' in designing and implementing Clayton HOPE, a pragmatic framework of implementation (PFI) was developed. The PFI included six steps. 1: Determine client needs; 2: Plan the model of care; 3: Determine the workforce and other resource requirements to achieve client needs; 4: Establish the workforce and finalize the team; 5: Facilitate stakeholder buy-in and 6: Regular monitoring and evaluation. The steps of the PFI, fit within the Quality Implementation Framework, albeit in a different sequence, owing to variations in settings, organizational circumstances, and readiness for change. The PFI also enhances the Levels of Change model by including additional requirements. A five-stage model of care was developed and implemented. They are 1: Early engagement and empathetic support (within 24 h of referral); 2: Assessment of psychosocial needs and suicidal risk (within 72 h of referral) 3: Construction of a personal safety plan (within 7 days of referral) 4: Implementation of the personal safety plan and risk management (week 2 - week12) and 5: Discharge and handover to ongoing supports (12 weeks from enrollment).

CONCLUSIONS

The main implications of this work are twofold: (1) The implementation of innovative models of care can be achieved by a 'project champion' with the relevant experience, authority and determination when funding is available and (2) Indicated suicide prevention models of care can strike a balance between clinical and non-clinical interventions that are tailored to client needs.

Supporting partnerships in knowledge mobilization: what existing implementation strategies can tell us

BACKGROUND

The need for partnership between knowledge producers and knowledge users to foster effective implementation is well-established in the implementation science literature. While many theories, models, and frameworks (TMF) have been developed to guide knowledge mobilization (KM) activities, seldom do these frameworks inform approaches for establishing and maintaining KM partnerships (i.e., relationships between researchers and individuals with relevant expertise in KM activities). Thus, there is a significant knowledge-to-action gap related to operationalizing engagement in partnerships and leveraging the evidence that exists to support them. Given the abundance of TMFs, it is prudent to consider whether any may be suitable to inform approaches to partnership. The aim of this commentary is to discuss the necessity for strategies to support engagement in partnerships for KM activities, as well as to explore the potential to apply strategies from an existing implementation taxonomy to inform partnerships approaches in KM.

MAIN BODY

Using a case study, this commentary explores the opportunity to apply existing implementation strategies put forward by the Expert Recommendations for Implementing Change (ERIC) taxonomy to inform partnership strategies. This case study utilized qualitative evidence from a qualitative study about KM in children's pain management informed by the Consolidated Framework for Implementation Research (CFIR). It explored partner perspectives (i.e., knowledge producers and users) on factors that supported their engagement in KM activities. The factors generated were subsequently mapped onto the ERIC taxonomy to identify relevant strategies to support partnerships development for KM activities (e.g., shared goals among team members mapped onto the ERIC strategy Build a Coalition). Each factor generated was determined to have a corresponding ERIC strategy to support the operationalization of that factor.

CONCLUSIONS

This case example and discussion bolster the utility of existing taxonomies and frameworks to support the development and sustainability of partnerships to support engagement in KM activities, a promising next step for developing strategies to support partnerships. Opportunities for future development are also discussed, including identifying other theories, models, and frameworks that may contribute to a comprehensive suite of empirically informed partnership strategies, as well as the necessity to make strategies and approaches available to non-specialist audiences.

Mechanism-Based Middle-Range Theories: Using Realist Syntheses to Reconcile Specificity to Context and Generalizability

Realist synthesis is a recognized methodological approach to evidence synthesis to inform evidence-based health policy and practice. The implicit assumption behind research synthesis is that the evidence it generates should be generalizable--drawing broad inferences from specific observations. While this understanding is generally shared among social scientists, tensions exist between having generalizable evidence and how this evidence can be useful in specific contexts. This paper considers the role of mechanism-based middle-range theories obtained from realist synthesis in bridging specificity to context and generalizability. Retroductive theorizing in realist synthesis helps to identify ideas about mechanisms related to the phenomenon embedded in the social and organizational contexts that could, in principle, have a much broader application. Also, because mechanism-based middle-range theories are linked to contextual features, they capture contextual nuances to enhance evidence implementation. We conclude that middle-range mechanisms provide an opportunity to achieve generalizability and contextualization in implementation science.

Real-world implementation of geriatric assessment in cancer care among older adults: the role of implementation science frameworks

PURPOSE OF REVIEW

The evidence supporting geriatric assessment (GA) in cancer care is well established, and GA is recommended by the American Society of Clinical Oncology, the International Society of Geriatric Oncology, and other oncology bodies. However, effective implementation of GA remains inadequate. Using selected papers indexed in Medline from the most recent 18 months to July 2024, including two outstanding interest papers, this review aimed to describe enablers and barriers to GA implementation in oncology and contrasts implementation with and without an implementation science framework. Finally, we make recommendations on applying an implementation science framework to facilitate integrating GA in oncology.

RECENT FINDINGS

Implementation science frameworks have been widely employed in health services research, but their use in geriatric oncology, particularly to guide GA implementation and evaluation, is limited. Lack of time in busy practices coupled with workforce shortages adds to the challenges of GA implementation and adoption. A variety of screening and assessment tools such as the G8, electronic rapid fitness assessment, and Eastern Cooperative Oncology Group are often used in lieu of geriatrician review and to streamline GA. When effectively implemented in oncology, GA informs care and treatment decisions for improved outcomes.

SUMMARY

Despite the benefits for older adults, embedding GA into routine clinical practice is critical yet not common practice. The variety of available GA tools, logistics, and individual beliefs are some of the identified barriers to GA adoption in oncology. Enablers include organization readiness, adaptability, communication, and the use of multidisciplinary teams. Further research is needed to examine how implementation science frameworks could provide guidance and structure for successful GA implementation in oncology.

Implementing the Eat, Sleep, Console Model of Care: A Scoping Review

OBJECTIVE

The Eat, Sleep, Console (ESC) model of care is an innovative care approach for infants diagnosed with neonatal abstinence syndrome, improving patient and health system outcomes for this equity-deserving population. Little is known about sustainably implementing this model into practice. The objective is to map evidence on implementing the ESC model into clinical practice, including strategies, barriers and facilitators to implementation, and evaluation outcomes.

METHODS

Data sources include MEDLINE, Embase, CINAHL, PsycINFO, Google Scholar, and websites identified by a Google search. The study selection included articles exploring the implementation or evaluation of the ESC model in clinical practice since its 2017 conception. Two reviewers independently screened each study using a predetermined screening tool. Data were extracted by 2 independent reviewers from included articles.

RESULTS

The review identified 34 studies. Barriers to implementing the ESC model include resource limitations and systemic oppression and bias. Facilitators include health care provider education and empowerment of parent engagement. The most reported cluster of strategies (31.6%) included training and educating stakeholders. Gaps were noted in the exploration of implementation outcomes/processes, and equity implications on implementation.

CONCLUSIONS

The ESC model of care has been successfully implemented in various settings with positive patient and health system outcomes, including decreased hospital stay and pharmacological treatment of infants. However, there is a gap in exploring implementation processes and outcomes. Future research should explore the contextual elements of the implementation by equitably examining implementation outcomes specific to the ESC model of care.

The NASSS (Non-Adoption, Abandonment, Scale-Up, Spread and Sustainability) framework use over time: A scoping review

The Non-adoption, Abandonment, Scale-up, Spread, Sustainability (NASSS) framework (2017) was established as an evidence-based, theory-informed tool to predict and evaluate the success of implementing health and care technologies. While the NASSS is gaining popularity, its use has not been systematically described. Literature reviews on the applications of popular implementation frameworks, such as the RE-AIM and the CFIR, have enabled their advancement in implementation science. Similarly, we sought to advance the science of implementation and application of theories, models, and frameworks (TMFs) in research by exploring the application of the NASSS in the five years since its inception. We aim to understand the characteristics of studies that used the NASSS, how it was used, and the lessons learned from its application. We conducted a scoping review following the JBI methodology. On December 20, 2022, we searched the following databases: Ovid MEDLINE, EMBASE, PsychINFO, CINAHL, Scopus, Web of Science, and LISTA. We used typologies and frameworks to characterize evidence to address our aim. This review included 57 studies that were qualitative (n=28), mixed/multi-methods (n=13), case studies (n=6), observational (n=3), experimental (n=3), and other designs (e.g., quality improvement) (n=4). The four most common types of digital applications being implemented were telemedicine/virtual care (n=24), personal health devices (n=10), digital interventions such as internet Cognitive Behavioural Therapies (n=10), and knowledge generation applications (n=9). Studies used the NASSS to inform study design (n=9), data collection (n=35), analysis (n=41), data presentation (n=33), and interpretation (n=39). Most studies applied the NASSS retrospectively to implementation (n=33). The remainder applied the NASSS prospectively (n=15) or concurrently (n=8) with implementation. We also collated reported barriers and enablers to implementation. We found the most reported barriers fell within the Organization and Adopter System domains, and the most frequently reported enablers fell within the Value Proposition domain. Eighteen studies highlighted the NASSS as a valuable and practical resource, particularly for unravelling complexities, comprehending implementation context, understanding contextual relevance in implementing health technology, and recognizing its adaptable nature to cater to researchers' requirements. Most studies used the NASSS retrospectively, which may be attributed to the framework's novelty. However, this finding highlights the need for prospective and concurrent application of the NASSS within the implementation process. In addition, almost all included studies reported multiple domains as barriers and enablers to implementation, indicating that implementation is a highly complex process that requires careful preparation to ensure implementation success. Finally, we identified a need for better reporting when using the NASSS in implementation research to contribute to the collective knowledge in the field.

Research priority setting for implementation science and practice: a living systematic review protocol

BACKGROUND

Research priority setting has the potential to bridge knowledge gaps, optimize resource allocation, foster collaborations, and inform funding directions for implementation science and practice when these priorities are properly acted upon. This systematic review aims to determine the extent of research in priority setting for implementation science and practice, examine the methodologies employed, synthesize these research priorities, and identify strategies for evaluating and implementing these priorities.

METHODS

We will conduct a living systematic review following the Cochrane guidance. We will search literature from six databases, the website of James Lind Alliance, five implementation science-focused journals and several related journals, Google Scholar, and the reference lists of included studies. Two reviewers will independently screen studies based on the eligibility criteria. The characteristics of the included documents, their prioritization methods, and outcomes, as well as the evaluation and implementation strategies, will be extracted. We will critically appraise these documents using the nine common themes of good practice for research priority setting, and synthesize data using a narrative approach. We will re-run the search 12 months after the original search date to monitor the development of new literature and determine the time to update the review.

DISCUSSIONS

By conducting this living systematic review, we will gain a comprehensive and dynamic understanding of the potential research gaps and hotspots in implementation science as perceived by researchers and practitioners. The findings of this review will inform the future research directions of implementation science and practice.

SYSTEMATIC REVIEW REGISTRATION

This review has been registered with the Open Science Framework ( https://osf.io/sr69k ).

A Perspective on Home-Based Sexual Health Care: Evidence, Access, and Future Directions

PURPOSE

This perspective explores the impact of home-based sexual health services on accessibility to STI and HIV testing for priority populations. This study evaluates home-based services as independent care options and as complementary components of traditional clinic-based care.

RECENT FINDINGS

Challenges for persons to attend clinic-based sexual health care can be overcome by offering lower threshold home-based sexual health care. Implementing home-based services has successfully reached priority populations, including previously untested men who have sex with men (MSM) and individuals with a high exposure risk for sexually transmitted infections (STI) including human immunodeficiency virus (HIV), attending location-based sexual health care. A challenge in home-based services is to ensure equitable care, such as for individuals with limited access to digital resources or low health literacy. While home-based sexual health services enhance the accessibility of sexual healthcare, to ensure equitable care, research into the needs of still underserved populations and subsequent tailoring of the care offered, is needed. Continuous monitoring and evaluation of the implementation of home-based services may maximize the advantages of this promising type of care.

Patient safety incident reporting systems and reporting practices in African healthcare organisations: a systematic review and meta-analysis

BACKGROUND

Patient safety incident reporting and learning systems are crucial for improving the safety and quality of healthcare. However, comprehensive evidence of their availability and use in African healthcare organisations is lacking. Therefore, this review aims to synthesise the existing literature on these systems and reporting practices within African healthcare organisations.

METHODS

A systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Five electronic databases, including PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCOhost, Scopus, Web of Science and the Excerpta Medica Database (Embase), were searched to identify relevant records. Peer-reviewed articles and guidelines published in English were included in this review. Quality appraisal was performed using the Joanna Briggs Institute and Quality Assessment with Diverse Studies tool. A random effects model was used to compute the pooled prevalence using Stata V.17.0.

RESULTS

A systematic search retrieved 9279 records, of which 39 (36 articles and 3 guidelines) were included in this review. Eight patient safety incident reporting and learning systems were identified, with compliance rates ranging from low (16%) to high (87%) based on the WHO criteria. The pooled prevalence of patient safety incident reporting practices was 48% (95% CI 40% to 56%). However, the studies exhibited high heterogeneity (I²=98.75%, p<0.001).

CONCLUSION

In African healthcare organisations, it is imperative to establish robust patient safety incident reporting and learning systems, as none of the existing systems fully meet WHO criteria. In addition, optimising the existing systems and encouraging healthcare professionals to improve reporting practices will enhance patient safety and outcomes.

PROSPERO REGISTRATION NUMBER

CRD42023455168.

A qualitative descriptive study on the perspectives and experiences of multidisciplinary HCPs in providing nutritional care to older adults with cancer

OBJECTIVES

To explore the perceptions and experiences of healthcare professionals (HCPs) caring for older adults with cancer regarding dietary advice provision and dietetic referral.

METHODS

Qualitative descriptive study providing rich descriptions of the experiences of multidisciplinary HCPs in providing care to older adults with cancer, excluding dietitians or nutritionists. Purposive and snowball sampling methods were used for recruitment. Semi-structured interviews and a focus group session were conducted. Data was analysed using qualitative content analysis. Inductive codes were generated, and codes representing factors influencing HCPs' referral to dietetics and dietary advice provision were then mapped to domains in the Tailored Implementation of Chronic Diseases (TICD) checklist using a deductive approach.

RESULTS

Twenty HCPs across various Australian healthcare settings participated, with a broad range of working experience (1.5 to 53 years) being interviewed. Most participants perceived their role in the provision of general dietary advice, and there was a consensus that nutrition is important. Key barriers (e.g. lack of time and resources, perceived lack of knowledge, scope of practice), including unique patient-related barriers (e.g. co-morbidities, fatalistic mindset), and key facilitators (e.g. need for education, evidence-based resources, multidisciplinary team approach) to dietary advice provision fell within five TICD domains (intervention, health professional factors, patient factors, professional interactions, incentives and resources). Common barriers (e.g. disconnections in multidisciplinary care, lack of structured referral pathways) and facilitators (e.g. clear referral pathways) to referral fell within four TICD domains (intervention, health professional factors, professional interactions, incentives and resources).

CONCLUSION

The barriers and facilitators to referral and provision of dietary advice by HCPs suggest the need for system-level changes via a multi-pronged approach. Simple and accessible nutrition resources, stronger nutrition education for HCPs, improved referral pathways and role clarity are required to support a multidisciplinary approach to nutritional care. More qualitative research on patient-level factors involving older adults with cancer is warranted.

Exploring co-adaptation for public health interventions: insights from a rapid review and interviews

BACKGROUND

Adapting co-creation research processes and/or public health interventions improves the fit between the intervention and population of interest, potentially resulting in more relevant and effective interventions. Mode 2 research approaches (e.g., co-creation, co-production, co-design, community-based participatory research, and participatory action research) can ensure that adaptations fit the socio-cultural and economic contexts. However, an overview of existing practices and how to co-adapt is lacking. This study aimed to provide an overview of the use of co-adaptation in co-creation processes and/or public health interventions.

METHODS

We conducted a rapid review search on the Health CASCADE co-creation database. Relevant peer-reviewed studies reporting on co-adaptation of public health interventions were identified. A call for case studies via social media and co-authors' snowballing was issued to perform interviews with co-creation researchers gaining insights into how co-adaptation was applied from unpublished studies and practice. Interviews were analysed using template analysis.

RESULTS

Fourteen studies addressed various public health issues by co-adapting co-creation processes, intervention activities, communication platforms, monitoring strategies, training components, and materials' language and tone. Most studies lacked detailed reporting on the co-adaptation process, though some provided information on group composition and number, duration, and methods applied. Two out of 14 studies used a framework (i.e., Intervention Mapping Adapt), seven described their adaptation procedure without naming a specific framework, and five did not report any procedures or frameworks. Five of seven case studies used adaptation frameworks (e.g., ADAPT guidance). Interviews provided insights into the co-adaptation process emphasising the importance of contextual fit, integrating prior knowledge, and logging adaptations.

CONCLUSIONS

This study is the first introducing the concept of and exploring co-adaptation of co-creation processes and/or public health interventions. It provides details regarding adaptations made, whether and which frameworks were used, and procedures applied to adapt. The findings highlight the need for tailored frameworks for co-adaptation and better reporting of co-adaptation processes.

Evaluating the feasibility of using the Multiphase Optimization Strategy framework to assess implementation strategies for digital mental health applications activations: a proof of concept study

Background

Despite the effectiveness and potential of digital mental health interventions (DMHIs) in routine care, their uptake remains low. In Germany, digital mental health applications (DiGA), certified as low-risk medical devices, can be prescribed by healthcare professionals (HCPs) to support the treatment of mental health conditions. The objective of this proof-of-concept study was to evaluate the feasibility of using the Multiphase Optimization Strategy (MOST) framework when assessing implementation strategies.

Methods

We tested the feasibility of the MOST by employing a 24 exploratory retrospective factorial design on existing data. We assessed the impact of the implementation strategies (calls, online meetings, arranged and walk-in on-site meetings) individually and in combination, on the number of DiGA activations in a non-randomized design. Data from N = 24,817 HCPs were analyzed using non-parametric tests.

Results

The results primarily demonstrated the feasibility of applying the MOST to a non-randomized setting. Furthermore, analyses indicated significant differences between the groups of HCPs receiving specific implementation strategies [χ2 (15) = 1,665.2, p < .001, ɛ 2 = 0.07]. Combinations of implementation strategies were associated with significantly more DiGA activations. For example, combinations of arranged and walk-in on-site meetings showed higher activation numbers (e.g., Z = 10.60, p < 0.001, χ2  = 1,665.24) compared to those receiving other strategies. We found a moderate positive correlation between the number of strategies used and activation numbers (r = 0.30, p < 0.001).

Discussion and limitations

These findings support the feasibility of using the MOST to evaluate implementation strategies in digital mental health care. It also gives an exploratory example on how to conduct factorial designs with information on implementation strategies. However, limitations such as non-random assignment, underpowered analysis, and varying approaches to HCPs affect the robustness and generalizability of the results. Despite these limitations, the results demonstrate that the MOST is a viable method for assessing implementation strategies, highlighting the importance of planning and optimizing strategies before their implementation. By addressing these limitations, healthcare providers and policymakers can enhance the adoption of digital health innovations, ultimately improving access to mental health care for a broader population.

A framework to integrate equity in public health emergency response dashboards: Dashboard instrument to review equity (DIRE)

OBJECTIVES

COVID-19 created an urgent element of clinical and financial strain to the public health system, forcing it into rapid response mode. Key public health decisions were quickly made, with limited data and guidance to address decision trade-offs and community inequities. Gaps identified in the pandemic confirmed the need for a new tool, like this study's Dashboard Instrument to Review Equity (DIRE) Framework, to ensure decision-makers are given quick and equitable decision-making guidance.

STUDY DESIGN

Scoping review and tool development.

METHODS

The scoping review was conducted through PRISMA-ScR, and by utilizing tools like PubMed, Scopus, and Paper Piles to compile and cite. Three levels of thematic analysis were completed. Tool development consisted of building a conceptual model on the DIKW Pyramid and Informatics Stack. Then the review's five themes were integrated into DIRE.

RESULTS

The review closed at a final count of 102 articles, with five themes emerging: COVID-19 impact, Health Equity, Decisions During Emergencies, Dashboards and Decision Support, and Frameworks. COVID-19 dashboards were also reviewed. DIRE was designed into three layers (context, data flow, and dashboard users) and three data flow buckets (data sources, DIK pillars, and interventions).

CONCLUSIONS

This study aimed to (1) Establish a research foundation of health equity, COVID-19 lessons learned, and decision support, and (2) Develop an evidence-based framework. Though further research is still recommended, DIRE is now the first 3-point framework aimed at preparing decision-makers to respond quickly and equitably to future emergencies.

Context makes a difference: a qualitative study exploring how to implement a multifactorial falls prevention intervention in the community

BACKGROUND

Falls are a major problem in community-dwelling older people. Multifactorial falls prevention interventions are recommended as intervention. However, poor implementation impacts successful outcomes of multifactorial falls prevention interventions. The context is critical to understand variation in implementation and clinical outcomes. This study aims to analyze and describe determinants at all levels of the context that influence the implementation of a multifactorial falls prevention intervention in the community in Flanders (Belgium).

METHODS

This study consists of semi-structured interviews with 6 key persons, 3 focus group interviews with healthcare professionals (n = 16), 1 focus group with local policy makers (n = 6) and 4 semi-structured interviews and 1 focus group (n = 3) with older people. The Integrated Checklist of Determinants of Practice (TICD checklist) was used to develop the interview guide and to make sure that there was enough understanding of the contextual determinants at the different domains. The interviews and focus groups were verbatim transcribed and analyzed using the Qualitative Analysis Guide of Leuven (QUAGOL). To clarify themes, data were coded in NVivo 12™.

RESULTS

We identified 4 key themes related to successful implementation of a multifactorial falls prevention intervention in the community setting: (1) stakeholder involvement and participation, (2) Fostering awareness, beliefs, knowledge, and skills for falls prevention, (3) working proactively and (4) communication, collaboration, coordination and financing care. This study identified 33 determinants of the TICD checklist and all 7 domains were represented.

CONCLUSIONS

Understanding the existing structures, norms, policies and contextual factors allows us to proactively tailor the implementation strategies and a multifactorial falls prevention intervention to the community context.

HEAL-D Online: Exploring the potential for the spread and adoption of a virtual culturally tailored diabetes self-management programme for adults of African and Caribbean heritage

BACKGROUND

People of African and Caribbean heritage in the UK have a higher prevalence of Type 2 Diabetes (T2D) and poorer health outcomes than white Europeans. Healthy Eating and Active Lifestyles for Diabetes Online (HEAL-D Online) is a co-designed, culturally tailored T2D self-management programme for black African and Caribbean adults, which, due to online delivery, is well positioned for spread. This qualitative evaluation uses the Exploration-Preparation-Implementation-Sustainment (EPIS) framework to explore factors affecting scale-up from delivery and commissioning perspectives.

METHODS

Semi-structured interviews were conducted with nine commissioners and providers of T2D services from three English areas with varying population characteristics to explore scale-up. Focus groups were held with 15 people of African and Caribbean heritage with T2D lived experience to explore the impact of a digital model of participation. Data were analysed using thematic analysis, with themes mapped onto the EPIS framework exploration phase constructs to consider the outer and inner contextual factors for planning implementation.

RESULTS

Six EPIS constructs were identified by commissioners and providers as key in scaling HEAL-D Online. People with T2D lived experience explored the online mode of delivery, using the patient advocacy construct as the analytical lens. In delivering an online T2D programme, two themes were identified: (1) aligning course content with people's preferences; (2) practicalities to ensure online delivery was acceptable and accessible to the community.

CONCLUSIONS

HEAL-D Online was acceptable with the potential to help address health inequalities. The EPIS framework provided a structure to understand factors in planning scale-up for an intervention targeting underserved communities.

Navigating the complex landscape of waterborne disease research

Waterborne pathogens and associated diseases continue to pose a significant global health challenge, requiring effective monitoring, detection, and treatment strategies. This review examines the current state of waterborne pathogen management, highlighting persistent issues and recent advancements. Here, we review cutting-edge detection methods and treatment technology, emphasizing their roles in water safety and outbreak prevention. The impact of climate change on waterborne pathogen dynamics is explored, alongside a discussion of interdisciplinary research approaches. We also aimed to investigate the crucial relationship between waterborne disease control and Sustainable Development Goals (SDGs), focusing on community engagement, well-being, water sanitation, public health policies, and international cooperation. The PRISMA protocol systematic process was used to filter papers for this study and carry out the review process. Machine learning and remote sensing techniques are promising features in the pathogen detection field. SDGs 3, 6, 11, 13, and 17 are the most closely interrelated with waterborne diseases. This review provides an in-depth overview of waterborne pathogen management, contributing to improved global water quality and public health strategies. This integrated approach aims to enhance health outcomes and promote resilience against waterborne diseases, particularly for vulnerable communities.

Considerations for establishment of a private virtual hospital identified using an implementation science approach

Virtual hospitals are rapidly being implemented internationally. Research has predominantly focused on clinical outcomes not implementation. We aimed to identify pre-implementation determinants to enable health services to tailor virtual hospital models, increasing likelihood of suitability, acceptability, uptake, clinical effectiveness, and sustainability. We aimed to inform the design and implementation of a private Australian virtual hospital by identifying contextual barriers, enablers, and considerations. We conducted a qualitative pre-implementation determinant study using snowball sampling and semi-structured interviews (n = 37) between February and July 2023 with consumers/carers/both (n = 11), clinicians (doctors/allied health/nursing/personal carers), hospital, health service and aged care leadership (n = 22), and public health stakeholders (n=4). Deductive framework analysis based on the PERCS implementation science framework was used. The following key determinants were identified: Enablers - strong executive leadership support; enthusiasm for expanding rural and remote services; need for a clear vision; strong tension for change; commitment to high-quality healthcare. Major barrier: restrictive funding models that stifle opportunities for innovation. Other barriers: technological limitations; communication challenges; workforce issues; clinicians' opinions varied on safety and suitability of virtual healthcare. This implementation science approach enabled identification of a broad set of determinants not previously reported, relevant locally and for an international audience. Evaluation of implementation outcomes is necessary.

Application of an implementation premortem: A novel qualitative approach leveraging prospective hindsight to enhance barbershop health interventions for Black men

Barbershop-based efforts to promote health among Black men have been uniquely successful. Despite the success of these efforts, the emphasis on outcomes as opposed to how these outcomes can be achieved has created a gap in the literature. The present study addresses this gap by describing implementation-related program priorities that Black men identify for barbershop-based interventions. Twenty-three Black men participated in implementation premortem activities. Participants were: (i) given details about a barbershop-based health promotion effort, (ii) told that the effort had failed, and (iii) were asked to identify potential sources of program failure and strategies to overcome those challenges. The frequency of program priorities was calculated based on the Exploration, Preparation, Implementation, and Sustainment (EPIS) Framework, and focus group data were analyzed using an inductive thematic qualitative data analytic approach. Data analyses occurred in three phases: (i) excerpts were grouped by Phase, Domain, and Construct of the EPIS Framework; (ii) themes within each excerpt were then identified using an inductive approach; and (iii) themes were organized into conceptually similar and parsimonious categories. Participants suggested that the biggest source of program failure was that more attention needed to be paid to Program Fit during the Implementation Phase. Participants reported concerns with the accessibility and convenience of the effort. Additional participant concerns included economic issues, community ownership, climate, staffing processes, cultural sensitivity, engagement, and trust. The implementation of health promotion programs for Black men should pay particular attention to how the intervention fits the needs, lives, and contexts of potential participants.

Stakeholder perspectives on implementation of internet-delivered cognitive behaviour therapy in physical medicine rehabilitation setting using the Consolidated Framework for Implementation Research

INTRODUCTION

Despite the growing evidence for the effects of tailored internet-delivered cognitive behaviour therapy (ICBT) programmes for those receiving physical rehabilitation, there is a lack of implementation of these programmes in a clinical or community setting. The aim of the current study was to evaluate barriers and facilitators of implementing an ICBT programme into a physical medicine rehabilitation setting.

METHODS

Stakeholders with expertise in physical medicine rehabilitation were recruited (n = 25) including: 16 clinicians, 4 administrators, 3 persons with lived experience, and 2 care partners. Individual semi-structured interviews were conducted based on the domains of the Consolidated Framework for Implementation Research (CFIR). Transcripts were analysed using a positivist approach, using deductive thematic content analysis. Themes were coded based on the domains of CFIR.

RESULTS

Facilitators for implementation primarily fell under intervention characteristics including relative advantage, strong evidence and quality, and design quality. Perceived barriers for implementation were identified in the inner setting including leadership engagement, culture, and available resources.

CONCLUSIONS

The results from the current study provide insight on the factors that may contribute towards successful implementation of an ICBT programme in a physical medicine setting.

Implementation processes and capacity-building needs in Ontario maternal-newborn care hospital settings: a cross-sectional survey

BACKGROUND

Maternal-newborn care does not always align with the best available evidence. Applying implementation science to change initiatives can help move evidence-informed practices into clinical settings. However, it remains unknown to what extent current implementation practices in maternal-newborn care align with recommendations from implementation science, and how confident nurses, other health professionals, and leaders are completing steps in the implementation process. We aimed to understand Ontario maternal-newborn teams' (1) approaches to implementing practice changes and the extent to which their implementation processes aligned with an implementation science planned-action framework; and (2) perceptions of importance and confidence completing implementation activities.

METHODS

We conducted a cross-sectional survey between September-November 2023. Using purposive sampling, we invited Ontario maternal-newborn nurses, other healthcare professionals, and leaders who had experience participating in or leading implementation projects to complete an online questionnaire. The questionnaire was informed by an implementation science framework, which includes three core phases (identify issue; build solutions; implement, evaluate, sustain). The questions probed respondents' perceptions of frequency of completion, importance, and confidence for each of the 28 implementation activities. We used descriptive statistics for the closed-ended questions and grouped the written responses into categories.

RESULTS

We received 73 responses from 57 Ontario maternal-newborn hospitals, the majority being nurses in point-of-care and leadership roles. Nearly all respondents agreed that each of the 28 implementation activities were important. Respondents reported always completing a median of 8 out of 28 activities, with the number of activities completed declining from phase 1 through to 3. Most respondents indicated they were somewhat confident completing the implementation activities and agreed their teams would benefit from increasing their knowledge and skills to use an evidence-informed approach to implementing practice changes.

CONCLUSIONS

Despite viewing implementation activities as important, many teams are not consistently doing them and lack confidence, particularly in later phases of the implementation process. These findings inform where further capacity-building and supports may be needed to enable maternal-newborn nurses, other healthcare professionals, and leaders to apply implementation science to their change initiatives.

Using Implementation Science to Assess Barriers to Agreement on Sedation Goal Setting and Assessment

OBJECTIVES

Sedation assessment and goal setting using a validated assessment tool are key components of the ICU Liberation bundle. Appropriate integration of these bundle elements into daily practice remains challenging. Understanding barriers is an important step toward implementation of these best practice bundle elements.

DESIGN

Two-phased explanatory mixed methods assessment carried out 2022-2023.

SETTING

Forty-bed quaternary PICU.

SUBJECTS

Bedside nurses and prescribers caring for mechanically ventilated patients on sedative infusions.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Forty-one nurses and 32 prescribers participated in the phase 1 pre-education assessments (2022). We identified lack of correlation between the providers' stated State Behavioral Scale (SBS) numerical goal and descriptive goal and hypothesized that this discrepancy was either due to a knowledge gap or disagreement on sedation goals. To investigate this hypothesis, we performed a phase 2 assessment (2022-2023), starting with a multipronged educational activity, followed by a repeat survey that included a qualitative interview. One hundred ninety nurses and 45 prescribers received the educational activity. Twenty-eight nurses and 22 prescribers participated in the phase 2 assessments with the qualitative interview. Although correlation of the sedation goal between providers improved, it remained poor. Subsequent qualitative interview data indicated that the reasons for persistent disagreement in the sedation goal for a given patient were related to individual providers' beliefs and attitudes toward sedation, rather than lack of understanding about using the SBS to set a target sedation goal.

CONCLUSIONS

Barriers to setting and managing daily patient sedation goal in the PICU extend beyond providers' knowledge gaps. An improved understanding of underlying barriers is essential for successful implementation of evidence-based sedation guidelines.

Exploring the complexity of the implementation determinants of human papillomavirus vaccination in Africa through a systems thinking lens: A rapid review

A rapid review was conducted to explore the implementation determinants of human papillomavirus (HPV) vaccination in the World Health Organization African Region and describe their dynamic relationship. PubMed and Google Scholar were searched in October 2023 to find relevant literature. A total of 64 published studies that reported factors affecting HPV vaccination were identified. Analysis of identified factors yielded 74 implementation determinants of HPV vaccination across the five domains of the Consolidated Framework for Implementation Research (CFIR): two (2.70%) were in the innovation domain, seven (9.46%) were in the outer setting domain, 14 (18.92%) were in the inner setting domain, 37 (50%) were in the individual domain and 14 (18.92%) were in the implementation process domain. A causal loop diagram of these implementation determinants revealed four balancing and seven reinforcing loops. Applying systems lens promoted a more holistic understanding of the implementation determinants of HPV vaccination, exposing leverage points for interventions.

Development, Implementation, and Evaluation Methods for Dashboards in Health Care: Scoping Review

Background

Dashboards have become ubiquitous in health care settings, but to achieve their goals, they must be developed, implemented, and evaluated using methods that help ensure they meet the needs of end users and are suited to the barriers and facilitators of the local context.

Objective

This scoping review aimed to explore published literature on health care dashboards to characterize the methods used to identify factors affecting uptake, strategies used to increase dashboard uptake, and evaluation methods, as well as dashboard characteristics and context.

Methods

MEDLINE, Embase, Web of Science, and the Cochrane Library were searched from inception through July 2020. Studies were included if they described the development or evaluation of a health care dashboard with publication from 2018-2020. Clinical setting, purpose (categorized as clinical, administrative, or both), end user, design characteristics, methods used to identify factors affecting uptake, strategies to increase uptake, and evaluation methods were extracted.

Results

From 116 publications, we extracted data for 118 dashboards. Inpatient (45/118, 38.1%) and outpatient (42/118, 35.6%) settings were most common. Most dashboards had ≥2 stated purposes (84/118, 71.2%); of these, 54 of 118 (45.8%) were administrative, 43 of 118 (36.4%) were clinical, and 20 of 118 (16.9%) had both purposes. Most dashboards included frontline clinical staff as end users (97/118, 82.2%). To identify factors affecting dashboard uptake, half involved end users in the design process (59/118, 50%); fewer described formative usability testing (26/118, 22%) or use of any theory or framework to guide development, implementation, or evaluation (24/118, 20.3%). The most common strategies used to increase uptake included education (60/118, 50.8%); audit and feedback (59/118, 50%); and advisory boards (54/118, 45.8%). Evaluations of dashboards (84/118, 71.2%) were mostly quantitative (60/118, 50.8%), with fewer using only qualitative methods (6/118, 5.1%) or a combination of quantitative and qualitative methods (18/118, 15.2%).

Conclusions

Most dashboards forego steps during development to ensure they suit the needs of end users and the clinical context; qualitative evaluation-which can provide insight into ways to improve dashboard effectiveness-is uncommon. Education and audit and feedback are frequently used to increase uptake. These findings illustrate the need for promulgation of best practices in dashboard development and will be useful to dashboard planners.

Revisiting Therapeutic Communication as an Evidence-Based Intervention to Decrease Violence by Patients Against Staff on Psychiatric Wards-A Quality Improvement Project

BACKGROUND

Violence against healthcare workers continues to be a widespread problem and adversely impacts both healthcare providers and consumers.

OBJECTIVES

To evaluate the effectiveness of a staff education and training program in therapeutic communications in decreasing violence by patients against staff in an acute inpatient behavioral hospital. Further, the project measured the effect of the training on the self-efficacy and knowledge level of the 15 recruited staff in the use of therapeutic communications, and its overall impact on the participants' reaction, learning, behavior and observed results at the hospital.

METHODS

This study used a pretest and posttest design.

RESULTS

There was a decrease (73%) in violence incidents which correlated with the staff training and education sessions compared with violence occurrence incidents during the 12 weeks preceding the implementation. There was also a significant increase in the staff's self-efficacy, {t(-11.4), df = 114, p < 0.001}, and knowledge level {t(-10.40), df = 14, p < 0.001)} in the use of therapeutic communications, and an overall positive impact on staff's reaction, learning, behavior and observed effects as a result of the training program.

CONCLUSION

Staff training in effective therapeutic communications had a multidimensional effect, the most important was its effect on decreasing violence. These findings underscore the need to revisit and emphasize therapeutic communications in promoting a safety culture in behavioral health settings.

Proposal of the Implementation Theory Selection Model and exemplar application in fall injury prevention

INTRODUCTION

The use of theories, models and/or frameworks (TMFs) in implementation research and practice is essential for developing useful and testable implementation strategies. Recommendations and tools exist to aid implementation groups in selecting TMFs, but they do not explicitly outline a systematic method for identifying and selecting TMFs. This paper aimed to (1) propose a systematic consensus-based method to select TMFs to support implementation processes, and to (2) demonstrate the use of this novel method in the context of researching the implementation of hip protectors for fracture prevention in long-term care (LTC).

MATERIALS & METHODS

We developed a systematic, consensus-based method for selecting TMFs, referred to as the Implementation Theory Selection Model (ITSM). The ITSM comprises five steps: (1) identify potentially relevant TMFs; (2) narrow the pool of TMFs; (3) appraise the relevance of eligible TMFs; (4) prioritize a short-list of TMFs for further, in-depth consideration; and (5) select TMFs through consensus with investigators and research user partners. We operationalized each step of the ITSM through a project investigating determinants of hip protector use and organizational readiness for implementation in a LTC organization in Ontario, Canada.

RESULTS

Using the ITSM in our case example, we identified 66 TMFs (Step 1). Of these, 23 met our eligibility criteria (Step 2) and were appraised twice, by five appraisers (Step 3). Six TMFs (Step 4) advanced to the consensus meeting, which was attended by nine investigators and three research users, including two organizational partners and one older adult. Three rounds of voting yielded a tie between the TMFs the group felt would be most appropriate. Research users from our partner LTC organization made the final selection preferring the combination of the Practical, Robust Implementation and Sustainability Model and Consolidated Framework for Implementation Research (Step 5).

CONCLUSIONS

The ITSM offers a step-by-step guide for implementation groups to adopt a rigorous, transparent and reproducible method for TMF selection. Although we have demonstrated the feasibility of operationalizing each step of the ITSM in our case example, continued research is needed to evaluate and refine the ITSM to ensure it is appropriate for a wide variety of implementation contexts.

Applying health equity implementation science frameworks to population genetic screening

Introduction

Implementation science frameworks with a focus on health equity have emerged to help guide the introduction of new interventions into healthcare and community settings while limiting health disparities. The purpose of this research was to explore the applicability of such frameworks to guide the equitable implementation of population genetic screening programs.

Methods

We searched PubMed and reference lists for relevant frameworks and examples of their use in health settings. We then assessed if and how selected frameworks provide guidance for different stages of population genetic screening: recruitment, sample collection, result return, follow-up care and long-term management, and cascade screening. Findings were synthesized into a list of health equity considerations specific to each stage.

Results

We identified 5 implementation frameworks that focus on health equity. Guidance varied by framework type: determinant (explaining what affects implementation outcomes), process (translating research into practice), or evaluation (assessing implementation). Common characteristics included focusing implementation efforts on populations who have historically experienced health inequities and adapting interventions to fit local contexts. Process models also highlighted the importance of community partnerships.

Discussion

Overall, frameworks offered broad recommendations applicable to population genetic screening program implementation. However, gaps still exist in guidance provided for later stages of population genetic screening. To improve the equitable implementation of genetic screening, future programs may benefit from utilizing one or more of these frameworks or by incorporating the health equity considerations and outcomes compiled in this analysis.

Scalable and successful patient portal lifestyle coaching training for primary care clinical staff

Maintaining a healthy weight postintentional weight loss is crucial for preventing chronic health conditions, yet many regain weight postintervention. Electronic health record (EHR) portals offer a promising avenue for weight management interventions, leveraging patient-primary care relationships. Our previous research demonstrated that coaching alongside self-monitoring improves weight maintenance compared to monitoring alone. Integrating weight management into routine clinical practice by training existing staff could enhance scalability and sustainability. However, challenges such as inconsistent staff qualifications and high coach turnover rates could affect intervention effectiveness. Standardizing services, training, and coaching continuity seem crucial for success. To report on developing, testing, and evaluating an EHR-based coaching training program for clinical staff, guided by an implementation tool for the MAINTAIN PRIME study. Conducted across 14 University of Utah primary care sites, we developed, tested, and evaluated a coaching training for clinical staff. Guided by a planning model and the Predisposing, Enabling, and Reinforcing (PER) tool, stakeholders actively participated in planning, ensuring alignment with clinic priorities. All clinical staff were invited to participate voluntarily. Evaluation measures included staff interest, training effectiveness, confidence, and readiness. Data collection utilized REDCap, with survey results analyzed using descriptive statistics. Despite increased clinical workload and reassignments posed by coronavirus disease 2019, we were able to train 39 clinical staff, with 34 successfully coaching patients. Feedback indicated high readiness and positive perceptions of coaching feasibility. Coaches reported satisfaction with training, support, and enjoyed establishing connections with patients. The PER strategies allowed us to implement a well-received training program found effective by primary care coaches.

A new normal in primary care: the rapid normalization of a major eHealth program in public health centers

BACKGROUND

This study aimed to contribute to a better understanding of the context, mechanisms and outcomes in the implementation process of an eHealth video consultation program in primary care. The study focused on how the program is normalized in the primary care setting. The primary research question for this study is "in what ways is the implementation of video consultation normalized in primary care?".

METHODS

The qualitative design and content analysis of primary data from the transcripts were based on in-depth interviews, complemented with free-text answers to open-ended survey questions and various documents. The study focuses on the large-scale implementation of the public eHealth program Närhälsan Online, which represents more than 100 health centers in Sweden's largest region of Västra Götaland. Multiagent perspectives on how the program is normalized were drawn from expressed perceptions by professions directly linked to both strategic and functional implementation, as well as administration and clinical operation.

RESULTS

This study both confirms and enhances the field with a theoretical contribution in six ways to the reviewed previous research, as well as showing practical implications. It also provides multi-agent perspectives on the rapid normalization of the implementation program studied.

CONCLUSIONS

In relation to the rapid progression of different initiatives in eHealth, this study contributes to perspectives on specific challenges as expressed by professions directly linked to both strategic and functional implementation as well as administration and clinical operation.

Protocol for leading health services innovation: a hybrid type 2 mixed method implementation trial for developing and assessing a codesigned graduate certificate program in health innovation

BACKGROUND

A significant issue with innovative problem-solving in healthcare is an existing deficiency in continuing education for many healthcare professionals, which hinders the successful implementation of inventive solutions and progress in the field. Educators play a crucial role in guiding students to cultivate the knowledge and skills necessary to confront these challenges, including problem solving, collaboration, and the use of rapidly advancing technologies. It is vital to design educational programs that empower and motivate students to develop the proficiency and knowledge they need to be effective problem solvers, collaborators, and cultivators of innovative solutions. This project aims to assess the implementation and effectiveness of a codesigned postgraduate university program for a multidisciplinary health workforce.

METHODS

The Leading Health Services Innovation Project is a hybrid type 2 mixed method implementation trial of a codesigned Graduate Certificate in Health Services Innovation. In collaboration with a large tertiary and quaternary health service, we developed a codesign process to guide the project, with time quarantined to create space for two-way learning between health sector partners and healthcare academics. Qualitative interviews and quantitative surveys for primary users will evaluate the implementation strategies. The reach, effectiveness, adoption implementation, and maintenance (RE-AIM) framework will guide the evaluation and maintenance of the program.

RESULTS

Integrating a codesign strategy complemented by a well-structured implementation and evaluation protocol that is a combination of implementation science theoretical frameworks (Knowledge to Action, Evidence-Based Co-design, RE-AIM) may lead to translational competence as a potential outcome.

ANTICIPATED OUTCOMES

The application, resourcing and commitment to codesigned tertiary-level learning and qualification will demonstrate the achievement of a contemporary and comprehensive postgraduate university degree program in health innovation management.

Implementing palliative care in the intensive care unit: a systematic review and mapping of knowledge to the implementation research logic model

PURPOSE

The importance and effectiveness of palliative care (PC) in intensive care units (ICU) are known. Less is known about the implementation and integration of ICU-based PC interventions. This systematic review aims to use a modified implementation research logic model (IRLM) to identify, map, and synthesise evidence on implementation of ICU-PC (primary and/or specialist) interventions.

METHODS

This systematic review used an adapted Smith's IRLM to understand relationships between implementation factors-determinants (barriers and facilitators), strategies, and mechanisms-and report intervention characteristics and outcomes. Searches up to 2nd December 2023, of MEDLINE, Embase, Cochrane, CINAHL, and PsycINFO, combined PC, intensive care, and implementation terms.

RESULTS

84 studies (8 process evaluations, 76 effectiveness studies) were included. Published evidence on ICU-PC interventions is substantial, but reporting on implementation factors is variable and often lacking, especially for patient and family-related determinants and for all aspects of mechanisms. Main facilitators for implementation are adequate resources and collaboration between PC and ICU teams. Main barriers to implementation are lack of resources, negative perceptions of PC, and high ICU acuity. Implementation strategies include auditing resources, building stakeholder collaboratives, creating adaptable interventions, utilising champions, and supporting education. Mechanisms most commonly worked by facilitating collaborative working.

CONCLUSION

This review provides recommendations for ICUs when designing (stakeholder involvement, ICU-PC collaboration, assessment of culture and resources); implementing (targeted and adapted strategies, champions, and education); and evaluating/reporting (collect effectiveness and implementation data, including mechanisms) ICU-PC interventions. Use of implementation structures and patient/family involvement are both needed and important to be included.

Participatory logic model for a precision child and youth mental health start-up: scoping review, case study, and lessons learned

Background

The precision child and youth mental health (PCYMH) paradigm has great potential to transform CYMH care and research, but there are numerous concerns about feasibility, sustainablity, and equity. Implementation science and evaluation methodology, particularly participatory logic models created with stakeholders, may help catalyze PCYMH-driven system transformation. This paper aims to: (1) report results of a PCYMH logic model scoping review; (2) present a case study illustrating creation of a participatory logic model for a PCYMH start-up; and (3) share the final model plus lessons learned.

Methods

Phase 1: Preparation for the logic model comprised several steps to develop a preliminary draft: scoping review of PCYMH logic models; two literature reviews (PCYMH and implementation science research); an environmental scan of our organization's PCYMH research; a gap analysis of our technological capability to support PCYMH research; and 57 stakeholder interviews assessing PCYMH perspectives and readiness. Phase 2: Participatory creation of the logic model integrated Phase 1 information into a draft from which the final logic model was completed through iterative stakeholder co-creation.

Results

Phase 1: The scoping review identified 0 documents. The PCYMH literature review informed our Problem and Impact Statements. Reviewing implementation and evaluation literature resulted in selection of the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) and Behavior Change Wheel (BCW) frameworks to guide model development. Only 1.2% (5/414) of the organization's research projects involved PCYMH. Three technological infrastructure gaps were identified as barriers to developing PCYMH research. Stakeholder readiness interviews identified three themes that were incorporated into the draft. Phase 2: Eight co-creation cycles with 36 stakeholders representing 13 groups and a consensus decision-making process were used to produce the final participatory logic model.

Conclusions

This is the first study to report the development of a participatory logic model for a PCYMH program, detailing involvement of stakeholders from initial planning stages to the final consensus-based product. We learned that creating a participatory logic model is time- and labour-intensive and requires a multi-disciplinary team, but the process produced stakeholder-program relationships that enabled us to quickly build and implement the PCYMH start-up. Our processes and final model can inform similar efforts at other sites.

Assessing health technology implementation during academic research and early-stage development: support tools for awareness and guidance: a review

For successful health technology innovation and implementation it is key to, in an early phase, understand the problem and whether a proposed innovation is the best way to solve the problem. This review performed an initial exploration of published tools that support innovators in academic research and early stage development with awareness and guidance along the end-to-end process of development, evaluation and implementation of health technology innovations. Tools were identified from scientific literature as well as in grey literature by non-systematic searches in public research databases and search engines, and based on expert referral. A total number of 14 tools were included. Tools were classified as either readiness level tool (n = 6), questionnaire/checklist tool (n = 5) or guidance tool (n = 3). A qualitative analysis of the tools identified 5 key domains, 5 innovation phases and 3 implementation principles. All tools were mapped for (partially) addressing the identified domains, phases, and principles. The present review provides awareness of available tools and of important aspects of health technology innovation and implementation (vs. non-technological or non-health related technological innovations). Considerations for tool selection include for example the purpose of use (awareness or guidance) and the type of health technology innovation. Considerations for novel tool development include the specific challenges in academic and early stage development settings, the translation of implementation to early innovation phases, and the importance of multi-disciplinary strategic decision-making. A remaining attention point for future studies is the validation and effectiveness of (self-assessment) tools, especially in the context of support preferences and available support alternatives.

Multi-level barriers and facilitators to implementing evidence-based antipsychotics in the treatment of early-phase schizophrenia

Introduction

Long-acting injectable (LAI) antipsychotic medications and clozapine are effective yet underutilized medical therapies in early intervention services. The purpose of this study was to conduct a pre-implementation evaluation of contextual determinants of early intervention programs to implement innovations optimizing LAI antipsychotic and clozapine use within a shared decision-making model.

Methods

Semi-structured interviews explored barriers and facilitators to implementing LAI antipsychotics and clozapine in early intervention services. Participants were: prescribers (n = 2), non-prescribing clinicians (n = 5), administrators (n = 3), clients (n = 3), and caregivers (n = 3). Interviews were structured and analyzed using the Consolidated Framework for Implementation Research (CFIR 2.0).

Results

Participants were supportive of using LAI antipsychotics, despite barriers (e.g., transportation, insurance coverage), while most were unfamiliar with clozapine (Innovation). Critical incidents (e.g., COVID-19) did not interfere with implementation, while barriers included lack of performance measures; stigma affecting willingness to take medication; and clozapine considered to be a "last resort" (Outer Setting). Treatment culture was described as client-centered and collaborative, and most participants indicated LAI antipsychotic use was compatible with clinic workflows, but some were in need of resources (e.g., individuals trained to administer LAI antipsychotics; Inner Setting). Participants on the healthcare team expressed confidence in their roles. Family education and collaborative decision-making were recommended to improve client/family engagement (Individuals). Participants related the importance of tracking medication compliance, addressing client concerns, and providing prescribers with updated guidelines on evidence-based treatment (Implementation Process).

Discussion

Results may guide implementation strategy selection for future programs seeking to optimize the use of LAI antipsychotics and clozapine for early-phase schizophrenia, when appropriate.