Barriers and Facilitators for Implementing a Decision Support System to Prevent and Treat Disease-Related Malnutrition in a Hospital Setting: Qualitative Study

A scoping review, novel taxonomy and catalogue of implementation frameworks for clinical decision support systems

BACKGROUND

The primary aim of this scoping review was to synthesise key domains and sub-domains described in existing clinical decision support systems (CDSS) implementation frameworks into a novel taxonomy and demonstrate most-studied and least-studied areas. Secondary objectives were to evaluate the frequency and manner of use of each framework, and catalogue frameworks by implementation stage.

METHODS

A scoping review of Pubmed, Scopus, Web of Science, PsychInfo and Embase was conducted on 12/01/2022, limited to English language, including 2000-2021. Each framework was categorised as addressing one or multiple stages of implementation: design and development, evaluation, acceptance and integration, and adoption and maintenance. Key parts of each framework were grouped into domains and sub-domains.

RESULTS

Of 3550 titles identified, 58 papers were included. The most-studied implementation stage was acceptance and integration, while the least-studied was design and development. The three main framework uses were: for evaluating adoption, for understanding attitudes toward implementation, and for framework validation. The most frequently used framework was the Consolidated Framework for Implementation Research.

CONCLUSIONS

Many frameworks have been published to overcome barriers to CDSS implementation and offer guidance towards successful adoption. However, for co-developers, choosing relevant frameworks may be a challenge. A taxonomy of domains addressed by CDSS implementation frameworks is provided, as well as a description of their use, and a catalogue of frameworks listed by the implementation stages they address. Future work should ensure best practices for CDSS design are adequately described, and existing frameworks are well-validated. An emphasis on collaboration between clinician and non-clinician affected parties may help advance the field.

Artificial Intelligence in Malnutrition: A Systematic Literature Review

Malnutrition among the population of the world is a frequent yet underdiagnosed problem in both children and adults. Development of malnutrition screening and diagnostic tools for early detection of malnutrition is necessary to prevent long-term complications to patients' health and well-being. Most of these tools are based on predefined questionnaires and consensus guidelines. The use of artificial intelligence (AI) allows for automated tools to detect malnutrition in an earlier stage to prevent long-term consequences. In this study, a systematic literature review was carried out with the goal of providing detailed information on what patient groups, screening tools, machine learning algorithms, data types, and variables are being used, as well as the current limitations and implementation stage of these AI-based tools. The results showed that a staggering majority exceeding 90% of all AI models go unused in day-to-day clinical practice. Furthermore, supervised learning models seemed to be the most popular type of learning. Alongside this, disease-related malnutrition was the most common category of malnutrition found in the analysis of all primary studies. This research provides a resource for researchers to identify directions for their research on the use of AI in malnutrition.

Barriers and facilitators of improved nutritional support for patients newly diagnosed with cancer: a pre-implementation study

BACKGROUND

Disease-related malnutrition affects a significant number of patients with cancer and poses a major social problem worldwide. Despite both global and national guidelines to prevent and treat malnutrition, the prevalence is high, ranging from 20 to 70% in all patients with cancer. This study aimed to explore the current practice of nutritional support for patients with cancer at a large university hospital in Norway and to explore potential barriers and facilitators of the intervention in the Green Approach to Improved Nutritional support for patients with cancer (GAIN), prior to implementation in a clinical setting.

METHODS

The study used individual interviews and a focus group discussion to collect data. Study participants included different healthcare professionals and patients with cancer treated at a nutrition outpatient clinic. The Consolidated Framework for Implementation Research (CFIR) was used to guide the thematic data analysis.

RESULTS

Barriers connected to the current nutritional support were limited resources and undefined roles concerning responsibility for providing nutritional support among healthcare professionals. Facilitators included a desire for change regarding the current nutritional practice. The GAIN intervention was perceived as feasible for patients and healthcare professionals. Potential barriers included limited knowledge of technology, lack of motivation among patients, and a potential added burden experienced by the participating patients.

CONCLUSIONS

The identification of the potential barriers and facilitators of the current nutritional support to patients with cancer will be used to plan the implementation of improved nutritional support in a randomized controlled trial for patients with cancer prior to clinical implementation. The current findings may be of value to others trying to implement either or both nutritional support and digital application tools in a clinical healthcare setting.

TRIAL REGISTRATION

The study was registered in the National Institutes of Health Clinical trials 08/09/22. The identification code is NCT05544318.

Barriers and facilitators of severe acute malnutrition management at Felege Hiwot Comprehensive Specialized Hospital, Bahir Dar, North West Ethiopia, descriptive phenomenological study

BACKGROUND

Malnutrition is a clinical condition that affects all age groups, and it remains a major public health threat in Sub-Saharan Africa. As a result, this research aimed to investigate the barriers and facilitators of treating severe acute malnutrition at Felege Hiwot Comprehensive Specialized Hospital in Bahir Dar City, North West Ethiopia.

METHODS

A descriptive phenomenological study was conducted from February to April 2021. The final sample size taken was fifteen based on data saturation. In-depth and key informant interviews were conducted with nine caregivers, three healthcare workers, and three healthcare managers supported by observation. A criterion-based, heterogeneous purposive sampling technique was used to select the study participants. Each interview was audio-taped to ensure data quality. Thematic analysis was done to analyze the data using Atlas. ti version 7 software.

RESULTS

Two major themes and six sub-themes emerged. Barriers related to severe acute malnutrition management include subthemes on socio-economic and socio-cultural conditions, perceived causes of severe acute malnutrition and its management, and the healthcare context. Facilitators of severe acute malnutrition management include severe acute malnutrition identification, service delivery, and being a member of community-based health insurance.

CONCLUSIONS

Effective management of severe acute malnutrition was affected by a multiplicity of factors. The results reaffirm how socioeconomic and sociocultural conditions, perceived causes of severe acute malnutrition (SAM) and its management and the health care context were the major barriers, while able to identifying severe acute malnutrition, service delivery, and is a member of community-based health insurance were the major facilitators for SAM management. Therefore, special attention shall be given to SAM management.

Exploring the role of professional identity in the implementation of clinical decision support systems-a narrative review

BACKGROUND

Clinical decision support systems (CDSSs) have the potential to improve quality of care, patient safety, and efficiency because of their ability to perform medical tasks in a more data-driven, evidence-based, and semi-autonomous way. However, CDSSs may also affect the professional identity of health professionals. Some professionals might experience these systems as a threat to their professional identity, as CDSSs could partially substitute clinical competencies, autonomy, or control over the care process. Other professionals may experience an empowerment of the role in the medical system. The purpose of this study is to uncover the role of professional identity in CDSS implementation and to identify core human, technological, and organizational factors that may determine the effect of CDSSs on professional identity.

METHODS

We conducted a systematic literature review and included peer-reviewed empirical studies from two electronic databases (PubMed, Web of Science) that reported on key factors to CDSS implementation and were published between 2010 and 2023. Our explorative, inductive thematic analysis assessed the antecedents of professional identity-related mechanisms from the perspective of different health care professionals (i.e., physicians, residents, nurse practitioners, pharmacists).

RESULTS

One hundred thirty-one qualitative, quantitative, or mixed-method studies from over 60 journals were included in this review. The thematic analysis found three dimensions of professional identity-related mechanisms that influence CDSS implementation success: perceived threat or enhancement of professional control and autonomy, perceived threat or enhancement of professional skills and expertise, and perceived loss or gain of control over patient relationships. At the technological level, the most common issues were the system's ability to fit into existing clinical workflows and organizational structures, and its ability to meet user needs. At the organizational level, time pressure and tension, as well as internal communication and involvement of end users were most frequently reported. At the human level, individual attitudes and emotional responses, as well as familiarity with the system, most often influenced the CDSS implementation. Our results show that professional identity-related mechanisms are driven by these factors and influence CDSS implementation success. The perception of the change of professional identity is influenced by the user's professional status and expertise and is improved over the course of implementation.

CONCLUSION

This review highlights the need for health care managers to evaluate perceived professional identity threats to health care professionals across all implementation phases when introducing a CDSS and to consider their varying manifestations among different health care professionals. Moreover, it highlights the importance of innovation and change management approaches, such as involving health professionals in the design and implementation process to mitigate threat perceptions. We provide future areas of research for the evaluation of the professional identity construct within health care.

Steps to implementation: Understanding barriers and enablers for implementing Arts on Prescription at Home for people impacted by dementia

ISSUE ADDRESSED

Arts on Prescription at Home (AoP@Home) involves a professional artist visiting a person with dementia and their informal carer(s) in their own home to engage them in participatory art making. While there is evidence for the use of these programs, more work is needed to facilitate effective implementation. This study explored contextual barriers and enablers to implementation of AoP@Home within a real-world community aged care service.

METHODS

Two remote focus groups were conducted at a community aged care provider in Sydney, Australia. Key stakeholders (n = 14) were recruited, representing: people with dementia, informal (family) carers, AoP artists, service referrers and community service managers. Focus group transcripts were analysed using qualitative content analysis and mapped onto the Consolidated Framework for Implementation Research (CFIR). Outcomes were reviewed against the Expert Recommendations for Implementing Change (ERIC) strategy compilation to inform development of a tailored implementation strategy.

RESULTS

Four overarching themes described the range of barriers and enablers to AoP@Home implementation: (1) "I don't know enough about it" (awareness and engagement within the sector), (2) artists delivering programs, (3) awareness and engagement of people impacted by dementia, (4) practicalities of implementation. All five domains of the CFIR were represented across the four themes. The ERIC compilation provided a list of practical strategies for implementation of AoP@Home.

CONCLUSIONS

The implementation of psychosocial interventions for people living with dementia within a community aged care service is complex and multifactorial. So what?: Organisations planning implementation should consider conducting their own pre-implementation analysis to identify context-specific strategies.

Polypharmacy and malnutrition in older people: A narrative review

Polypharmacy is the simultaneous use of multiple medicines, usually more than five. Polypharmacy is highly prevalent among older individuals and is associated with several adverse health outcomes, including frailty. The role of polypharmacy in nutritional status seems to be crucial: although a clear association between polypharmacy and malnutrition has been widely reported in older people, the magnitude of the effect of increased number of drugs in combination with their type on the risk for malnutrition remains to be largely explored. Therefore, this review aims to discuss the association between polypharmacy and malnutrition in older people and to provide suggestions for its management. Polypharmacy is prevalent among malnourished frail patients, and the relative contribution of comorbidities and polypharmacy to malnutrition is difficult to be determined. Several mechanisms by which commonly used medications have the potential to affect nutritional status have been identified and described. Deprescribing (i.e., a systematic process of identification and discontinuation of drugs or a reduction of drug regimens) could be an essential step for minimizing the effects of polypharmacy on malnutrition. In this regard, the literature suggests that in older patients taking several medications, the best method to solve this problem is the comprehensive geriatric assessment, based on a holistic approach, including drug review, to find potential unnecessary and inappropriate medications. Nutritional and deprescribing interventions must be tailored to patient needs and to the local context to overcome barriers when applied in different settings.

Intervention-related, contextual and personal factors affecting the implementation of an evidence-based digital system for prevention and treatment of malnutrition in elderly institutionalized patients: a qualitative study

BACKGROUND

Malnutrition in elderly institutionalized patients is a significant challenge associated with adverse health outcomes. The 'MyFood' decision support system was designed to prevent and treat malnutrition and has previously been studied in a hospital setting. The aim of this study was to explore the experiences of nursing staff regarding the implementation of MyFood in settings treating elderly patients.

METHODS

The study was conducted in two settings treating elderly patients in Norway. Nursing staff received training in how to follow-up patients with MyFood. Qualitative interviews were conducted with 12 nursing staff. The Consolidated Framework for Implementation Research (CFIR) was used to guide the data collection and the thematic data analysis.

RESULTS

The implementation of a digital decision support system to prevent and treat malnutrition into settings treating elderly patients was found to be affected by intervention-related, contextual, and personal factors. Although nursing staff experienced several advantages, the leadership engagement was low and hampered the implementation.

CONCLUSION

Nursing staff experienced several advantages with implementing a digital decision support system for the prevention and treatment of malnutrition in institutionalized elderly patients, including quality improvements and time savings. The results indicate that the leadership engagement was weak and that some nursing staff experienced low self-efficacy in digital competence. Future improvements include increasing the level of training, using MyFood throughout the patient course and involving the patient's next-of-kin.

TRIAL REGISTRATION

The study was acknowledged by The Norwegian Centre for Research Data (NSD), ref. number 135175.

Barriers to adequate nutrition care for child malnutrition in a low-resource setting: Perspectives of health care providers

Introduction

Several studies in developing countries found that more need-based training is required for health care providers (HCPs) in child malnutrition management.

Methods

An exploratory cross-sectional study was conducted to explore barriers to providing adequate nutrition care as perceived by the healthcare providers (HCPs) in the child malnutrition clinic at a Children's University Hospital in Egypt. Participants were selected using the purposive sampling technique. Five out of seven HCPs in the clinic were included (two male physicians, one female physician, and two female nurses). Qualitative data were collected through in-depth interviews. The interview guide consisted of semi-structured open-ended questions. Quantitative data were the resulting scores from the scoring system used to assess the understandability and actionability of the patient education materials (PEMs) that are available in the clinic. The Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P) for the scoring. Statistical analysis: The thematic content analysis technique was employed for qualitative data. The percent score was generated for the PEM actionability and understandability for quantitative data.

Results

Most common child malnutrition conditions encountered by HCPs were nutritional deficiencies. Barriers to the delivery of adequate nutrition care to children were physician-centered: limited nutrition education in the medical school, health system-centered: an insufficient number of HCPs, lack of nutritional supplements, lack of patient education materials (PEMs) that suit the characteristics of the served community, lack of updated standard of practice (SOP) and guidelines, inadequate nutrition training of HCPs, and insufficient time for each patient, and caregivers-centered: the low socioeconomic status and false cultural, nutritional beliefs.

Conclusion

There are different barriers to adequate nutrition care for child malnutrition in low-resource healthcare settings. Mainly nutritional deficiencies. Most of the barriers were health system-related in the form of insufficient resources (shortage of workforce; concerning the high caseload, nutritional supplements, and PEMs) and inadequate management of resources (lack of skill-based training, lack of updated SOP and guidelines, and lack of properly designed PEMs that facilitate communication with the target caregivers).

Patient-mediated interventions in hospital: A systematic review

AIMS

To describe the characteristics of hospital-based, patient-mediated interventions and their impact on patient, clinician and organization outcomes.

DESIGN

Systematic review.

DATA SOURCES

Health literature databases (MEDLINE, CINAHL and EMBASE) were searched in August 2021. Backward and forward citation searching was conducted.

REVIEW METHODS

Studies investigating patient-mediated interventions, targeted at adult hospitalized patients were eligible. Data were extracted related to study and intervention characteristics. Narrative synthesis was used to understand intervention impact on patient, clinician and organization outcomes (as per a framework). Methodological quality was assessed using the Mixed Methods Assessment Tool.

RESULTS

Thirty-three studies, reporting 18 interventions, were included. Twelve interventions prompted patients to report health information about their own health/needs/concerns and six interventions encouraged patients to provide feedback about clinical practice. Across all interventions, there was evidence that patients used patient-mediated interventions and that they may improve patient communication. Healthcare professional outcomes were mixed for actual/intended use, acceptability and usefulness of interventions; yet there was some evidence of healthcare professional behaviour change. Interventions that encouraged patients to report health information about their own health/needs/concerns appeared more successful than other types of interventions.

CONCLUSIONS

There is some evidence that hospital-based patient-mediated interventions may influence patient communication and healthcare professional behaviour. Patient-mediated interventions that encourage patients to report patient data before a clinical encounter may be more impactful than interventions that encourage patient feedback during or post-encounter.

IMPACT

To date, most patient-mediated intervention research has been conducted in primary care settings; we uncovered the types of patient-mediated interventions that have been trialled in hospitals. We found that patient communication and healthcare professional behaviour may be influenced by these patient-mediated interventions. Future researchers could explore the suitability and effectiveness of a wider range of hospital-based patient-mediated interventions.

NO PATIENT OR PUBLIC CONTRIBUTION

There was no funding to remunerate a patient/member of the public for this review.

Health care personnel's perspectives on human papillomavirus (HPV) self-sampling for cervical cancer screening: a pre-implementation, qualitative study

BACKGROUND

Persistent infection with high-risk human papillomavirus (hrHPV) types is a well-documented cause of cervical cancer. Since the implementation of cervical cancer screening methods (e.g., Pap tests), cervical cancer rates have declined. However, Pap tests are still unacceptable to many women and require complex infrastructure and training. Self-sampling techniques for collecting HPV specimens (or "HPV self-sampling") have been proposed as a possible alternative to overcome these barriers. The objective of this study was to capture perspectives from health care personnel (providers, leaders, and clinic staff) across primary care systems on the potential implementation of an HPV self-sampling practice.

METHODS

Between May and July 2021, a study invitation was emailed to various health care professional networks across the Midwest, including a snowball sampling of these networks. Eligible participants were invited to a 45-60-min Zoom-recorded interview session and asked to complete a pre-interview survey. The survey collected sociodemographics on age, occupation, level of educational attainment, race/ethnicity, gender, and awareness of HPV self-sampling. The semi-structured interview was guided by the Consolidated Framework for Implementation Research and asked participants about their views on HPV self-sampling and its potential implementation. All interviews were audio-recorded, transcribed, and analyzed using NVivo 12.

RESULTS

Key informant interviews were conducted with thirty health care personnel-13 health care providers, 6 clinic staff, and 11 health care leaders-from various health care systems. Most participants had not heard of HPV self-sampling but reported a general enthusiasm for wanting to implement it as an alternative cervical cancer screening tool. Possible barriers to implementation were knowledge of clinical evidence and ease of integration into existing clinic workflows. Potential facilitators included the previous adoption of similar self-sampling tools (e.g., stool-based testing kits) and key decision-makers.

CONCLUSION

Although support for HPV self-sampling is growing, its intervention's characteristics (e.g., advantages, adaptability) and the evidence of its clinical efficacy and feasibility need to be better disseminated across US primary care settings and its potential adopters. Future research is also needed to support the integration of HPV self-sampling within various delivery modalities (mail-based vs. clinic-based).

Harmonization and standardization of malnutrition screening for all adults - A systematic review initiated by the Norwegian Directorate of Health

BACKGROUND & AIMS

The Norwegian Directorate of Health has identified a need to harmonize and standardize the malnutrition screening practice in Norwegian hospitals and primary health care settings, in order to provide a seamless communication of malnutrition screening along the patient pathway. Our aim was to perform a systematic review of the validity and reliability of screening tools used to identify risk of malnutrition across health care settings, diagnoses or conditions and adult age groups, as a first step towards a national recommendation of one screening tool.

METHODS

A systematic literature search for articles evaluating validity, agreement, and reliability of malnutrition screening tools, published up to August 2020, was conducted in: MEDLINE, Embase, APA PsycInfo, Cinahl, Cochrane Databases, Web of Science, Epistemonikos, SveMed+, and Norart. The systematic review was registered in PROSPERO (CRD42022300558). For critical appraisal of each included article, the Quality Criteria Checklist by The Academy of Nutrition and Dietetics was used.

RESULTS

The review identified 105 articles that fulfilled the inclusion and exclusion criteria. The most frequently validated tools were Mini Nutritional Assessment short form (MNA), Malnutrition Universal Screening Tool (MUST), Malnutrition Screening Tool (MST), and Nutritional Risk Screening 2002 (NRS-2002). MNA, MST and NRS-2002 displayed overall moderate validity, and MUST low validity. All four tools displayed low agreement. MST and MUST were validated across health care settings and age groups. In general, data on reliability was limited.

CONCLUSIONS

The screening tools MST and NRS-2002 displayed moderate validity for the identification of malnutrition in adults, of which MST is validated across health care settings. In addition, MNA has moderate validity for the identification of malnutrition in adults 65 years or older.

A Short Digital Food Frequency Questionnaire (DIGIKOST-FFQ) Assessing Dietary Intake and Other Lifestyle Factors Among Norwegians: Qualitative Evaluation With Focus Group Interviews and Usability Testing

Background

In-person dietary counseling and interventions have shown promising results in changing habits toward healthier lifestyles, but they are costly to implement in large populations. Developing digital tools to assess individual dietary intake and lifestyle with integrated personalized feedback systems may help overcome this challenge. We developed a short digital food frequency questionnaire, known as the DIGIKOST-FFQ, to assess diet and other lifestyle factors based on the Norwegian Food-Based Dietary Guidelines. The DIGIKOST-FFQ includes a personalized feedback system, the DIGIKOST report, that benchmarks diet and lifestyle habits. We used qualitative focus group interviews and usability tests to test the feasibility and usability of the DIGIKOST application.

Objective

We aimed to explore attitudes, perceptions, and challenges in completing the DIGIKOST-FFQ. We also investigated perceptions and understanding of the personalized feedback in the DIGIKOST report and the technical flow and usability of the DIGIKOST-FFQ and the DIGIKOST report.

Methods

Healthy individuals and cancer survivors were invited to participate in the focus group interviews. The transcripts were analyzed using thematic analysis. Another group of healthy individuals completed the usability testing, which was administered individually by a moderator and 2 observers. The results were analyzed based on predefined assignments and discussion with the participants about the interpretation of the DIGIKOST report and technical flow of the DIGIKOST-FFQ.

Results

A total of 20 individuals participated in the focus group interviews, divided into 3 groups of healthy individuals and 3 groups of cancer survivors. Each group consisted of 3 to 4 individuals. Five main themes were investigated: (1) completion time (on average 19.1, SD 8.3, minutes, an acceptable duration), (2) layout (participants reported the DIGIKOST-FFQ was easy to navigate and had clear questions but presented challenges in reporting dietary intake, sedentary time, and physical activity in the last year), (3) questions (the introductory questions on habitual intake worked well), (4) pictures (the pictures were very helpful, but some portion sizes were difficult to differentiate and adding weight in grams would have been helpful), and (5) motivation (users were motivated to obtain personalized feedback). Four individuals participated in the usability testing. The results showed that the users could seamlessly log in, give consent, fill in the DIGIKOST-FFQ, and receive, print, and read the DIGIKOST report. However, parts of the report were perceived as difficult to interpret.

Conclusions

The DIGIKOST-FFQ was overall well received by participants, who found it feasible to use; however, some adjustments with regard to reporting dietary intake and lifestyle habits were suggested. The DIGIKOST report with personalized feedback was the main motivation to complete the questionnaire. The results from the usability testing revealed a need for adjustments and updates to make the report easier to read.

Barriers and facilitators to implementing the HEADSS psychosocial screening tool for adolescents living with HIV/AIDS in teen club program in Malawi: health care providers perspectives

BACKGROUND

Adolescents living with HIV (ALHIV) are at high risk of experiencing mental health problems. Depression is a major contributor to the burden of HIV-related disease amongst ALHIV and is significantly linked to non-adherence to anti-retroviral therapy (ART), yet it is under-recognized. In 2015, the Baylor College of Medicine International Pediatric AIDS Initiative (BIPAI) recommended that the psychosocial screening tool Home, Education, Activities, Drugs, Sexuality, Suicide/Depression (HEADSS) be used to screen ALHIV in Malawi who were part of an adolescent antiretroviral therapy program termed "Teen Club". However, the HEADSS tool has been substantially under-utilized. This study assessed barriers and facilitators to implementing HEADSS for ALHIV attending Teen Club Program in four selected health facilities in Malawi.

METHODS

We conducted a qualitative study using semi-structured interviews at four program sites (one district hospital and one health center each in two districts) between April and May 2019. Twenty key informants were purposively selected to join this study based on their role and experiences. We used the five domains of the Consolidated Framework for Implementation Research (CFIR) to guide the development of the interview guides, analysis and interpretation of results.

RESULTS

Barriers included inadequate planning for integration of the HEADSS approach; concerns that the HEADSS tool was too long, time consuming, lacked appropriate cultural context, and increased workload; and reports by participants that they did not have knowledge and skills to screen ALHIV using this tool. Facilitators to implementing the screening were that health care providers viewed screening as a guide to better systematic counselling, believed that screening could build better client provider relationship, and thought that it could fit into the existing work practice since it is not complex.

CONCLUSIONS

A culturally adapted screening tool, especially one that can be used by non-clinicians such as lay health workers, would improve the ability to address mental health needs of ALHIV in many primary care and social service settings where resources for professional mental health staff are limited. These findings are a springboard for efforts to culturally adapt the HEADSS screening tool for detection of mental and risky behaviors among ALHIV attending ART program in Malawi.

Process evaluation of the implementation of a decision support system to prevent and treat disease-related malnutrition in a hospital setting

Background

Malnutrition is present in 30% of hospitalized patients and has adverse outcomes for the patient and the healthcare system. The current practice for nutritional care is associated with many barriers. The MyFood decision support system was developed to prevent and treat malnutrition.

Methods

This paper reports on a process evaluation that was completed within an effectiveness trial. MyFood is a digital tool with an interface consisting of an app and a website. MyFood includes functions to record and evaluate dietary intake. It also provides reports to nurses, including tailored recommendations for nutritional treatment. We used an effectiveness-implementation hybrid design in a randomized controlled trial. The RE-AIM (Reach, Efficiency, Adoption, Implementation, Maintenance) framework was used to perform a process evaluation alongside the randomized controlled trial, using a combination of quantitative and qualitative methods. An implementation plan, including implementation strategies, was developed to plan and guide the study.

Results

Reach: In total, 88% of eligible patients consented to participate (n = 100). Adoption: Approximately 75% of the nurses signed up to use MyFood and 50% used the reports. Implementation: MyFood empowered the patients in their nutritional situation and acted as a motivation to eat to reach their nutritional target. The compliance of using MyFood was higher among the patients than the nurses. A barrier for use of MyFood among the nurses was different digital systems which were not integrated and the log-in procedure to the MyFood website. Despite limited use by some nurses, the majority of the nurses claimed that MyFood was useful, better than the current practice, and should be implemented in the healthcare system.

Conclusions

This study used a process evaluation to interpret the results of a randomized controlled trial more in-depth. The patients were highly compliant, however, the compliance was lower among the nurses. MyFood empowered the patients in their nutritional situation, the usability was considered as high, and the experiences and attitudes towards MyFood were primarily positive. Focus on strategies to improve the nurses’ compliance may in the future improve the MyFood system’s potential.

Trial registration

The trial was registered in ClinicalTrials.gov 26/01/2018 (NCT03412695).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06236-3.

Health Care Staff's Experiences of Engagement When Introducing a Digital Decision Support System for Wound Management: Qualitative Study

Background

eHealth solutions such as digital decision support systems (DDSSs) have the potential to assist collaboration between health care staff to improve matters for specific patient groups. Patients with hard-to-heal ulcers have long healing times because of a lack of guidelines for structured diagnosis, treatment, and follow-up. Multidisciplinary collaboration in wound management teams is essential. A DDSS could offer a way of aiding improvement within wound management. The introduction of eHealth solutions into health care is complicated, and the engagement of the staff seems crucial. Factors influencing and affecting engagement need to be understood and considered for the introduction of a DDSS to succeed.

Objective

This study aims to describe health care staff’s experiences of engagement and barriers to and influencers of engagement when introducing a DDSS for wound management.

Methods

This study uses a qualitative approach. Interviews were conducted with 11 health care staff within primary (n=4), community (n=6), and specialist (n=1) care during the start-up of the introduction of a DDSS for wound management. The interviews focused on the staff’s experiences of engagement. Content analysis by Burnard was used in the data analysis process.

Results

A total of 4 categories emerged describing the participants’ experiences of engagement: a personal liaison, a professional commitment, an extended togetherness, and an awareness and understanding of the circumstances.

Conclusions

This study identifies barriers to and influencers of engagement, reinforcing that staff experience engagement through feeling a personal liaison and a professional commitment to make things better for their patients. In addition, engagement is nourished by sharing with coworkers and by active support and understanding from leadership.

Promoting dietary awareness: Home-dwelling older adults' perspectives on using a nutrition application

AIMS AND OBJECTIVES

This study investigated older adults' experiences of using the Appetitus app with support from healthcare professionals.

BACKGROUND

Good nutrition status is important for good health when ageing. However, as undernutrition remains a prevalent and persistent problem among older adults, the study explored whether technology affords innovative support for nutritional self-care among older adults.

DESIGN

The study was explorative and qualitative in approach.

METHODS

Appetitus was developed as a tablet-based application to prevent and alleviate undernutrition among older adults. Eighteen home-dwelling older adults used the app for 8 weeks. Older adults received home care, and local healthcare professionals introduced the app and gave support during the study.

RESULTS

Appetitus served as a source of inspiration and a reminder of available, relevant food options. Appetitus encouraged some participants to eat or drink more by the end of the day while others became more aware of selecting food options to ensure sufficient protein, energy and fluids. However, some participants made no active effort to change their diet despite feedback from the app that suggested they did not eat or drink enough. Technical support from healthcare professionals facilitated participants' use of the app and tablet. Some participants also received more specific nutritional follow-up that helped to make their experience of using the app more meaningful.

CONCLUSION

Older adults' awareness about the importance of keeping a diet that helps prevent undernutrition was reinforced through the use of Appetitus and discussing nutrition with healthcare professionals.

IMPLICATION FOR PRACTICE

The findings affirm feasibility of using technology in nutritional interventions enhancing self-care among older adults.

What will it take? Using an implementation research framework to identify facilitators and barriers in implementing a school-based referral system for sexual health services

BACKGROUND

Across the United States, sexually transmitted infections and unintended pregnancy rates are alarmingly high among youth. Schools, due to their proximity and access to youth, can increase student access to sexual health services (SHS) by creating referral systems (RS) to link students to school- and community-based SHS. From 2013 to 2018, the Centers for Disease Control and Prevention's Division of Adolescent and School Health funded 17 Local Education Agencies (LEA) to partner with priority schools and stakeholders to develop and implement RS to increase student access to SHS. Cicatelli Associates Inc. (CAI) was funded to provide capacity-building to LEA. In 2016-2017, CAI conducted case studies at two LEA, both large and urban sites, but representing different geographical and political contexts, to elucidate factors that influence RS implementation.

METHODS

Nineteen LEA and community-based healthcare (CBH) staff were interviewed in the Southeastern (n = 9) and Western U.S. (n = 10). Key constructs (e.g., leadership engagement, resources, state and district policies) across the five domains of the Consolidated Framework for Implementation Research (CFIR) framework guided the methodology and analysis. Qualitative data was analyzed using the Framework Method and contextual factors and themes that led to RS implementation were identified.

RESULTS

Interviewees strongly believed that school-based RS can decrease STI, HIV and unintended pregnancy and increase students' educational attainment. We identified the following contextual key factors that facilitate successful implementation and integration of an RS: enforcing state and district policies, strong LEA and CBH collaboration, positive school culture towards adolescent health, knowledgeable and supportive staff, leveraging of existing resources and staffing structures, and influential district and school building-level leadership and champions. Notably, this case study challenged our initial assumptions that RS are easily implemented in states with comprehensive SHS policies. Rather, our conversations revealed how districts and local-level policies can have significant impact and influence to impede or promote those policies.

CONCLUSIONS

Through the use of the CFIR framework, the interviews identified important contextual factors and themes associated with LEAs' implementation barriers and facilitators. The study's results present key recommendations that other LEA can consider to optimize integration of RS-related evidence-based practices, systems, and policies in their districts.

Effects of using the MyFood decision support system on hospitalized patients' nutritional status and treatment: A randomized controlled trial

BACKGROUND & AIMS

Compliance to guidelines for disease-related malnutrition is documented as poor. The practice of using paper-based dietary recording forms with manual calculation of the patient's nutritional intake is considered cumbersome, time-consuming and unfeasible among the nurses and does often not lead to appropriate nutritional treatment. We developed the digital decision support system MyFood to deliver a solution to these challenges. MyFood is comprised of an app for patients and a website for nurses and includes functions for dietary recording, evaluation of intake compared to requirements, and a report to nurses including tailored recommendations for nutritional treatment and a nutritional care plan for documentation. The study aimed to investigate the effects of using the MyFood decision support system during hospital stay on adult patients' nutritional status, treatment and hospital length of stay. The main outcome measure was weight change.

METHODS

The study was a parallel-arm randomized controlled trial. Patients who were allocated to the intervention group used the MyFood app during their hospital stay and the nurses were encouraged to use the MyFood system. Patients who were allocated to the control group received routine care.

RESULTS

We randomly assigned 100 patients (51.9 ± 14 y) to the intervention group (n = 49) and the control group (n = 51) between August 2018 and February 2019. Losses to follow-up were n = 5 in the intervention group and n = 1 in the control group. No difference was found between the two groups with regard to weight change. Malnutrition risk at discharge was present in 77% of the patients in the intervention group and 94% in the control group (p = 0.019). Nutritional treatment was documented for 81% of the patients in the intervention group and 57% in the control group (p = 0.011). A nutritional care plan was created for 70% of the intervention patients compared to 16% of the control patients (p < 0.001).

CONCLUSIONS

The intervention had no effect on weight change during hospital stay. A higher proportion of the patients in the control group was malnourished or at risk of malnutrition at hospital discharge compared to the patients in the intervention group. The documentation of nutritional intake, treatment and nutritional care plans was higher for the patients using the MyFood system compared to the control group. This trial was registered at clinicaltrials.gov (NCT03412695).