Key Informants in Applied Qualitative Health Research

Themes in the Management of Pediatric Brain Death Contestation: Exploratory Qualitative Work From Multidisciplinary Health Professionals in the United States

OBJECTIVES

To explore health professionals' experiences of contested pediatric brain death/death by neurologic criteria (BD/DNC) cases, including factors contributing to conflict, resource needs and utilization, perceived utility of supports available, and case resolution and aftermath.

DESIGN AND METHODS

Inductive thematic analysis of semistructured interviews with members of the Society of Critical Care Medicine (SCCM) Contestation of Pediatric Brain Death Task Force.

SETTING

Ten institutions across seven U.S. states and the District of Columbia.

PARTICIPANTS

Nineteen Task Force members were interviewed in 2023, including pediatric intensivists, neurologists, nurses, respiratory therapists, attorneys, palliative care clinicians, social workers, ethicists, and hospital leadership. Task Force members were recruited primarily because of their experience with contested BD/DNC, although some were recruited because of expertise in other relevant topics, such as communication, information acquisition in BD/DNC, and health equity.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We identified five themes relevant to managing pediatric BD/DNC contestation: 1) personnel to consider involving, including subspecialty consultation, social work, hospital leadership and administration, ethics teams, legal counsel, and security; 2) timelines to maintain, including factors to consider when deciding the most appropriate family accommodations; 3) support for families and patients, including strategies to enhance communication, identifying and mitigating mistrust, and connecting families with support both within and outside the hospital; 4) support for staff, including disseminating information throughout the care team, staff support for one another, and establishing written documentation and policies; and 5) complementary strategies that may augment approaches to BD/DNC contestation, such as policies addressing requests for potentially inappropriate treatment.

CONCLUSIONS

Family contestation of pediatric BD/DNC challenges all parties involved. The five themes identified from our qualitative analysis of interviews with experienced professionals do not constitute SCCM clinical practice guidance, but they will be used to inform the development of approaches to BD/DNC contestation through further scholarship and community consultation.

Compatibility of the CEN-ISO/TS 82304-2 Health App Assessment Framework With Catalan and Italian Health Authorities' Needs: Qualitative Interview Study

BACKGROUND

Health authorities of European Union (EU) member states are increasingly working to integrate quality health apps into their health care systems. Given the current lack of unified EU assessment criteria, the European Commission initiated Technical Specification (TS) CEN-ISO 82304-2:2021-Health and wellness apps-Quality and reliability (hereinafter the "TS") to address the scattered EU landscape of assessment frameworks (AFs) for health apps. The adoption of an AF, such as the TS, falls within member state competence and is considered an uncertainty-reduction process. Evaluations by peers as well as ensuring the compatibility of the TS with the needs of health authorities can reduce uncertainty and mediate harmonization.

OBJECTIVE

This study aims to examine the compatibility of the TS with the needs of Catalan and Italian health authorities.

METHODS

Semistructured interviews were conducted with key informants from a regional (Catalonia in Spain) and national (Italy) health authority, and a thematic analysis was carried out. Main themes were established deductively, following the aspects defined by the value proposition canvas: (1) health authorities' needs ("gains," "pains," and "jobs") and (2) the TS "products and services" and their distinct characteristics ("gain creators" and "pain relievers"). Subthemes were generated inductively. The compatibility of the needs with the TS was theoretically determined by the researchers. The results were visualized using the value proposition canvas. Two participant validation steps confirmed that the most relevant aspects of the predefined themes had been captured.

RESULTS

Despite the diversity of the 2 health authorities, subthemes were common and categorized into 9 gains, 9 pains, and 11 jobs. Key findings include the health authorities' perceived value of, and need for, integrating quality health apps and using an AF (gains), along with the related policy, implementation, and operational activities (jobs). The lack of enabling EU legislation and standardization, resulting in a need for the multiple authorities involved to consent, made achieving an AF challenging (pains). Nine products and services related to the TS and 17 distinct characteristics (eg, its multistakeholder evidence base) were found to be compatible with 3 gains (eg, stimulating the prescription and use of apps), 7 pains (eg, legislation and harmonization issues), and 6 jobs (eg, assessing apps). Indirect effects, 3 anticipated future services, and 1 anticipated gain creator and pain reliever increase this compatibility.

CONCLUSIONS

Our results suggest that the health authorities share common fundamental needs, and that the TS is compatible with these needs. The identified needs and compatibility can potentially reduce peer authorities' uncertainties in adopting an AF in general and the TS in particular. More research is recommended to confirm and translate our results in other contexts and further fine-tune compatibility to achieve wide adoption of the TS and accelerate the uptake of health apps.

Can public education campaigns equitably counter the use of substandard and falsified medical products in African countries?

Substandard and falsified (SF) medical products are a serious health and economic concern that disproportionately impact low- and middle-income countries and marginalized groups. Public education campaigns are demand-side interventions that may reduce the risk of SF exposure, but the effectiveness of such campaigns, and their likelihood of benefitting everybody, is unclear. Nationwide pilot risk communication campaigns, involving multiple media, were deployed in Ghana, Nigeria, Sierra Leone, and Uganda in 2020-21. Focus group discussions (n = 73 with n = 611 total participants) and key informant interviews (n = 80 individual interviews and n = 4 group interviews with n = 111 total informants) were conducted within each of the four countries to ascertain the reach and effectiveness of the campaign. Small proportions of focus group discussants (8.0-13.9%) and key informants (12.5-31.4%) had previously encountered the campaign materials. Understandability varied: the use of English and select local languages, combined with high rates of illiteracy, meant that some were not able to understand the campaign. The capacity for people to act on the messages was extremely limited: inaccessibility, unavailability, and unaffordability of quality-assured medicines from official sources, as well as illiteracy, constrained what people could realistically do in response to the campaign. Importantly, reach, understandability, and capacity to respond were especially limited among marginalized groups, who are already at the greatest risk of exposure to SF products. These findings suggest that there may be potential for public education campaigns to help combat the issue of SF medicines through prevention, but that the impact of public education is likely to be limited and may even inadvertently widen health inequities. This indicates that public education campaigns are not a single solution; they can only be properly effective if accompanied by health system strengthening and supply-side interventions that aim to increase the effectiveness of regulation.

Advancing home health nursing competencies in Canada to reflect a dynamic care environment and complex population health needs: a modified eDelphi study

BACKGROUND

Home health nursing competencies outline the knowledge, skills and attributes home health nurses need for safe and ethical practice. Since the Canadian Home Health Nursing Competencies were first developed in 2010, several important contextual changes have occurred. To ensure competencies reflect current practice contexts, this study aimed to update Canada's home health nursing competencies.

METHODS

A four-phase modified eDelphi study was conducted using online surveys, consensus meetings and feedback forms. An environmental scan was conducted to identify home health competencies emerging since 2010, to create a comprehensive set of preexisting competencies to serve as the starting point for a 3-round modified eDelphi process. The eDelphi was conducted with a panel of home health nurses (n = 43) to identify core competencies relevant to current home health nursing practice environments. Broader consultations with home health nurses (n = 41) and interdisciplinary home care team members (n = 12) were held to validate eDelphi findings. An advisory working group (n = 24) of home health nursing leaders provided guidance on study decision-making and final recommendations.

RESULTS

Three hundred fifty-nine preexisting competencies were consolidated into 96 unique home health nursing competencies. In Round 1 of the eDelphi, home health nurses reached consensus (agreement ≥ 75%) that 94 competencies were relevant to current practice environments and suggested five new competencies. Subsequent eDelphi rounds resulted in 93 competencies being brought forward as both relevant and essential for current home health nursing practice. Further consultations refined recommendations, resulting in a final set of 79 competencies. Qualitative feedback provided insights into the relevance and importance of competencies, opportunities for comprehension improvements, and implementation considerations.

CONCLUSIONS

The home health nursing competency set generated through this study incorporates core concepts in home health nursing practice, such as evidence-informed practice and interdisciplinary collaboration, along with several new concepts, such as trauma-informed care, data-driven decision-making, and provision of culturally safe care. This updated competency set can be used to inform prelicensure education and professional development opportunities to enhance home health workforce capacity. Future work exploring strategies to support competency uptake in education and home and community care organizations is needed.

Perspectives on AI and Novel Technologies Among Older Adults, Clinicians, Payers, Investors, and Developers

Importance

Artificial intelligence (AI) and novel technologies, such as remote sensors, robotics, and decision support algorithms, offer the potential for improving the health and well-being of older adults, but the priorities of key partners across the technology innovation continuum are not well understood.

Objective

To examine the priorities and suggested applications for AI and novel technologies for older adults among key partners.

Design, Setting, and Participants

This qualitative study comprised individual interviews using grounded theory conducted from May 24, 2023, to January 24, 2024. Recruitment occurred via referrals through the Johns Hopkins Artificial Intelligence and Technology Collaboratory for Aging Research. Participants included adults aged 60 years or older or their caregivers, clinicians, leaders in health systems or insurance plans (ie, payers), investors, and technology developers.

Main Outcomes and Measures

To assess priority areas, older adults, caregivers, clinicians, and payers were asked about the most important challenges faced by older adults and their caregivers, and investors and technology developers were asked about the most important opportunities associated with older adults and technology. All participants were asked for suggestions regarding AI and technology applications. Payers, investors, and technology developers were asked about end user engagement, and all groups except technology developers were asked about suggestions for technology development. Interviews were analyzed using qualitative thematic analysis. Distinct priority areas were identified, and the frequency and type of priority areas were compared by participant groups to assess the extent of overlap in priorities across groups.

Results

Participants included 15 older adults or caregivers (mean age, 71.3 years [range, 65-93 years]; 4 men [26.7%]), 15 clinicians (mean age, 50.3 years [range, 33-69 years]; 8 men [53.3%]), 8 payers (mean age, 51.6 years [range, 36-65 years]; 5 men [62.5%]), 5 investors (mean age, 42.4 years [range, 31-56 years]; 5 men [100%]), and 6 technology developers (mean age, 42.0 years [range, 27-62 years]; 6 men [100%]). There were different priorities across key partners, with the most overlap between older adults or caregivers and clinicians and the least overlap between older adults or caregivers and investors and technology developers. Participants suggested novel applications, such as using reminders for motivating self-care or social engagement. There were few to no suggestions that addressed activities of daily living, which was the most frequently reported priority for older adults or caregivers. Although all participants agreed on the importance of engaging end users, engagement challenges included regulatory barriers and stronger influence of payers relative to other end users.

Conclusions and Relevance

This qualitative interview study found important differences in priorities for AI and novel technologies for older adults across key partners. Public health, regulatory, and advocacy strategies are needed to raise awareness about these priorities, foster engagement, and align incentives to effectively use AI to improve the health of older adults.

Digital determinants of sexual and reproductive health-workforce perspectives on digital and data literacies

This article explores the impact of digital transformation on sexual and reproductive health promotion from an interdisciplinary perspective, focusing on the implications of rapidly evolving policy landscapes for the Australian health promotion workforce. We draw on 29 key informant interviews and workshops with 18 current sexual and reproductive health professionals (aged 18-29). Both groups were invited to reflect on how digital and data literacies are currently understood and applied within the Australian sexual and reproductive health promotion sector. Interviewees shared concerns related to digital and data literacy, equity, and the challenges of integrating digital technologies into health practice. Findings highlight the need for strategic approaches that shift focus away from individual literacies towards broader organisational capabilities. These capabilities include: an understanding of digital policy and platform governance (e.g. in relation to social media content moderation); an understanding of how health consumers and service users currently utilise digital systems to support sexual health and wellbeing; and an understanding of the ways digital equity and data justice can be undermined or advanced in organisational settings. We conclude with recommendations for enhancing workforce digital and data capabilities and integrating DDoH into health promotion policy and practice to improve health equity. Significantly, we conclude that dedicated resources and training are needed to address the complexities of DDoH in the sexual and reproductive health context.

Frameworks for the design and reporting of anaesthesia interventions in perioperative clinical trials

Background

Interventions from RCTs can only be replicated and implemented if reported in sufficient detail. This study developed frameworks to assist researchers with describing, monitoring, and reporting the key components of anaesthetic interventions in trials.

Methods

This study comprised three phases: (1) initial framework development-text describing the delivery of anaesthetic interventions was coded and categorised into components using thematic analysis; (2) refinement of frameworks-facilitated structured group discussions were conducted with perioperative clinicians, researchers, and journal editors to elicit additional framework categories and consider clarity and feasibility; (3) framework testing and further refinement-cognitive interviews with professionals undertaking trials evaluating anaesthesia interventions to test the feasibility of using the frameworks in contemporary perioperative trials.

Results

Three frameworks were developed for general, regional, and sedation anaesthesia interventions. Data saturation of categories within the frameworks was reached after inclusion of 15 RCTs for general and regional anaesthesia, and 13 for sedation. Each framework is structured into three main sections: (1) professional(s) delivering the intervention; (2) setting; and (3) intervention components, with descriptions of the preoperative, intraoperative, and postoperative stages unique to each anaesthetic intervention. Each framework deconstructs an anaesthetic intervention into component parts to support researchers with the design and reporting of RCTs. Final frameworks are available at: https://anaesthesiaframeworks.blogs.bristol.ac.uk/.

Conclusions

We provide novel frameworks to be used during the design of perioperative trials to facilitate the design, delivery, and reporting of anaesthesia interventions.

Poly-skilling and advanced practice roles in perioperative care: protocol for a realist synthesis of evidence

INTRODUCTION

An ageing population and a workforce crisis have triggered an ambitious UK strategy for sustained delivery of healthcare. In perioperative care (the management of patients from contemplation of surgery until full recovery), it is recognised that interventions are needed to place the workforce on a more sustainable footing through cross-functionality and skill-shifting, namely with advanced practice roles. However, despite some reports and reviews in the literature, it is unclear how skills development efforts may potentially support workforce transformation for an effective and resilient perioperative care workforce. Thus, drawing causal inferences for policy-making that is both evidence based and rooted in theory is challenging. A scoping review, reported within this protocol, confirmed that 'poly-skilling' and 'advanced practice roles' are critical to this workforce transformation, but the mechanisms through which interventions in this area may work are not understood. A synthesis of evidence is, therefore, proposed in this protocol, to understand what works for whom and under what circumstances, in relation to poly-skilling and advanced practice roles in workforce transformation for sustained healthcare delivery.

METHODS AND ANALYSIS

This protocol sets out the plan to undertake a realist synthesis of the related literature, with theory elicitation (step 1), search for empirical evidence (step 2), selection and appraisal of evidence (step 3) and programme theory refinement (step 4). Exploratory reviews of the literature and key informants' inputs will produce initial hypotheses as to what it is about interventions in poly-skilling and advanced practice roles that work and why. Data from the literature will then be collected based on relevance, rigour and richness. The iterative analysis and synthesis of these data will produce causal links between contexts, mechanisms and outcomes. The results will inform a realist evaluation, to be undertaken as part of doctoral research, to better understand the mechanisms that support workforce transformation through poly-skilling and advanced practice roles.

ETHICS AND DISSEMINATION

As a review of previously published literature, the evidence synthesis proposed in this protocol does not require formal ethical approval. Recommended ethical considerations regarding the involvement of key informants, who are not study participants but a consultative group, are presented in this protocol. A formal ethics approval will be sought ahead of the later empirical stage of the research. The results of the realist synthesis proposed in this protocol will be fed back to the local National Health Service organisation and Integrated Care Board and disseminated to the research community via presentations at conferences and a peer-reviewed journal article.

PROSPERO REGISTRATION NUMBER

CRD42024512164.

Horror and Solidarity: Collective Health During the COVID-19 Emergency in Guayaquil, Ecuador

In 2020, Ecuador was among the most affected places in the world in the context of the COVID-19 emergency. Serious problems of structural inequality and governance resulted in corpses lying in the streets of Guayaquil-Ecuador's largest city-while local communities resisted in different ways. We interviewed 18 participants who engaged in actions of solidarity during this context, critically analyzed their discourses, and generated relevant themes. There was a structural scheme of (pandemic) brutality that determined embodied experiences of horror, conditioned by a governance of abandonment and its related problems. To confront such horror, solidary community resistance focused on food, physical and mental health, management of corpses, community-led communication, online education, and political participation. We interpret that this was a process of social determination of collective health and discuss important theoretical, methodological, and ethical-political implications.

Balancing between reality, ideality, and equity: critical reflections from recruiting key informants for qualitative health research

BACKGROUND

Key informant interviews (KII) are a widely used method in qualitative health research to gain in-depth insights from individuals with specialized knowledge, experience, or access that is crucial to the research topic. However, there is growing criticism regarding how the selection of key informants is insufficiently described in research. This opacity is problematic as the authority and knowledge of key informants may be given undue weight in research findings, potentially overshadowing other non-expert samples. The resulting imbalance in representation can lead to favoring certain viewpoints while marginalizing others, and thereby reinforcing existing inequities.

METHODS

Using our KII study as an example, we demonstrate how we initially composed an ideal sample based on theoretical considerations and subsequently operationalized it in the field. We employed a selective recruitment strategy informed by intersectional theory, targeting physicians with migration backgrounds from Middle Eastern countries for a study on cancer prevention and screening. Our recruitment process combined direct methods, including database searches and email outreach, with indirect methods like snowball sampling and engagement with multipliers. The recruitment strategy was iterative, allowing for ongoing assessment and adaptation to ensure a diverse and representative sample.

RESULTS

The KII study successfully recruited 21 physicians with diverse social categories, including different genders, migration backgrounds, language skills, and medical specialties. Direct recruitment was more effective than indirect methods and allowed for greater control in reaching out to specific subsamples. It highlights the importance of flexible and persistent recruitment strategies to achieve the desired sample.

CONCLUSIONS

This KII study underscores the interplay between methodological ideals and the practical realities of recruiting a diverse, carefully composed sample of key informants in health research. Our intersectional approach aimed to ensure equitable representation by considering power dynamics and refining recruitment strategies, while balancing the challenges of real-world fieldwork-such as engaging busy physicians with specific recruitment criteria-with practical adaptability. Our KII study emphasizes the need for ongoing reflexivity to balance ideality and equity with practical feasibility.

Ethical Dimensions of Population-Based Lung Cancer Screening in Canada: Key Informant Qualitative Description Study

Normative issues associated with the design and implementation of population-based lung cancer screening policies are underexamined. This study was an exposition of the ethical justification for screening and potential ethical issues and their solutions in Canadian jurisdictions. A qualitative description study was conducted. Key informants, defined as policymakers, scientists and clinicians who develop and implement lung cancer screening policies in Canada, were purposively sampled and interviewed using a semi-structured guide informed by population-based disease screening principles and ethical issues in cancer screening. Interview data were analyzed using qualitative content analysis. Fifteen key informants from seven provinces were interviewed. Virtually all justified screening by beneficence, describing that population benefits outweigh individual harms if high-risk people are screened in organized programs according to disease screening principles. Equity of screening access, stigma and lung cancer primary prevention were other ethical issues identified. Key informants prioritized beneficence over concerns for group-level justice issues when making decisions about whether to implement screening policies. This prioritization, though slight, may impede the implementation of screening policies in a way that effectively addresses justice issues, a goal likely to require justice theory and critical interpretation of disease screening principles.

Attending to Power: Stakeholder Perspectives on Training Physicians to Address Intimate Partner Violence

Intimate partner violence (IPV) is associated with a wide range of mental and physical health concerns. Research suggests that many physicians lack knowledge and skills to adequately respond to patients experiencing IPV. In order to better integrate physicians' contributions into intersectoral responses to IPV, we asked stakeholders with expertise and experience related to IPV about the knowledge, skills, attitudes, and behaviors they wanted them to have. Guided by principles of interpretive description, and using a key informant method, we conducted unstructured interviews with 18 stakeholders in IPV-related frontline, managerial, or policy roles in Ontario, Canada. Data collection and analysis proceeded iteratively through 2022; "thoughtful practitioners" outside the research team were recruited at key junctures to provide feedback on formative findings. Stakeholders suggested that "attending to power" should be a core principle for medical practice related to IPV. Attending to power encompassed understanding interactional, organizational, and structural power dynamics related to IPV and purposefully engaging with power, by taking action to empower people subjected to violence. Specific recommendations for practice concerned four focal contexts: relationships between partners, between patients and providers, between providers, and in social systems and structures. Strengthening physicians' capacity to attend to power dynamics relevant to their IPV practice is an important step in both improving medical care for people experiencing IPV and integrating physician contributions into other services and supports.

How do we fund Public Health in Australia? How should we?

OBJECTIVE

To map how public health is funded in Australia. To assess whether changes to funding methods might improve system performance.

METHODS

Review of publicly accessible documents and discussions with public health key informants.

RESULTS

Australia spent $140 per person on public health in 2019-20, (1.8% of total health spending). But there is considerable state and territory variation. This money flows through multiple channels and payment mechanisms. Responsibility for what is funded is largely delegated to authorities close to the problems. This makes it easier to choose the best mechanism for funding an activity. Much information is hidden from view, however. This makes it impossible to assess whether the potential for population benefit is fully realised.

CONCLUSIONS

Australia avoids some of the difficulties experienced elsewhere because funding is largely devolved to states in block grants; they shape their own investments. The US, by contrast, prefers categorical funds for specific purposes. Three suggestions for making the funding system here more visible, useful and accountable are canvassed, including 'satellite accounts'.

IMPLICATIONS FOR PUBLIC HEALTH

Funding needs to be more transparent before it is possible to assess whether public health system performance could be improved through changes to the way public health is funded.

Local Dynamics of Intersectional Stigma for Black LGBTQ People in Montreal, Quebec

Much academic literature on intersectional stigma is limited by a focus on relatively static and "universal" identity traits, such as ethnicity, gender, and sexuality. This paper addresses local dynamics of intersectional stigma for Black LGBTQ people in Montreal, QC, Canada. Findings draw from fourteen semi-structured, virtual interviews with key informants providing critical services to Black LGBTQ people living in Montreal. Findings suggest intersectional stigmatization via social identity and local power dynamics converge. Specifically, language and immigration are two domains determining intersectional stigma challenges and ameliorative opportunities for Black LGBTQ people in the city. Specific immigration-related challenges included (1) insecurity (e.g. concerning Canadian residency), (2) barriers to resource access (e.g. social and legal services), and (3) stressful identity challenges. Specific language issues included (1) Francophone limitations for expressing gender and sexual diversity and (2) exclusionary linguistic divisions (i.e. Franco/Anglo, Franco/non-Franco, and Western/non-Western). Local, place-based power inequities may determine black LGBTQ experiences of intersectional stigma.

Increasing Access To Perinatal Mental Health Care: The Perinatal Psychiatry Access Program Model

Perinatal psychiatry access programs offer a scalable approach to building the capacity of perinatal professionals to identify, assess, and treat mental health conditions. Little is known about access programs' implementation and the relative merits of differing approaches. We conducted surveys and semistructured interviews with access program staff and reviewed policy and procedure documents from the fifteen access programs that had been implemented in the United States as of March 2021, when the study was conducted. Since then, the number of access programs has grown to thirty state, regional, or national programs. Access programs implemented up to five program components, including telephone consultation with a perinatal psychiatry expert, one-time patient-facing consultation with a perinatal psychiatry expert, resource and referral to perinatal professionals or patients, trainings for perinatal professionals, and practice-level technical assistance. Characterizing population-based intervention models, such as perinatal psychiatry access programs, that address perinatal mental health conditions is a needed step toward evaluating and improving programs' implementation, reach, and effectiveness.

Acceptability and Feasibility of Maternal Mental Health Assessment When Managing Small, Nutritionally At-Risk Infants Aged < 6 Months: A Key Informant Interview Study

Maternal mental health (MMH) conditions and infant malnutrition are both major global public health concerns. Despite a well-established link between the two, many nutrition programmes do not routinely consider MMH. New World Health Organization (WHO) malnutrition guidelines do, however, emphasise MMH. To inform guideline rollout, we aimed to assess the feasibility and acceptability of MMH assessments in nutrition programmes in low-resource settings. Ten semi-structured interviews were conducted with international key informants who work on nutrition programmes or MMH research. Interview transcripts were coded using subthemes derived from the key points discussed. The benefits and risks were highlighted. These included ethical dilemmas of asking about MMH if local treatment services are suboptimal. Commonly reported challenges included governance, staff training and finance. Community and programme staff perceptions of MMH were primarily negative across the different settings. Many points were raised for improvements and innovations in practice, but fundamental developments were related to governance, care pathways, advocacy, training, funding and using existing community networks. Future implementation research is needed to understand whether assessment is safe/beneficial (as it is in other settings) to promote MMH screening. Current service providers in low-resource settings can undertake several steps, as recommended in this paper, to improve the care offered to mothers and infants.