Development of a theory of implementation and integration: Normalization Process Theory

Exploring factors influencing the consistent adoption of a post-stroke upper extremity outcome measure using Normalisation Process Theory

BACKGROUND

Stroke rehabilitation guidelines recommend using outcome measures like the Fugl-Meyer Assessment for Upper Extremity (FMA-UE) to assess post-stroke upper extremity function. However, integrating such outcome measures into routine clinical practice remains challenging, highlighting the need to understand factors affecting their implementation in evolving healthcare models.

OBJECTIVE

Our study aimed to identify the barriers and facilitators to sustain the routine use of the FMA-UE among hospital-based occupational therapists (OTs) using a theory-driven approach.

METHODS

Employing a mixed-method sequential exploratory study design rooted in Normalisation Process Theory (NPT), we gathered quantitative data through a validated survey followed by qualitative insights analysed with directed content analysis from focus group discussions involving occupational therapists from four hospitals.

RESULTS

Survey findings (n = 34) revealed barriers primarily associated with NPT constructs of collective action and coherence. Facilitators were linked to the cognitive participation construct. Key barriers identified in focus groups included insufficient coaching, competing priorities, and perceived limited value of the FMA-UE. Facilitators included legitimation of therapists' role in outcome measurements and an open learning culture.

CONCLUSIONS

Through a theory-based approach, we identified barriers and facilitators to sustain the routine of the FMA-UE. Our findings offer insights for designing implementation strategies to embed the FMA-UE into routine practice, supporting its sustained use in stroke rehabilitation.

Study protocol for assessing the effectiveness, implementation fidelity and uptake of attachment & child health (ATTACH™) Online: helping children vulnerable to early adversity

BACKGROUND

Exposure to early childhood adversities, such as family violence, parental depression, or low-income, undermine parent-child relationship quality and attachment leading to developmental and mental health problems in children. Addressing impacts of early childhood adversity can promote children's development, giving them the best start in life. Parental reflective function (RF), or parents' ability to understand their own and children's mental states, can strengthen parent-child relationships and attachment and buffer the negative effects of early adversity. We developed and tested ATTACH™ (Attachment and Child Health), an effective RF intervention program for parents and their preschool-aged children at-risk from early adversity. Pilot studies revealed significantly positive impacts of ATTACH™ from in-person (n = 91 observations of 64 dyads) and online (n = 10 dyads) implementation. The two objectives of this study are to evaluate: (1) effectiveness, and (2) implementation fidelity and uptake of ATTACH™ Online in community agencies serving at-risk families in Alberta, Canada. Our primary hypothesis is ATTACH™ Online improves children's development. Secondary hypotheses examine whether ATTACH™ Online improves children's mental health, parent-child relationships, and parental RF.

METHODS

We will conduct an effectiveness-implementation hybrid (EIH) type 2 study. Effectiveness will be examined with a quasi-experimental design while implementation will be examined via descriptive quantitative and qualitative methods informed by Normalization Process Theory (NPT). Effectiveness outcomes examine children's development and mental health, parent-child relationships, and RF, measured before, after, and 3 months post-intervention. Implementation outcomes include fidelity and uptake of ATTACH™ Online, assessed via tailored tools and qualitative interviews using NPT, with parents, health care professionals, and administrators from agencies. Power analysis revealed recruitment of 100 families with newborn to 36-month-old children are sufficient to test the primary hypothesis on 80 complete data sets. Data saturation will be employed to determine final sample size for the qualitative component, with an anticipated maximum of 20 interviews per group (parents, heath care professionals, administrators).

DISCUSSION

This study will: (1) determine effectiveness of ATTACH™ Online and (2) understand mechanisms that promote implementation fidelity and uptake of ATTACH™ Online. Findings will be useful for planning spread and scale of an effective online program poised to reduce health and social inequities affecting vulnerable families.

TRIAL REGISTRATION

Name of registry: https://clinicaltrials.gov/ .

REGISTRATION NUMBER

NCT05994027. Date of registration: July 22, 2023.

PROTOCOL VERSION

Version 1.

Neonatal nurses' experiences with generative AI in clinical decision-making: a qualitative exploration in high-risk nicus

BACKGROUND

Neonatal nurses in high-risk Neonatal Intensive Care Units (NICUs) navigate complex, time-sensitive clinical decisions where accuracy and judgment are critical. Generative artificial intelligence (AI) has emerged as a supportive tool, yet its integration raises concerns about its impact on nurses' decision-making, professional autonomy, and organizational workflows.

AIM

This study explored how neonatal nurses experience and integrate generative AI in clinical decision-making, examining its influence on nursing practice, organizational dynamics, and cultural adaptation in Saudi Arabian NICUs.

METHODS

An interpretive phenomenological approach, guided by Complexity Science, Normalization Process Theory, and Tanner's Clinical Judgment Model, was employed. A purposive sample of 33 neonatal nurses participated in semi-structured interviews and focus groups. Thematic analysis was used to code and interpret data, supported by an inter-rater reliability of 0.88. Simple frequency counts were included to illustrate the prevalence of themes but were not used as quantitative measures. Trustworthiness was ensured through reflexive journaling, peer debriefing, and member checking.

RESULTS

Five themes emerged: (1) Clinical Decision-Making, where 93.9% of nurses reported that AI-enhanced judgment but required human validation; (2) Professional Practice Transformation, with 84.8% noting evolving role boundaries and workflow changes; (3) Organizational Factors, as 97.0% emphasized the necessity of infrastructure, training, and policy integration; (4) Cultural Influences, with 87.9% highlighting AI's alignment with family-centered care; and (5) Implementation Challenges, where 90.9% identified technical barriers and adaptation strategies.

CONCLUSIONS

Generative AI can support neonatal nurses in clinical decision-making, but its effectiveness depends on structured training, reliable infrastructure, and culturally sensitive implementation. These findings provide evidence-based insights for policymakers and healthcare leaders to ensure AI integration enhances nursing expertise while maintaining safe, patient-centered care.

Scientific research in primary health care: Lessons learned from a pragmatic multicenter implementation study in 101 general practices in the Netherlands

In this short report, the challenges and lessons learned from implementing scientific research in primary care are discussed. It highlights the complexities of conducting studies in primary care, where 'Lasagna's Law' rules too often. Using the CONCRETE trial - a pragmatic multicenter implementation trial - as an example, eight key elements are identified as important factors for successfully conducting scientific research in primary care, such as optimizing digital processes and improving engagement.

Realities of opioid and gabapentinoid deprescribing in socioeconomically disadvantaged communities: a qualitative evaluation

BACKGROUND

Opioid and gabapentinoid prescribing has increased substantially in recent years despite having limited effectiveness in treating chronic primary pain. This is concerning, with the prescribing rates and adverse effects of these medications being higher in more socioeconomically disadvantaged groups. Guidance for prescribing and deprescribing these medications exists but the understanding of how deprescribing is operationalised, especially in areas of socioeconomic disadvantage, is limited.

AIM

To explore primary healthcare professionals' views and experiences of designing and implementing an intervention to reduce opioid and gabapentinoid prescribing.

DESIGN & SETTING

A qualitative evaluation, using participant observation and semi-structured interviews with primary healthcare professionals, working in practices serving areas of substantial socioeconomic disadvantage in the North East of England.

METHOD

Interviewees were purposively recruited with subsequent snowballing with participant observation of the peer-support meetings. Interview transcripts and notes from the participant observation were inductively coded and thematically analysed.

RESULT

Thirteen healthcare professionals from five practices were interviewed. Person-centred care with shared decision-making was strived for, which was time-consuming owing to the complexity of the problem and patients. Where shared decision-making was not possible, owing to patient refusal or non-engagement, risk was used to determine the appropriate action. This work involved an emotional toll on staff and patients, but was at times conversely easier and more rewarding than expected. Ultimately, demedicalising pain with a culture change is required to ensure patients are not prescribed these medications for inappropriate reasons or doses.

CONCLUSION

This study demonstrates key operational aspects to consider when undertaking opioid and gabapentinoid deprescribing in primary care, such as funding dedicated time to enable deprescribing.

Lessons Learned From 2 Research Studies Enrolling Underrepresented Patients With Ventricular Assist Devices and Their Family Caregivers

Given the continued challenges of and barriers to recruiting and retaining underrepresented groups in cardiovascular studies, this study aimed to describe successful recruitment strategies used by 2 related ventricular assist device (VAD) studies. The 2 exemplar studies focused on understanding how adults with a VAD and their family caregivers discuss, reflect upon and act on their personal values. To recruit a more representative and diverse sample reflective of the substantial Black population receiving care at the local academic hospital outpatient clinic, we developed multipronged recruitment strategies for a convergent mixed-methods study (Study 1) and a sequential explanatory mixed-methods study (Study 2). Two underlying principles guided recruitment strategies: (1) clinician-scientist collaboration, and (2) personalized participant interactions. This article reflects on lessons learned by an early career investigator and her mentors from 2 studies, which will support ongoing inclusive recruitment in future projects.

"We are doing it together, don't worry" - A qualitative study on the implementation of electronic medical records in German hospitals

BACKGROUND

The ongoing implementation of electronic medical records (EMRs) in German hospitals is currently slow. Implementation science widely acknowledges the barriers and facilitators to implementation. Thus, specific preconditions are necessary to address the former and to support an effective EMR implementation. However, a lack of knowledge exists about these necessary preconditions in Germany. This study aims to gain insight into key stakeholders' experiences with implementing EMR systems in German hospitals to identify preconditions for embedding EMRs in this social context.

METHODS

Expert interviews were conducted with members of hospital-wide implementation teams concerning EMR implementation. The interviewees belonged to the nursing, IT, medical, and pharmaceutical professions and worked in hospitals with different contextual characteristics. The interview guideline was based on the practical Consolidated Framework for Implementation, which supports the systematic assessment of potential barriers and facilitators to identify implementation strategies and necessary adaptations. Data was collected between May 2021 and September 2022, and the interviews were analyzed using qualitative content analysis.

RESULTS

Thirteen interviews were conducted with employees from eleven hospitals. Five critical preconditions emerged for EMR implementation based on our analysis: 1) adaptation, where the clinical context and EMRs are aligned; 2) stakeholder co-production, where all relevant stakeholders (e. g., professional groups, departments, and hierarchical levels) are involved in planning, implementing, and evaluating; 3) end-user participation, where end-users are involved in the implementation through close support and training; 4) integration into daily routines, where EMRs are integrated into daily work, including work processes that initially require additional effort but are necessary to experience the relative advantages; and 5) the continuous Plan-Do-Check-Act cycle, where the EMR implementation process is continuously reviewed and adjusted. In addition, activities to enact these preconditions were derived based on the interview data.

DISCUSSION

Our findings indicate that overall contextual adaptation is required. The five preconditions include essential activities to facilitate the integration of the EMR into daily routines. Participation, communication, and support are fundamental, as described in the international literature. Failure to comply with these preconditions can lead to challenges during implementation, such as end-user resistance.

CONCLUSION

Considering social and technical aspects is paramount in implementing EMRs, which may also apply to future digital innovations' change management processes.

The Interactive Work of Implementing Synchronous Video-Conference Calls-A Qualitative Study Within Early Intervention for Infants With Childhood-Onset Neurodisability

INTRODUCTION

This study explores the 'peripandemic' implementation of synchronous videoconference calls during COVID-19 for delivering physiotherapy early intervention services to families of infants with childhood-onset disability. The interactional experience of conducting early intervention through videoconference calls is under researched. We aimed to understand parents' and therapists' experiences of communication and learning within early intervention sessions for infants with cerebral palsy conducted via video conference calls.

METHODS

Data were collected through interviews, video case studies and focus groups involving 15 parents and 16 therapists. We used qualitative analytical methods inspired by grounded theory and multimodality.

RESULTS

Undertaking early intervention sessions via synchronous videoconference calls creates complexities and disrupts communication norms between parent, therapist and infant. These audio-visual constraints have implications for developing shared understanding and learning. Resolving these challenges necessitated increased interactive work within the parent-therapist partnership. The onus placed on parents to have additional logistical roles in some circumstances created strain, which diverted attention from optimal learning.

CONCLUSION

The post-pandemic healthcare landscape pushes for digital innovation challenging traditional therapy models. Our contribution outlines that while videoconference calls may improve efficiency, they also add cognitive load and interaction challenges, which require modification to routine in-person session designs. We provide recommendations for adaptive implementation strategies for videoconference calls that will benefit from further iterative codesign cycles.

PUBLIC AND PATIENT CONTRIBUTION

We partnered with parents through public and patient involvement. Parents (n = 9) who were previous NHS early intervention service users formed the Parent Advisory Group (PAG). These parent partners came from a variety of backgrounds and provided their unique perspectives to directly contribute and guide decision-making throughout the project. Their contribution influenced approach to recruitment and consent; the participant information and consent form development; topic guide development; considerations of the use of video in the project design and sense checking of analytical interpretations.

Experiences of support to return to work after stroke: longitudinal case studies from RETAKE trial

Background

Returning to work after stroke has physical, psychological and financial benefits for stroke survivors. However, global evidence estimates return-to-work rates 1 year post stroke at < 50%. Although its importance is acknowledged by policy-makers and healthcare providers, vocational rehabilitation is not always part of National Health Service usual care post stroke. Currently, there is limited evidence of the effectiveness of return-to-work support interventions. RETurn to work After stroKE was a multicentre individually randomised controlled pragmatic trial, with embedded process and health economic evaluations. RETurn to work After stroKE aimed to establish whether Early Stroke Specialist Vocational Rehabilitation plus usual care improves the likelihood of return to work at 12 months post stroke compared to usual care alone. As part of an embedded process evaluation, longitudinal case studies enabled exploration of participants' experiences of support to return to work in the trial.

Objectives

This article aims to understand participants' experiences of being supported to return to work and explores the social and structural factors which support, or act as barriers to, implementation of the Early Stroke Specialist Vocational Rehabilitation intervention.

Method

A longitudinal case-study approach was used to compare experiences of post-stroke return-to-work support received over 12 months by 15 participants who received the Early Stroke Specialist Vocational Rehabilitation intervention plus usual care, and 11 participants who received usual care only. Data were gathered at three time points using follow-up questionnaires, health records, intervention delivery records and semistructured interviews with participants and seven nominated informal carers. Interviews were also conducted with 1 employer and 11 occupational therapists delivering the intervention.

Setting

Sixteen National Health Service sites across England and Wales.

Findings

In the intervention arm, stroke survivors, carers and employers reported benefits from information and support from the treating occupational therapist to facilitate acceptance of, and adaptation to, post-stroke abilities. Participants also valued occupational therapists' provision of sustained and tailored vocational rehabilitation, co-ordinating their care and advocating for them in return-to-work discussions with their employers. Those unable to return to their previous employment were supported to consider alternative options. In contrast, participants who received usual care only reported feeling abandoned when community rehabilitation support ended, typically after 2-8 weeks. Usual care largely focused on restoring physical function, leaving these participants struggling to find return-to-work information, advice and support. Longitudinal case studies enabled psychosocial and environmental factors impacting on participants' return-to-work experiences to be considered.

Limitations

Recruitment to the process evaluation was impacted by the COVID-19 pandemic. It proved difficult to recruit employers for interview, and fewer women participated in the case studies (21 men, 5 women). Direct observation of intervention delivery could not be carried out as planned due to pandemic restrictions on access to clinical areas.

Conclusions

These case studies highlighted self-reported differences between recipients of the Early Stroke Specialist Vocational Rehabilitation intervention plus usual care and participants allocated to usual care only. Aspects perceived as important in underpinning the differences in support included the length of Early Stroke Specialist Vocational Rehabilitation intervention, occupational therapist advocacy, employer liaison and ongoing workplace monitoring. Provision of these core components as part of post-stroke services may support and help to sustain return to work, with associated benefits for stroke survivors and wider society.

Funding

This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 15/130/11.

Enhancing the Innovation Ecosystem: Overcoming Challenges to Introducing Information-Driven Technologies in Health Care

As health care demands rise and resources remain constrained, optimizing health care systems has become critical. Information-driven technologies, such as data analytics and artificial intelligence (AI), offer significant potential to inform and enhance health care delivery at various levels. However, a persistent gap exists between the promise of these technologies and their implementation in routine practice. In this paper, we propose that fragmentation of the innovation ecosystem is behind the failure of new information-driven technologies to be taken up into practice and that these goals can be achieved by increasing the cohesion of the ecosystem. Drawing on our experiences and published literature, we explore five challenges that underlie current ecosystem fragmentation: (1) technology developers often focus narrowly on perfecting the technical specifications of products without sufficiently considering the broader ecosystem in which these innovations will operate; (2) lessons from academic studies on technology implementation are underused, and existing knowledge is not being built upon; (3) the perspectives of healthcare professionals and organizations are frequently overlooked, resulting in misalignment between technology developments and health care needs; (4) ecosystem members lack incentives to collaborate, leading to strong individual efforts but collective ecosystem failure; and (5) investment in enhancing cohesion between ecosystem members is insufficient, with limited recognition of the time and effort required to build effective collaborations. To address these challenges, we propose a series of recommendations: adopting a wide-lens perspective on the ecosystem; developing a shared-value proposition; fostering ecosystem leadership; and promoting local ownership of ecosystem investigation and enhancement. We conclude by proposing practical steps for ecosystem members to self-assess, diagnose, and improve collaboration and knowledge sharing. The recommendations presented in this paper are intended to be broadly applicable across various types of innovation and improvement efforts in diverse ecosystems.

Values of Stakeholders Involved in Applying Surveillance Technology for People With Dementia in Nursing Homes: Scoping Review

BACKGROUND

Due to the progressive nature of dementia, concerns about the safety of nursing home residents are frequently raised. Surveillance technology, enabling visual and auditory monitoring, is often seen as a solution for ensuring safe and efficient care. However, tailoring surveillance technology to individual needs is challenging due to the complex and dynamic care environment involving multiple formal and informal stakeholders, each with unique perspectives.

OBJECTIVE

This study aims to explore the scientific literature on the perspectives and values of stakeholders involved in applying surveillance technology for people with dementia in nursing homes.

METHODS

We conducted a scoping review and systematically searched 5 scientific databases. We identified 31 articles published between 2005 and 2024. Stakeholder characteristics were extracted and synthesized according to the theory of basic human values by Schwartz.

RESULTS

In total, 12 stakeholder groups were identified, with nursing staff, residents, and informal caregivers being the most frequently mentioned. Among stakeholder groups close to residents, values related to benevolence, security, conformity, and tradition were most commonly addressed. Furthermore, values such as self-direction, power, and achievement seemed important to most stakeholder groups.

CONCLUSIONS

Several stakeholder groups emphasized the importance of being and feeling involved in the application of surveillance technologies. In addition, they acknowledged the necessity of paying attention to stakeholders' perspectives and values. Across these stakeholder groups, values related to benevolence, security, and self-direction were represented, although various stakeholders assigned different meanings to these values. Awareness of stakeholders' perspectives demands a willingness to acknowledge each other's values and bridge differences.

Process Evaluation Alongside a Cluster-Randomized Trial of a Multicomponent Intervention Designed to Improve Patient Access to Kidney Transplantation

Background

In a cluster-randomized trial, we learned that a novel multicomponent intervention designed to improve access to kidney transplantation did not significantly increase the rate of completed steps toward receiving a kidney transplant. Alongside the trial, we conducted a process evaluation to help interpret our findings.

Objective

To determine whether the intervention addressed targeted barriers to transplant and whether the implementation occurred as planned.

Design

Mixed-methods process evaluation informed by implementation science theories.

Setting

Chronic kidney disease (CKD) programs in Ontario, Canada. These programs, providing care to patients with advanced CKD, participated in the trial from November 1, 2017 to December 31, 2021 (either in the intervention or usual care group).

Participants

Health care providers (eg, nurses, managers) at Ontario's 27 CKD programs.

Methods

We conducted surveys (n = 114/162 [70.4%]) and semi-structured interviews (n = 17/26 [65.4%]) with providers in CKD programs in Ontario, Canada. In both the intervention-group and control-group surveys, using the Theoretical Domains Framework, we assessed perceived barriers to transplant and how barriers changed throughout the trial period. In the intervention-group surveys and interviews, using the normalization process theory, we assessed the extent to which the intervention was embedded into daily routines. In the intervention-group surveys, and by completing an implementation checklist, we assessed fidelity of implementation.

Results

Perceived barriers to transplant did not substantially differ between providers in the intervention and usual care groups, and both groups reported disagreeing or feeling neutral that the targeted barriers impeded transplant access. Intervention-group providers reported that intervention activities were becoming a regular part of their work and that they engaged with its components. However, they also felt the intervention was complex and described needing more resources, a better execution plan, and more buy-in from frontline staff. Fidelity was high for administrative support, quality improvement teams, delivery of educational resources, and patient peer support. The use of performance reports was low.

Conclusions

We identified several possible reasons why the intervention was unsuccessful. Improving access to kidney transplantation remains a high priority for health care systems. We will continue to foster a quality improvement culture, and our results will guide future interventions.

Limitations

Two of the 13 intervention-group CKD programs did not participate in this evaluation.

Trial Registration

ClinicalTrials.gov Identifier: NCT03329521.

Consistent, Concise and Meaningful: Clinician Perceptions of a Novel Dyspnea Assessment Tool

BackgroundDyspnea is a prevalent and distressing symptom in interstitial lung diseases with significant effects on patients' quality of life and associated with poorer prognosis. Guidelines recommend a multidimensional dyspnea assessment tool. We developed a validated 9-item scale, the Edmonton Dyspnea Inventory (EDI), in which dyspnea severity is rated across different settings including at rest, during activities of daily living, and self-reported exercise and crises. The standardized, multidimensional tool captures dyspnea intensity for specific contexts, which clinicians can use to manage dyspnea more individually and effectively. Early studies support the feasibility to use the EDI in outpatient settings. The purpose of this study was to explore perceptions of the EDI by community health care professionals.MethodsWe conducted a qualitative study using an inductive approach and open coding for content analysis. Email invitations were sent to community health care professionals and informed consent obtained from the twelve participants. Two focus groups and one key informant interview were conducted. Themes were extracted from transcripts and field note analyses.ResultsFour main themes described their dyspnea assessment with the EDI: the EDI is a meaningful clinical assessment tool; they explicitly engage and educate patients to effectively use the EDI; they use the EDI to personalize and evaluate dyspnea management; and the EDI is valuable for communication and interprofessional collaboration.ConclusionCommunity health care professionals perceived the EDI as valuable to assess dyspnea and personalize management. They recommended it be used in clinical practice and healthcare education for interprofessional dyspnea management for ILD patients.

WORKWELL process evaluation: qualitative data analyses of the participant interviews at 12- and 36-month follow-ups

Objectives

This study aimed to qualitatively examine the delivery of the WORKWELL trial, a job retention vocational rehabilitation (JRVR) programme designed to help individuals with inflammatory arthritis (IA) maintain employment. A qualitative process evaluation used the Normalization Process Theory (NPT) to understand participant experiences and identify factors influencing implementation and outcomes.

Methods

Data were collected via one-to-one telephone interviews with trial participants at 12 and 36 months. An inductive reflexive thematic analysis was followed by a deductive analysis based on NPT's four constructs (coherence, cognitive participation, collective action and reflexive monitoring).

Results

Sixty-two participants (mean age 51.0; 82.3% female) were interviewed, most diagnosed with RA (75.8%). Four secondary themes were generated under NPT constructs. For 'Coherence', themes included 'Exploring the Purpose and Impact of Taking Part in WORKWELL' and 'Questionnaires as Instrument for Reflection'. In 'Cognitive Participation', the theme was 'Commitment and Investment to WORKWELL'. For 'Collective Action', we identified 'Key Actions for Successful WORKWELL', and under 'Reflexive Monitoring', the theme was 'Suggestions for Improving WORKWELL'. These themes reflected participants' mixed feelings about the intervention, finding value in the intervention but highlighting the need for more tailored, timely and relevant content. Workplace support was crucial but often insufficient. Follow-up calls from researchers to ensure questionnaire completion were seen as a way to reflect and monitor their conditions. The pandemic's impact on work environments also influenced outcomes.

Conclusion

Findings suggest that WORKWELL provided work support for participants, though its impact could be enhanced through greater customization, early intervention and stronger workplace engagement.

Trial registration

ClinicalTrials.gov NCT03942783. Registered on 8 May 2019. ISRCTN Registry ISRCTN61762297. Registered on 13 May 2019. Retrospectively registered.

Implementation of a patient decision aid for discharge planning of hospitalized patients with stroke: aprocess evaluation using a mixed-methods approach

OBJECTIVES

To promote shared decision-making (SDM) during discharge planning of patients with stroke, a patient decision aid (PtDA) was implemented in seven Dutch hospitals. This mixed-methods process evaluation assessed: 1) PtDA use, 2) the SDM process, 3) facilitators and barriers influencing health care professional (HCP) adoption of the PtDA, and 4) HCP experiences with the PtDA.

METHODS

Rates of PtDA use were derived from hospital registries and PtDA log data. SDM levels in consultations were quantitatively assessed using OPTION-5 (score range 0-100); the SDM process was analyzed qualitatively. Facilitators and barriers were identified via the MIDI questionnaire. HCP experiences were explored through interviews.

RESULTS

PtDA use varied across hospitals, with 10-96 % of patients receiving it and 27-100 % of those ultimately using it. OPTION-5 scores were low in both pre-implementation (n = 68, median:0, Q1-Q3:0-0) and post-implementation consultations (n = 49, median:0, Q1-Q3:0-15). Barriers included lack of whole-team engagement and limited recognition of PtDA benefits. Frequent PtDA use was associated with HCP confidence and self-efficacy in SDM.

CONCLUSIONS

Successful PtDA implementation in stroke care requires whole-team engagement, emphasis on PtDA benefits, and enhancing HCP confidence and self-efficacy in SDM.

PRACTICE IMPLICATIONS

Highlighting positive SDM outcomes and patient benefits may encourage HCPs to adopt the PtDA.

Musculoskeletal triage physiotherapists' perspectives on their role, the patient journey and implementation of interface triage clinics in primary care in Ireland

OBJECTIVES

To explore musculoskeletal triage clinical specialist physiotherapists' (CSPs) perspectives on the patient journey and their perspectives on the acceptability of implementing MSK triage interface clinics in primary care in Ireland.

METHODS

A qualitative descriptive study design using a thematic approach was conducted. Semi-structured focus groups were conducted with 11 CSPs in 8 hospitals with urban and rural catchment areas across Ireland. Data analysis involved a two-stage framework; thematic analysis, followed by exploration of the findings on interface clinic implementation through the lens of Normalisation Process Theory (NPT).

RESULTS

Four themes were identified: (1) Development of MSK pathways; (2) Clinical governance; (3) Implementation of interface clinics and (4) Physiotherapy role and identity. Interface clinics achieved some degree of 'coherence' (i.e. made sense) and 'cognitive participation' (i.e. fostered engagement) for CSPs with the expectation of patients receiving expert MSK care earlier in their journey. However, this was less beneficial to CSPs if interface clinics were not implemented as part of a wider integrated care pathway, and if clinics were established near the main hospital instead of primary care locations in the wider catchment area. CSPs conveyed strong recommendations on 'collective action' such as development and resourcing of integrated care pathways and primary care physiotherapy, investing in information technology infrastructure (electronic health records) and obtaining the ability to order investigations (e.g. MRI/x-ray).

CONCLUSIONS

These findings contribute new knowledge about MSK triage CSPs' perspectives on the patient journey through MSK services in Ireland, which can inform future implementation phases of MSK triage interface clinics.

Implementation of a Web-Based Program for Advance Care Planning and Evaluation of its Complexity With the Nonadoption, Abandonment, Scale-Up, Spread, And Sustainability (NASSS) Framework: Qualitative Evaluation Study

BACKGROUND

The implementation of eHealth applications often fails. The NASSS (nonadoption, abandonment, scale-up, spread, and sustainability) framework aims to identify complexities in eHealth applications; the more complex, the more risk of implementation failure.

OBJECTIVE

This study aimed to analyze the implementation of the web-based advance care planning (ACP) program "Explore Your Preferences for Treatment and Care" using the NASSS framework.

METHODS

The NASSS framework enables a systematic approach to improve the implementation of eHealth tools. It is aimed at generating a rich and situated analysis of complexities in multiple domains, based on thematic analysis of existing and newly collected data. It also aims at supporting individuals and organizations to handle these complexities. We used 6 of 7 domains of the NASSS framework (ie, condition, technology, value proposition, adopters, external context, and embedding and adaptation over time) leaving out "organization," and analyzed the multimodal dataset of a web-based ACP program, its development and evaluation, including peer-reviewed publications, notes of stakeholder group meetings, and interviews with stakeholders.

RESULTS

This study showed that the web-based ACP program uses straightforward technology, is embedded in a well-established web-based health platform, and in general appears to generate a positive value for stakeholders. A complexity is the rather broad target population of the program. A potential complexity considers the limited insight into the extent to which health care professionals adopt the program. Awareness of the relevance of the web-based ACP program may still be improved among target populations of ACP and among health care professionals. Furthermore, the program may especially appeal to those who value individual autonomy, self-management, and an explicit and direct communicative approach.

CONCLUSIONS

Relatively few complexities were identified considering the implementation of the web-based ACP program "Explore Your Preferences for Treatment and Care." The program is evidence-based, freestanding, and well-maintained, with straightforward, well-understood technology. The program is expected to generate a positive value for different stakeholders. Complexities include the broad target population of the program and sociocultural factors. People with limited digital literacy may need support to use the program. Its uptake might be improved by increasing awareness of ACP and the program among a wider population of potential users and among health care professionals. Addressing these issues may guide future use and sustainability of the program.

Everyday living with osteoarthritis in the global South: A qualitative focus group inquiry in Nigeria

Objective

Africa contributes significantly to the increasing global prevalence (>37 ​%), unmet need and treatment burden for people with osteoarthritis. Despite this, little research has examined the expressed needs of patients with osteoarthritis (OA) and joint pain in West-Africa. This study aimed to explore lived experiences, expressed needs and current care gaps for people living with osteoarthritis in low-health resource contexts using Nigeria as a case study.

Design

Qualitative study using Focus Groups. People aged 45 years and over living with osteoarthritis and joint pain were recruited at local health services or via wide advertisements in the community. Discussions were recorded and transcribed verbatim. Data were analyzed using thematic analysis (inductive approach).

Results

Three focus groups were conducted with people living with osteoarthritis (n ​= ​30, age range 45-90 years) across socio-demographic strata. Participants described their experiences of living with osteoarthritis as emotionally, physically, and socio-economically challenging. Four main themes (and 14 sub-themes) were identified. Participants expressed the need for an information and health education campaign and access to appropriate health professionals (especially physiotherapists) for providing support, guidance, and assistance with self-management.

Conclusions

The provision of an accessible, and contextually appropriate patient education package, in line with evidence-based recommendations is a critical need for people living with osteoarthritis in Nigeria. This will promote evidence-based care for OA in low-resource settings, empowering patients to self-manage and reducing confusion related to inconsistent advice and mixed messages about cause, healthcare access and OA care.

Examining implementation outcomes in health information exchange systems: A scoping review

BACKGROUND

Health information exchange (HIE) facilitates the secure exchange of digital health data across disparate health systems and settings. The implementation of information technology projects in healthcare is complex, further complicated by the fact that implementation success, through the measure of implementation outcomes, has been inconsistently defined and evaluated. There is no known scoping review examining implementation success through implementation outcomes in the field of HIE technologies. The aim of this scoping review was to provide a synthesis of studies related to reported implementation outcomes of HIE solutions (and related interoperability technologies) with a goal to inform the implementation of large-scale HIE projects in the future.

METHODS

A scoping review, guided by the Arksey and O'Malley Framework, was conducted in four databases (Medline, Embase, CINAHL, and Web of Science), gathering studies from January 2010 to June 2023. Studies that described the implementation of a technology supporting interoperability or HIE across different organizations and/or across different healthcare settings and described the evaluation of one or more implementation outcomes from the Implementation Outcome Framework (IOF) were included.

RESULTS

37 studies were included in this review. The implementation outcome adoption was most frequently reported (n = 24). Fidelity and penetration were not reported. Few studies provided definitions for the outcomes being evaluated. Few studies provided details surrounding the stage of implementation as it relates to the outcome examined. No studies used the IOF or other similar implementation science evaluation frameworks.

CONCLUSION

This review highlights the existing gaps in the field of HIE/interoperability solutions implementation studies. Future studies should employ theoretical frameworks to guide their research, standardize language used to describe implementation outcomes, and expand knowledge of salient outcomes at varying stages of implementation.

Development of a method for qualitative data integration to advance implementation science within research consortia

BACKGROUND

Methods of integrating qualitative data across diverse studies and within multi-site research consortia are less developed than those for integrating quantitative data. The development ofsuchmethods is essential to support the data exchange needed for cross-study qualitative inquiry and given the increasing emphasis on data sharing and open science. We describe methods for qualitative data integration within the National Cancer Institute's Improving the Management of symPtoms During And following Cancer Treatment (IMPACT) Consortium funded by the Cancer MoonshotSM. Data collection and analysis were guided by the Consolidated Framework for Implementation Research (CFIR). Our case study highlights potential solutions for unique challenges faced when integrating qualitative data across multiple settings in a research consortium.

METHODS

The IMPACT consortium is comprised of three research centers (RCs) each conducting pragmatic trials examining the effectiveness of routine symptom management on patient-centered outcomes. After reaching consensus on use of CFIR as the common implementation determinant framework, RCs developed a semi-structured interview guide and tailored it to features of their healthcare setting and symptom management interventions. RCs conducted interviews/focus groups with healthcare system partners to examine contextual factors impacting implementation. RCs exchanged 1-2 transcripts (n = 5 total) for purposes of pilot testing the methodology.

RESULTS

Given the heterogeneity of study settings and contexts, it was challenging to simultaneously assign codes at both domain and construct levels and the process was resource intensive. Recommendations include employing a common framework for data collection and analyses from the outset, coding at domain level first and then incorporating construct codes, and centralizing processes via a coordinating center (or similar entity) and combining coded transcripts using qualitative software. We also generated an iteratively refined codebook that employed the CFIR schema and incorporated CFIR 2.0 to provide detailed guidance for coders conducting cross-study qualitative inquiry.

CONCLUSIONS

Limited guidance exists on how to support qualitative data integration, data exchange, and sharing across multiple studies. This paper describes a systematic method for employing an implementation determinant framework-guided approach to foster data integration. This methodology can be adopted by other research consortia to support qualitative data integration, cross-site qualitative inquiry, and generate improved understanding of evidence-based intervention implementation.

Rapid Verbal Persuasion to increase influenza vaccine uptake: protocol for a randomized hybrid type 2 effectiveness -implementation trial

BACKGROUND

While influenza vaccines are the most effective measure for preventing influenza, uptake rates in China remain relatively low. Rapid Verbal Persuasion (RVP), with highly rapid fashion, has a strong evidence base in promoting behavior change. Despite this, it is underused or rarely evaluated in the context of vaccination. Additionally, the success of RVP implementation in vaccination clinics hinges on the motivation of vaccination staff, which remains critical even with stable contextual factors. Multifaceted incentive-based implementation strategies, which aim to enhance motivation to promote the implementation of evidence-based practices, could be advantageous. This study protocol outlines an implementation-effectiveness hybrid type 2 design to evaluate the effectiveness of both the incentive-based implementation strategies on implementation outcomes and RVP on increasing influenza vaccination rates.

METHOD

This study will be conducted as a two-tiered cluster of randomized controlled trials over three months. Initially, 32 vaccination clinics will be randomly allocated to one of two study arms: (a) implementation of RVP or (b) no implementation. At the end of the study period, differences in influenza vaccination status between the intervention and control groups will be compared (primary outcome). Subsequently, a cluster randomized factorial trial will be conducted, involving 16 clinics implementing RVP. This trial will aim to compare the impact of various implementation strategies (different combinations of incentives) on fidelity in RVP implementation (primary outcome). Data collection for the primary outcomes will include unannounced exit interviews. Modified Poisson regression models and generalized linear mixed-effects models will be utilized to analyze the association between primary outcomes and interventions.

CONCLUSION

The study aims to enhance the influenza vaccination rate in China by developing financial and non-financial incentives that allow vaccination staff to deliver RVP with greater motivation. Furthermore, the evidence generated from this multi-center trial will assist policymakers in improving current incentive systems within immunization services.

TRIAL REGISTRATION

Chinese Clinical Trial Registry. Trial identifier: ChiCTR2400091302 (Registration Date: October 25, 2024); ChiCTR2400091324 (Registration Date: October 25, 2024).

Transformation to a Patient Centred Medical Home in an Urban Aboriginal Community Controlled Health Service: A Qualitative Study Using Normalisation Process Theory

RATIONALE

The Patient-Centred Medical Home (PCMH) is a model of team-based care that is patient centred, coordinated, accessible, and focused on quality and safety. To learn how this model of healthcare works in an Indigenous primary health care setting in Australia, we explored the experiences of health staff in an urban Aboriginal Community Controlled Health Service (ACCHS) transitioning to an adapted model of a PCMH. Normalisation Process Theory (NPT) was applied to better understand factors enabling and inhibiting implementation of the PCMH, and the work required to deliver it.

AIMS AND OBJECTIVES

Applying NPT, we aimed to examine enablers and barriers to implementing a PCMH in an ACCHS setting and identify practical strategies to strengthen its implementation and delivery.

METHODS

We employed semi-structured interviews with 19 health staff in an urban ACCHS to explore mechanisms that inhibit and promote the implementation and delivery of a PCMH in their setting. Interview data were analysed using thematic analysis that mapped codes against NPT constructs (Coherence, Cognitive Participation, Collective Action and Reflexive Appraisal) to generate themes.

RESULTS

Five key themes and 14 sub-themes related to NPT constructs were identified. Broadly, health staff found the model of the PCMH to be coherent, engaged with others to adapt their roles, and worked collectively to embed new practices. Characteristics and practice norms of the clinic already aligned with the PCMH model were key enablers. Barriers were related to inadequate resourcing and ill-defined roles. Stronger leadership and support, practical learning resources for staff, workforce mapping to better define staff roles, and training to address gaps in staff skills were strategies identified for strengthening implementation of a PCMH and sustaining its delivery in the ACCHS setting.

CONCLUSIONS

Applying NPT revealed the characteristics and practice norms of Indigenous community controlled health care as key enablers of implementing a PCMH in an urban ACCHS. Less than optimal resourcing and workforce development emerged as barriers needing to be resolved to strengthen implementation and delivery of a PCMH in this setting.

Evidence to practice - lessons learnt in developing an implementation strategy for an online digital health intervention (Eczema Care Online)

BACKGROUND

Eczema Care Online ( www.EczemaCareOnline.org.uk/ ) is an online self-management toolkit which includes tailored content for young people (13-25 years) and for parents of children that have eczema (0-12 years). Testing in two randomised controlled trials has shown that it is easy to use, cost effective and offers a sustained improvement in eczema symptoms. Implementing Eczema Care Online outside of a funded research study and ensuring that it reaches those that will most benefit from is now a key challenge. This paper describes the lessons learnt from developing and delivering an implementation strategy.

METHODS

Data from systematic reviews, stakeholder consultation meetings, interviews with trial participants, intervention usage data during the trial, and existing eczema information websites informed our implementation plan. Using Normalisation Process Theory, an implementation plan combined these findings with practical, context-specific actions to encourage wider adoption of the intervention.

RESULTS

Data was successfully mapped to the four constructs of Normalisation Process Theory, and factors and processes that encourage implementation identified. These include: promoting how Eczema Care Online is different to other sources of information; aligning to and embedding in existing eczema resources (from charities and healthcare providers); simplifying aspects to aid ease of use; and, highlighting evidence that shows that Eczema Care Online works. Key lessons in developing an implementation strategy include 1) start implementation work early 2) maintain flexibility to explore multiple routes to implementation 3) use secondary data sources 4) balance theory with practicalities 5) consider longer-term maintenance beyond the life of the research project.

CONCLUSION

Implementation planning is a key stage of the research process that is often not adequately resourced. Implementation planning ensures effective interventions developed and evaluated in research studies are utilised in everyday practice.

Perceptions and experiences of healthcare professionals of implementing the Organ Donation (Deemed Consent) Act in England during the Covid-19 pandemic

CONTEXT

In May 2020 during the COVID-19 pandemic, England implemented a 'soft' opt-out system of consent to deceased organ donation. As part of a wider evaluation, this analysis focused on the perceptions of health care professionals, specifically their experiences of implementation.

METHODS

Mixed-methods study informed by Normalisation Process Theory, based on two national surveys of health care professionals and interviews, observations and document analysis, across two case study sites. Routine NHS Blood and Transplant's audit data provided context.

FINDINGS

70 interviews with 59 staff and 244 first and 738 second surveys. COVID-19 affected every aspect of implementation. Although supportive in principle, many staff were unconvinced that legislative changes alone would increase consent rates. Many staff were redeployed or left their jobs. As a result, staff were not able to work collectively as intended for implementation. Staff received routine donor audit data suggesting the law was yet to make a difference to consent rates, reducing their enthusiasm and commitment.

CONCLUSIONS

Implementation could have been more impactful if delayed. The National Health Service needs to reprioritise organ donation and relaunch the implementation plan in the post-pandemic period, though it is unlikely the changes will bring about a significant increase in consent rates.

Study protocol: type II hybrid effectiveness-implementation study of routine functional status screening in VA primary care

BACKGROUND

Maintaining functional status, defined as the ability to perform daily activities such as bathing, dressing, and preparing meals, is central to older adults' quality of life, health, and ability to remain independent. Identifying functional impairments - defined as having difficulty or needing help performing these activities - is essential for clinicians to provide optimal care to older adults, and on a population level, understanding function can help anticipate service needs. Yet uptake of standardized measurement of functional status into routine patient care has been slow and inconsistent due to the burden posed by current tools. The goal of the Patient-Aligned Care Team (PACT) Functional Status Screening Initiative is to implement and evaluate a patient-centered, low-burden intervention to improve identification and management of functional impairment among older veterans in Veterans Health Administration (VHA) primary care settings.

METHODS

We will conduct a hybrid type 2 implementation-effectiveness cluster-randomized adaptive trial at 8 VHA sites using the Practical, Robust Implementation and Sustainability Model (PRISM) to guide implementation and evaluation. During a Pre-Implementation phase, we will engage clinical partners and develop local adaptations to maximize intervention-setting fit. During an Implementation phase, we will launch a standard bundle of implementation strategies (coalition building, champions, technical assistance) and system-level audit and feedback, identify sites with low uptake, and randomize those sites to receive continued standard vs. enhanced strategies (standard strategies plus clinician-level audit and feedback). The primary implementation outcome is reach (proportion of eligible patients at each site who receive screening/assessment) and the primary effectiveness outcome is appropriate management of impairment (proportion of patients with identified impairments who receive related referrals).

DISCUSSION

Implementing routine measurement of functional status in primary care has the potential to improve identification and management of functional impairment for older veterans. Improved management includes increasing access to services and supports for veterans and family caregivers, reducing potentially preventable acute care utilization, and allowing veterans to live in the least restrictive setting for as long as possible. Implementation will also provide data to inform the delivery of proactive interventions to prevent and delay development of functional impairment and improve quality of life, health, and independence.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov on May 7, 2024, at NCT06404970 ( https://clinicaltrials.gov/ ).

REPORTING GUIDELINES

Standards for Reporting Implementation Studies (Additional file 1).

Protocol for a feasibility study evaluating a supported self-management intervention for stroke survivors with aphasia (StarStep study)

BACKGROUND

There is a growing evidence base to support the use of self-management interventions for improving quality of life after stroke. However, stroke survivors with aphasia have been underrepresented in research to date. It is therefore unclear if self-management is an appropriate or effective approach for this group. To address this gap in the evidence base, we have developed a supported self-management intervention (the 'Living with Aphasia' intervention) specifically for stroke survivors with aphasia in the first year after stroke. The StarStep study aims to assess the feasibility of implementing and evaluating the intervention (including the feasibility of participant recruitment, the feasibility of delivering facilitator training, the acceptability of the intervention, the fidelity of intervention delivery and outcome data completeness).

METHODS

StarStep is a mixed-methods, non-randomised feasibility study. The Living with Aphasia intervention will be facilitated by speech and language therapists and implemented in two community stroke teams in the north of England. We aim to recruit 30 stroke survivors who have aphasia (and/or their family members) and who are ≤ 12-month post-stroke to participate in data collection for the study. Following informed consent, participants will complete a baseline data collection questionnaire which will include measures of quality of life, symptoms of depression and perceived communicative effectiveness. Follow-up questionnaires will be completed at 3-month post-intervention. Qualitative data collection will include implementation groups and semi-structured interviews with speech and language therapists, semi-structured interviews with stroke survivors with aphasia (and/or their family members) and observations of the delivery of the intervention. A joint display table will be used to integrate findings from each element of data collection in order to consider overall feasibility.

DISCUSSION

This study will provide the information necessary to optimise data collection processes and to optimise the implementation and delivery of the self-management intervention. Feasibility data will inform decision-making regarding progression to a future definitive cluster randomised controlled trial to evaluate the effectiveness of the intervention.

TRIAL REGISTRATION

ISRCTN registry, trial registration number: ISRCTN10401966. Date of registration: 07/10/2023. URL of trial registry record: https://doi.org/10.1186/ISRCTN10401966 .

The impact of specialised gastroenterology services for pelvic radiation disease (PRD): Results from the prospective multi-centre EAGLE study

To undertake a mixed-methodology implementation study to improve the well-being of men with gastrointestinal late effects following radical radiotherapy for prostate cancer. All men completed a validated screening tool for late bowel effects (ALERT-B) and the Gastrointestinal Symptom Rating Score (GSRS); men with a positive score on ALERT-B were offered management following a peer reviewed algorithm for pelvic radiation disease (PRD). Health-related quality of life (HRQoL) at baseline, 6 and 12 months; and healthcare resource usage (HRU) and patient, support-giver, staff experience and acceptability of staff training (qualitative analysis) were assessed. Two nurse- and one doctor-led gastroenterology services were set up in three UK cancer centres. Men (n = 339) who had had radical radiotherapy for prostate cancer at least 6 months previously, were recruited; of which 91/339 were eligible to participate; 58/91 men (63.7%) accepted the referral. Diagnoses included: radiation proctopathy (n = 18); bile acid malabsorption (n = 15); fructose or lactose intolerance and/or small intestinal bacterial overgrowth (n = 20); vitamin B12/D deficiency (n = 20). Increases in quality of life, sexual activity and/or sexual function, and decrease in specific symptoms (e.g. bowel-related or urinary) between 6 and 12 months were observed. Limited HRU modelling suggested staff costs were £117-£185, depending on the service model; total costs averaged £2,243 per patient. Both staff and patients welcomed the new service although there was concern about long-term funding and sustainability beyond the timeframe of the study (qualitative). PRD is increasingly recognised worldwide as an ongoing consequence of curative pelvic radiotherapy, despite widespread implementation of advanced radiotherapy techniques. Specialised services following national guidelines are required.

Effectiveness of using implementation frameworks to facilitate the implementation of a stroke management guideline in the traditional Chinese medicine hospitals in China: protocol for a factorial randomised controlled trial

INTRODUCTION

Traditional Chinese medicine (TCM) is commonly used alongside Western medicine for stroke management in China. However, there is significant variation in TCM practice, and the utilisation of evidence-based clinical practice guidelines is inadequate. This study aims to evaluate the effectiveness of three popular frameworks-Consolidated Framework for Implementation Research (CFIR), Theoretical Domains Framework (TDF) and Normalization Process Theory (NPT)-in improving implementation outcomes for the integrated TCM and Western medicine clinical practice guideline for stroke management.

METHODS AND ANALYSIS

This study employs a hybrid type III design with a factorial randomised controlled trial, where 45 TCM hospitals will be randomly assigned to one of eight experimental conditions based on the use or non-use of each framework (CFIR, TDF, NPT). The factorial design allows for the evaluation of the main effects of each framework and their two-way and three-way interactions, offering insights into which combination of frameworks is most effective in enhancing implementation outcomes. The factorial design provides greater efficiency compared with traditional designs by enabling the simultaneous testing of multiple interventions and their combinations with the same sample size, which increases statistical power. Implementation facilitators will be trained to support the guideline adoption process, with interventions aligned to specific framework components (eg, CFIR for identifying barriers and facilitators, TDF for understanding behavioural influences and NPT for normalising practices within organisational routines). Outcomes will be evaluated using the RE-AIM framework (reach, effectiveness, adoption, implementation and maintenance). Hierarchical logistic regression models will test the study hypotheses, and qualitative methods, such as interviews and focus groups, will provide contextual understanding. Additionally, a cost-effectiveness analysis will be conducted to assess the economic feasibility of the implementation strategies.

ETHICS AND DISSEMINATION

This trial has been approved by the Institutional Review Board of Southern Medical University (approval number: #202261) and follows all relevant ethical guidelines for research involving human participants. On completion, the findings will be shared with patients, healthcare providers and stakeholders through various dissemination activities, including workshops and presentations within relevant TCM and stroke management networks. The results will be published in peer-reviewed academic journals and presented at national and international conferences to inform future practice and policy on the integration of TCM and Western medicine for stroke management.

TRIAL REGISTRATION DETAILS

This study has been registered on the Open Science Framework with the DOI: 10.17605/OSF.IO/NJEVB.

Applying Normalisation Process Theory to a peer-delivered complex health intervention for people experiencing homelessness and problem substance use

BACKGROUND

The Supporting Harm Reduction through Peer Support (SHARPS) study involved designing and implementing a peer-delivered, harm reduction intervention for people experiencing homelessness and problem substance use. Normalisation Process Theory (NPT) provided a framework for the study.

METHODS

Four Peer Navigators (individuals with personal experience of problem substance use and/or homelessness) were recruited and hosted in six third sector (not-for-profit) homelessness services in Scotland and England (United Kingdom). Each worked with participants to provide practical and emotional support, with the aim of reducing harms, and improving well-being, social functioning and quality of life. NPT guided the development of the intervention and, the process evaluation, which assessed the acceptability and feasibility of the intervention for this cohort who experience distinct, and often unmet, health challenges. While mixed-methods data collection was undertaken, this paper draws only on the qualitative data.

RESULTS

The study found that, overall, the intervention is feasible, and acceptable to, the intervention participants, the Peer Navigators and staff in host settings. Some challenges were encountered but these were outweighed by benefits. NPT is particularly useful in encouraging our team to focus on the relationship between different aspects of the intervention and context(s) and identify ways of maximising 'fit'.

CONCLUSIONS

To our knowledge, this is the first application of NPT to this cohort, and specifically by non-clinicians (peers) in non-healthcare settings (homelessness services). Our application of NPT helped us to identify ways in which the intervention could be enhanced, with the key aim of improving the health/well-being of this underserved group.

Implementing a teleophthalmology referral platform in routine practice: Understanding a digital health intervention implementation using normalisation process theory

Objective

Digital health interventions have the potential to improve clinical processes and patient outcomes; however, many face challenges during the adoption and implementation stages, hindering their overall impact. Our study uses normalisation process theory (NPT) as a theoretical approach to explore the facilitators and barriers to the implementation of a teleophthalmology referral platform in the United Kingdom, as an illustrative case of the implementation of a digital health intervention in routine practice.

Methods

Semistructured interviews were conducted with 24 health professionals (18 optometrists and 6 ophthalmologists) involved in the implementation of a teleophthalmology referral platform. NPT guided data collection and analysis.

Results

Most participants were ready to engage with the teleophthalmology referral platform, recognising its potential value and benefits. However, during implementation, participants' perceptions varied; a major factor was whether their expectations from the technology were met, particularly regarding the feedback from the secondary eye care component of the referral platform. Several additional factors were identified that would influence the adoption of the platform. These included individual aspects (e.g. participants' IT skills), technology-related factors (e.g. the time required to complete referrals) and organisational factors (e.g. investment in community optometry services).

Conclusions

To successfully implement the teleophthalmology platform into routine practice, particularly on a large scale, multiple factors at different levels must be considered. This study highlights the complexity associated with implementing digital health interventions in routine practice and the contribution of NPT in untangling some of these complexities.

The engagement of healthcare providers in implementing the selfBACK randomised controlled trial - A mixed-methods process evaluation

Background

People with low back pain (LBP) are often recommended to self-manage their condition, but it can be challenging without support. Digital health interventions (DHIs) have shown promise in supporting self-management of LBP, but little is known about healthcare providers' (HCPs) engagement in implementing these.

Aims

We aimed to examine HCPs' engagement in patient recruitment for the selfBACK app clinical trial and explore their perceptions of the app.

Methods

In a mixed-methods design, we conducted a process evaluation alongside the selfBACK trial, triangulating quantitative data from trial recruitment logs and a vignette-based survey, and qualitative data from trial procedure documents, interviews with HCPs, and survey free-text responses. From 2019 to 2020, we recruited 57 HCPs from Norway and 39 health clinics in Denmark and collected quantitative and qualitative data in parallel. Results were integrated using displays.

Results

Overall, 825 patients were recruited by the HCPs. The vignette-based survey showed high agreement among HCPs (n = 62) with the self-management plans generated by the app (84.1-88.9%) but also highlighted concerns about tailoring and content. Interviews with HCPs (n = 19) revealed challenges with recruitment due to busy schedules, competing tasks, and varying levels of interest and engagement in the study.

Conclusions

The study identified factors that impact HCPs' engagement in recruiting patients for the selfBACK trial and highlighted overall positive views of the selfBACK app, although some concerns about the content and tailoring of the app were raised. Understanding HCP motivations and workload is crucial for the successful implementation of DHIs in clinical practice.

Health checks for autistic adults: study protocol for a cluster randomised controlled trial

BACKGROUND

Autistic people commonly have physical and mental health conditions. They also frequently experience barriers to accessing healthcare, contributing to problems identifying and treating health conditions. These factors may lead to increased and earlier morbidity and lower average life expectancy for autistic people. Health checks specifically designed for autistic people, incorporating adjustments to healthcare, may help to overcome these barriers and reduce health inequalities. This trial aims to investigate the clinical and cost-effectiveness of a primary care health check for autistic adults and explore factors related to implementation such as acceptability and feasibility of delivery. The trial is co-designed and delivered by health professionals, autistic people, carers and supporters, and researchers.

METHODS

This is a clinical and cost-effectiveness, cluster randomised controlled trial of a primary care health check for autistic adults. Primary care practices will be randomised into one of two groups (intervention or control). Two hundred autistic adults (aged 18 years and over) who provide baseline data will be recruited via participating practices. Data will be collected through quantitative and qualitative methods. The primary outcome will be the incidence of new health needs/conditions detected and met at 9 months (data gathered from participant's GP records). Secondary outcomes will include the following: cost-effectiveness, measured as incremental cost per quality-adjusted life year gained over 9 months; the extent of health monitoring and health promotion needs met at 9 months; the incidence of social care needs identified at 9 months; changes in participant or carer general health; changes in quality of life; primary and secondary health and social care resource usage and costs. A qualitative study will explore views about the acceptability of the health check, its utility and future use.

DISCUSSION

This study will examine the effectiveness and cost-effectiveness of a primary care health check for autistic adults in identifying new health conditions and needs. If the intervention is effective, it would provide strong evidence for implementation into routine healthcare, therefore enabling earlier health condition diagnosis and opportunities for treatment, reducing the health inequalities experienced by autistic people.

TRIAL REGISTRATION

ISRCTN, retrospectively registered on 20 July 2023. https://www.isrctn.com/ISRCTN30156776 (ISRCTN registration number: 30156776).

Barriers and facilitators to participation in electronic health interventions in older adults with cognitive impairment: an umbrella review

BACKGROUND

Research increasingly supports the role of electronic health technology in improving cognitive function. However, individuals with mild cognitive impairment or dementia often show low compliance with electronic health technology. To understand the barriers and facilitators for this group, this study was conducted.

METHODS

This study used the Joanna Briggs Institute (JBI) umbrella review method, searching relevant English articles in PubMed, Embase, Cochrane, Scopus, MEDLINE, Web of Science, and CINAHL from inception to May 2023. Two researchers independently selected articles based on predefined criteria, assessed study quality using Meta-QAT and A Measurement Tool to Assess Systematic Reviews (AMSTAR), and determined confidence in the evidence using GRADE-CERQual. The Unified Theory of Acceptance and Use of Technology (UTAUT) model was employed to analyze factors related to electronic health technology, and Behavior Change Techniques (BCTs) were used to develop implementation strategies.

RESULTS

This study included 21 reviews, covering 535 primary studies, identifying 13 factors. The three most impactful factors on engagement were Perceived Behavioral Control, Relative Advantage, and Social Factors. Six implementation strategies were formulated based on BCT: enhancing targeted approaches, adapting to existing contexts, involving care organizations, accommodating family involvement, accessing virtual community resources, and recognizing patient variability.

CONCLUSIONS

This umbrella review underscores the need for a multi-level stakeholder approach and a holistic perspective in developing targeted implementation strategies. Using the UTAUT framework, key influential factors have been identified, offering valuable insights for future interventions and enhancing participation in electronic health interventions.

REGISTRATION

This study was registered with the PROSPERO (CRD42023429410).

Facilitators and Barriers to Values Discussions Following LVAD Implantation: Perspectives from Diverse Patients and Family Caregivers

BACKGROUND

Delivering care that is responsive to who or what is most important to patients and family caregivers is a key aspect of quality care, yet it remains unclear how clinicians can best support individuals in expressing their personal values. We aimed to describe patient- and family caregiver-identified facilitators and barriers to engaging in values discussions with clinicians following implantation of a left ventricular assist device (LVAD).

METHODS AND RESULTS

Using a qualitative descriptive approach, patients with an LVAD and their caregivers participated in 1-on-1 semistructured interviews and self-reported sociodemographics (January 2023-July 2023). Qualitative data were analyzed using thematic analysis and descriptive statistics were computed for quantitative data.

RESULTS

Patients (n = 27; ages 30-76 years) were predominantly male (59%) and non-Hispanic Black (67%). Caregivers (n = 21; ages 27-76) were female (76%), non-Hispanic Black (67%), and a spouse/partner (62%). Facilitators (5 shared across patient/caregiver groups; 8 unique across patient/caregiver groups) included a perceived close relationship (patient/caregiver), values alignment (patient/caregiver), clinician discussion initiation (patient/caregiver), facing an impending decision (patient/caregiver), 1-on-1 dyadic interactions (patient/caregiver), being assertive (patient), positive dyadic communication (caregiver), and involvement of a third party (caregiver). Barriers (2 shared; 7 unique) included belief that their values are already known (patient/caregiver), sensitivity about values (patient/caregiver), uncertainty about timing (patient), poor clinical communication (patient), patient hopelessness (patient), perceived lack of clinician time (caregiver), and having a reserved personality (caregiver).

CONCLUSION

Findings offer insight into actionable facilitators and barriers to discussions promoting incorporation of patient and family values into LVAD maintenance and chronic disease management.

Care for patients living with chronic conditions using the ICAN Discussion Aid: A mixed methods cluster-randomized trial

OBJECTIVES

To assess the effectiveness of the ICAN Discussion Aid in improving patients' experience of receiving care for their chronic conditions and health professionals' experience of providing their care.

METHODS

We conducted a pragmatic, mixed-methods, cluster-randomized trial of the ICAN Discussion Aid at 8 clinics in 4 independent health systems in the US from January 2017 and to August 2018. Sites were randomized 1:1 in pairs. Participants were primary care health professionals and their adult patients with ≥1 chronic condition. Quantitative outcomes were health professional assessment of chronic illness care and relational coordination and patient-reported self-efficacy to manage chronic disease, self-efficacy to communicate with clinician, treatment burden, assessment of chronic illness care, general health, and disruption from illness and treatment. Uptake of ICAN was assessed with patient qualitative interviews, clinician focus groups/interviews, visit video recordings, and chart review.

RESULTS

98 clinicians and 1733 patients participated. We found no significant differences between ICAN and usual care sites in mixed effect models on main outcome measures. In adjusted difference-in-differences analyses, we found patient self-efficacy to manage chronic disease (mean difference 0.61 (SE 0.27), p = 0.023), patient self-efficacy to communicate with their clinician (mean difference 0.31 (SE 0.14), p = 0.032), and health professional assessment of chronic illness care (1.42 (SE 0.52), p = 0.007) were significantly better at ICAN sites. Chart review indicated the aid was implemented in 19% of eligible encounters. Qualitative analyses highlighted limited implementation of ICAN as intended overall due to varying clinic challenges but showed that ICAN use as intended was a valued addition to the visit.

CONCLUSIONS

When patients and clinicians use ICAN as intended, which seldom occurred, important conversations emerge. This qualitative finding did not parlay into statistically significant effects on most outcomes of interest.

TRIAL REGISTRATION

The trial was registered at clinicaltrials.gov (# NCT03017196).

Integrating existing and novel methods to understand organizational context: A case study of an academic-public health department partnership

PURPOSE

In this manuscript we illustrate how implementation science (IS) researchers and practitioners can deploy and integrate existing and novel methods to develop a more comprehensive understanding of organizational context, particularly organizational routines and processes, to inform adaptation and implementation of evidence-based interventions.

METHODS

The work reported here was part of a broader investigation of how to adapt and implement a three-component combination intervention in a county health department in Mobile, Alabama. Based on pre-implementation efforts to assess local context and barriers to implementation, we first describe three approaches that can be effectively used to elucidate organizational routines and processes, followed by a description of how these approaches were applied in our study. We conclude with a discussion of lessons learned and recommendations for how these approaches can be applied and improved upon by other IS researchers.

RESULTS/CONCLUSIONS

Multiple methods used iteratively and collaboratively with implementation partners can enhance our understanding of nuanced organizational routines and better inform efforts to adapt and implement evidence-based interventions in complex organizational settings.

Exploring variations in the implementation of a health system level policy intervention to improve maternal and child health outcomes in resource limited settings: A qualitative multiple case study from Uganda

BACKGROUND

Despite growing literature, few studies have explored the implementation of policy interventions to reduce maternal and perinatal mortality in low- and middle-income countries (LMICs). Even fewer studies explicitly articulate the theoretical approaches used to understand contextual influences on policy implementation. This under-use of theory may account for the limited understanding of the variations in implementation processes and outcomes. We share findings from a study exploring how a health system-level policy intervention was implemented to improve maternal and child health outcomes in a resource limited LMIC.

METHODS

Our qualitative multiple case study was informed by the Normalization Process Theory (NPT). It was conducted across eight districts and among ten health facilities in Uganda, with 48 purposively selected participants. These included health care workers located at each of the cases, policy makers from the Ministry of Health, and from agencies and professional associations. Data were collected using semi-structured, in-depth interviews to understand uptake and use of Uganda's maternal and perinatal death surveillance and response (MPDSR) policy and were inductively and deductively analyzed using NPT constructs and subconstructs.

RESULTS

We identified six broad themes that may explain the observed variations in the implementation of the MPDSR policy. These include: 1) perception of the implementation of the policy, 2) leadership of the implementation process, 3) structural arrangements and coordination, 4) extent of management support and adequacy of resources, 5) variations in appraisal and reconfiguration efforts and 6) variations in barriers to implementation of the policy.

CONCLUSION AND RECOMMENDATIONS

The variations in sense making and relational efforts, especially perceptions of the implementation process and leadership capacity, had ripple effects across operational and appraisal efforts. Adopting theoretically informed approaches to assessing the implementation of policy interventions is crucial, especially within resource limited settings.

Implementation, barriers, solving strategies and future perspectives of reimbursed community pharmacy services - a nationwide survey for community pharmacies in Germany

BACKGROUND

Since June 2022, the legal framework has been created for German community pharmacies to offer their patients five reimbursed community pharmacy services that go beyond the current operating regulations. However, little is known about barriers that hinder their implementation. We therefore aimed to investigate the implementation of reimbursed community pharmacy services (i), barriers to the implementation (ii), solving strategies to overcome the barriers (iii), and future perspectives (iv). The objective of this study is to find out how the implementation of community pharmacy services can be facilitated for community pharmacies so that more services can be offered.

METHODS

In July 2023, we created an online survey and sent it to pharmacists in community pharmacies, including those who offered reimbursed community pharmacy services and those who did not.

RESULTS

Overall, 218 pharmacists from 218 different community pharmacies participated. (i) Of those, 176 (81%) already offered at least one reimbursed community pharmacy service. (ii) For hypertension service, 33% of the offering pharmacists reported barriers in "Communicating with patients," and 41% reported "Too little patient demand." For polymedication service, 53% of the offering pharmacists indicated "Barriers in communication with physicians," and 44% mentioned "Fear of competing with physicians." (iii) The most frequently reported solving strategies of pharmacists in offering pharmacies were taking advanced training (median of all five services 42%) and developing standardized procedures (median of all five services 34%). In contrast, pharmacists in non-offering pharmacies had not developed any solving strategies (median of all five services 40%). (iv) 64% of the pharmacists in non-offering pharmacies could imagine being able to offer reimbursed community pharmacy services in the future.

CONCLUSIONS

Many German pharmacies already offer reimbursed community pharmacy services. However, there are still barriers to widespread implementation. Therefore, customized support regarding the needs of the pharmacies should be provided since most pharmacists who do not yet offer these services today can imagine offering them in the future.

Mobile App for Improving the Mental Health of Youth in Out-of-Home Care: Development Study Using an Intervention Mapping Approach

BACKGROUND

Youth in out-of-home care encounter substantial mental health challenges because of the absence of stable family and social support systems. Their vulnerability is heightened by trauma, neglect, and abuse. They struggle, especially when transitioning to independent living, coping with loneliness, anxiety, and pressure.

OBJECTIVE

This study aimed to develop a mobile app with high accessibility and long-term continuous effects to support independent living and improve mental health among youth in out-of-home care. The approach used was the systematic and step-by-step intervention mapping (IM) framework.

METHODS

The program was created using the IM framework and had 6 steps. Drawing from data from individual and focus group interviews and literature reviews, we developed a logical model of the problem. We established program outcomes and objectives, defining performance objectives and variable determinants. We identified theoretical and evidence-based methods that influence determinants. The app design integrated these methods into practical applications, allowing for the creation of self-management and emotional support tools. The development process included ongoing discussions between app designers and the research team to ensure that user needs and preferences were addressed.

RESULTS

Individual interviews and focus group discussions revealed challenges in managing daily routines and regulating emotions. The program design was based on the transtheoretical model, social cognitive theory, and elaboration likelihood model. Key features included goal setting, structured routines, emotion recognition flashcards, character models demonstrating emotion regulation strategies, verbal persuasion, and self-monitoring tools to support habit formation and emotion regulation. An implementation plan was developed to facilitate the app's adoption, execution, and maintenance, while an evaluation plan was established, including app usage analytics, user logs, and feedback surveys. A randomized controlled trial will be conducted to assess the app's impact on mental health outcomes, focusing on reducing anxiety and depressive symptoms, improving emotion regulation, and enhancing daily living skills.

CONCLUSIONS

The IM framework was beneficial in developing a mobile app to enhance the mental health of youth in out-of-home care. The study produced a program grounded in theory and evidence that caters to the needs of these individuals. Further research should aim to verify the app's effectiveness in real-world settings and refine it continuously based on user input.

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.

Using normalisation process theory (NPT) to explore implementation of the maternal perinatal death surveillance and response (MPDSR) policy in Uganda: a reflection

BACKGROUND

The implementation of the maternal perinatal death surveillance and response (MPDSR) policy is among the envisaged strategies to reduce the high global burden of maternal and perinatal mortality and morbidity. However, implementation of this policy across various contexts is inconsistent. Theoretically informed approaches to process evaluation can support assessment the implementation of policy interventions such as MPDSR, particularly in understanding what the actors involved actually do. In this article, we reflect on how the normalisation process theory (NPT) was used to explore implementation of the MPDSR policy in Uganda. NPT is a sociological theory concerned with the social organisation of the work (implementation) of making practices routine elements of everyday life (embedding) and of sustaining embedded practices in their social contexts (integration).

METHODS

This qualitative multiple case study conducted across eight districts in Uganda and among 10 health facilities (cases) representing four out of the seven levels of the Uganda health care system. NPT was utilised in several ways including informing the study design, structuring the data collection tools (semi-structured interview guides), providing an organising framework for analysis, interpreting and reporting of study findings as well as making recommendations. Study participants were purposely selected to reflect the range of actors involved in the policy implementation process. This included direct care providers located at each of the cases, the Ministry of Health and from agencies and professional associations. Data were collected using semi-structured, in-depth interviews and were inductively and deductively analysed using NPT constructs and subconstructs.

RESULTS AND CONCLUSION

NPT served useful for process evaluation, particularly in identifying factors that contribute to variations in policy implementation. Considering the NPT focus on the agency of people involved in implementation, additional efforts are required to understand how recipients of the policy intervention influence how the intervention becomes embedded within the various contexts.

A person-centred primary care pharmacist-led osteoporosis review for optimising medicines (PHORM): a protocol for the development and co-design of a model consultation intervention

INTRODUCTION

Adherence to medicines in osteoporosis is poor, with estimated 1 year persistence rates between 16% and 60%. Poor adherence is complex, relating to combinations of fear of side effects, beliefs about medication being unnecessary, doubts about effectiveness and the burden of medication management. This is compounded by an absence of monitoring, as many patients are effectively discharged from ongoing care following the initial prescription. Clinical pharmacists in general practice are a relatively new workforce in the UK NHS; this is an unexplored professional group that could provide person-centred, adherence-focused interventions in an osteoporosis context.A model consultation intervention to be delivered by clinical pharmacists in general practice for patients already prescribed fracture prevention medications will be developed using existing evidence and theory and empirical qualitative work outlined in this protocol.

METHODS AND ANALYSIS

We will investigate the current practice and barriers and facilitators to a clinical pharmacist-led osteoporosis intervention, including exploring training needs, through focus groups with people living with osteoporosis, pharmacists, general practitioners, osteoporosis specialists and service designers/commissioners. Framework analysis will identify and prioritise salient themes, followed by mapping codes to the theoretical domains framework and normalisation process theory to understand integration and implementation issues.We will further develop the content and model of care for the new consultation intervention through co-design workshops with stakeholder and patient and public involvement and engagement group members. The intervention in practice will be refined in a sequential process with workshops and in-practice testing with people prescribed fracture prevention medication, pharmacists and the multidisciplinary team.

ETHICS AND DISSEMINATION

Ethical approval was obtained from NHS North West-Greater Manchester South Research Ethics Committee (Ref 23/NW/0199). Dissemination and knowledge mobilisation will be facilitated through a range of national bodies/stakeholders. Impact and implementation plans will accelerate this research towards a future clinical trial to determine cost and clinical effectiveness.

A self-efficacy enhancement alcohol reduction intervention for men on-remand in prison: the APPRAISE feasibility pilot RCT

Background

As many as 70% of remand prisoners have admitted to being under the influence of alcohol when committing the crime leading to their imprisonment. Providing support and advice regarding alcohol consumption can be effective in some groups of people. There is little evidence regarding this for men on remand in prison.

Objective

To pilot the study measures and evaluation methods to assess the feasibility of conducting a future definitive multicentre, pragmatic, parallel group, randomised controlled trial.

Design

A two-arm, parallel group, individually randomised pilot study of a self-efficacy-enhancing psychosocial alcohol intervention to reduce levels of alcohol consumption for males on remand in prison and on liberation.

Setting

Two purposively selected prisons in Scotland and England.

Participants

Adult men on remand in prison with an Alcohol Use Disorders Identification Test score of ≥ 8.

Intervention

The APPRAISE intervention delivery comprised four steps: Step 1: 1 × 40-minute face-to-face session, delivered by a trained practitioner from Change Grow Live in prison. Steps 2, 3 and 4: 20-minute sessions conducted by phone, on or as close as possible to days 3, 7 and 21 post liberation. Control: assessment, screening and referral onto further alcohol support options.

Main outcome measures

Recruitment and retention rates, completion of follow-ups, outcome measures at 12 months and interventions delivered. The primary outcome for the pilot study was alcohol consumed in the 28 days prior to Time Point 2, assessed using the extended Alcohol Use Disorders Identification Test-C.

Results

Of 182 men on remand approached across two study sites, 132 were randomised (90 in England; 42 in Scotland) with 46 randomised to intervention and 44 to care as usual in England and 22 randomised to intervention and 20 to care as usual in Scotland. A total of 53 in-prison interventions were delivered. One day-3 post-liberation intervention was delivered, no day-7 and one day-21. At 12 months, of 132 randomised, 18 (13%) were followed up, 53 (40%) were not liberated; 47 (36%) were uncontactable and 14 (11%) had been released but could not be located. Data completeness was 96% at baseline and 8% at 12 months. The process evaluation reported good acceptability of the intervention with investment in time, capacity and space to support implementation identified. The economic study produced guidance on how to assess costs associated with implementing the APPRAISE intervention which could be applied more broadly.

Harms

No adverse events or side effects were noted.

Conclusions

A future definitive trial would be possible, but only if follow-up mechanisms can be addressed as well as full access to recidivism and health data. Collaboration with the probation service in future could offer the opportunity to develop a robust process and system to optimise follow-up post liberation. Dedicated resources to support the intervention delivery both in and out of the prison setting are recommended.

Limitations

Coronavirus disease discovered in 2019 impacted recruitment and follow-up, with access to prisons restricted. We were unable to deliver the post-liberation element of the intervention. We did not include probation services or other agencies in the trial.

Trial registration

This trial is registered as Current Controlled Trials ISRCTN36066.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 17/44/11) and is published in full in Public Health Research; Vol. 12, No. 11. See the NIHR Funding and Awards website for further award information.

Exploration of patients' and healthcare professionals' perspectives on kidney failure risk and the use of the kidney failure risk equation in MULTIPle lOng-term condItions aNd frailTy (MULTIPOINT) study: a qualitative interview and focus group study protocol

INTRODUCTION

Clinical guidelines recommend the use of the kidney failure risk equation (KFRE) to guide the referral of individuals with chronic kidney disease (CKD) to secondary kidney care services. People living with CKD frequently experience multiple long-term conditions (multimorbidity) and/or frailty. This may impact patients' or carers' perceptions of kidney failure in the context of other health problems and associated risks and emphasises the need for shared decision-making. This paper presents the research protocol for the exploration of patients' and healthcare professionals' perspectives on kidney failure risk and the use of the KFRE in the MULTIPle lOng-term condItions aNd frailTy study. This study aims to investigate patient and healthcare professionals' perspectives and expectations of the use of KFRE in individuals with CKD and multimorbidity and/or frailty, with a focus on shared decision-making.

METHODS AND ANALYSIS

Analysis of semistructured interviews with adults who have CKD and multimorbidity and/or frailty and focus groups with healthcare professionals (who are involved in caring for patients with CKD). Framework analysis, underpinned by normalisation process theory, will be used to develop codes and explore themes from the interviews and focus groups. Patient and public involvement has been pivotal to the study conceptualisation and will continue to be embedded throughout the study.

ETHICS AND DISSEMINATION

The study protocol has undergone peer review by the NHS Greater Glasgow and Clyde Research and Innovation team and has been granted ethical approval in August 2023 by the NHS Health Research Authority following a favourable opinion from the West of Scotland Research Ethics Committee (REC) 3 (IRAS ID: 325848, REC reference: 23WS/0119, Protocol number GN22RE559).The results of the research will be disseminated through peer-reviewed publications and conferences, as well as to patient and public involvement groups who have been involved in the study and through knowledge exchange events.

Protocol for an implementation study of group metacognitive therapy for anxiety and depression in NHS cardiac rehabilitation services in England (PATHWAY-Beacons)

Background

Cardiac rehabilitation (CR) services aim to improve heart disease patients' health and quality of life and reduce the risk of further cardiac events. Depression and anxiety are common among CR patients but psychological treatments have usually had small effects. In contrast, the recent NIHR-funded PATHWAY trial found that group Metacognitive Therapy (MCT) was associated with improvements in anxiety and depression when added to CR and was more effective than usual CR alone. The next stage is to test implementation of MCT within the National Health Service through the creation of a network of CR beacon sites. The study will test the quality of data capture following addition of a new MCT data-field to the national audit of cardiac rehabilitation (NACR), examine level of adoption at sites, examine mental health outcomes benchmarked against usual CR and the PATHWAY data, examine the enablers and barriers to implementation and the expected resource requirements. The study has been registered: NCT05956912 (13th July, 2023).

Methods

Beacon sites will be recruited as preliminary adopters of group MCT from NHS CR services in England. A national invitation for expressions of interest from CR services will be issued and those meeting eligibility criteria will be considered for inclusion. Two staff at each site will receive training in MCT, and mixed-methods will be used to address questions concerning the quality of patient data recorded, level of adoption at sites, the characteristics of patients attending MCT, the impact of adding MCT to CR on mental health outcomes, and patient, healthcare staff and commissioner views of barriers/enablers to implementation. Exploration of implementation will be informed by Normalisation Process Theory.

Discussion

The study will support development of an NHS roll-out strategy, assess the mental health outcomes associated with MCT, examine treatment fidelity in real-world settings, and evaluate revised data collection structures that can be used to assess the impact of national-level implementation.

Trial Registration

NCT05956912; 13th July 2023.

An Organizational Case Study of Mental Models among Health System Leaders during Early-Stage Implementation of a Population Health Approach

Purpose

As the COVID-19 pandemic recedes, the importance of population health has come into sharp focus, prompting many health systems to explore leveraging population health data (PHD) for operational planning. This approach requires that healthcare leaders embrace the dual priorities of maintaining excellence in patient care while promoting the overall health of populations. However, many leaders are new to population-based thinking, posing a threat to successful operationalization if mental models are not aligned.

Patients and Methods

This qualitative case study explored the alignment of mental models among 13 senior leaders at Trillium Health Partners (THP), one of Canada's largest community hospitals, as they embark on embedding PHD within operational workflows.

Results

All leaders recognized the necessity of adopting a population health approach amid resource constraints and growing pressures. When discussing the operationalization of PHD, two distinct mental models emerged among leaders: one focused on patient care and the other on population health. While executive leaders demonstrated a fluidity in their thinking between the two, programmatic leaders favoured one over the other. For example, some viewed the organization's focus on PHD as competing with their patient care responsibilities, while others saw the use of PHD as a solution to the organization's operational pressures. Despite these divergences, leaders unanimously stressed the importance of increasing the organization's risk tolerance and devolving decision-making as a necessary precursor to realizing the transformation to a PHD-driven approach.

Conclusion

These divergent mental models highlight a need to clarify the shared vision for the use of PHD along with its impact on leadership roles and accountabilities. These findings illustrate the current state from which THP aims to evolve and underscore the importance of aligning leaders' mental models as a critical step to facilitating successful integration of PHD and advancing a collective vision for healthcare transformation.

Assessing the sensitivity and acceptability of the Royal Marsden Palliative Care Referral "Triggers" Tool for outpatients with cancer

PURPOSE

To evaluate the use, acceptability, and experience of a seven-item palliative care referral screening tool in an outpatient oncology setting.

METHODS

A two-phase convergent parallel mixed-methods study. Patient participants who met any of the "Royal Marsden Triggers Tool" criteria were compared with those who did not in terms of demographic data, palliative care needs (Integrated Palliative Outcome Scale, IPOS) and quality of life indicators (EORTC-QLQ-C30). In-depth interviews were carried out with patients and oncology staff about their views and experience of the "Royal Marsden Triggers Tool". Qualitative and quantitative data were triangulated at data interpretation.

RESULTS

Three hundred forty-eight patients were recruited to the quantitative phase of the study of whom 53% met at least one of the Triggers tool palliative care referral criteria. When compared with patients who were negative using the Triggers tool, "Royal Marsden Triggers Tool" positive patients had a lower quality of life (EORTC QLQ-C30 Global Health Status scale (p < 0.01)) and a higher proportion had severe or overwhelming physical needs on IPOS (38% versus 20%, p < 0.001). Median survival of "Royal Marsden Triggers Tool" positive patients was 11.7 months. Sixteen staff and 19 patients participated in qualitative interviews. The use of the tool normalised palliative care involvement, supporting individualised care and access to appropriate expertise.

CONCLUSION

The use of a palliative care referral tool streamlines palliative care within oncology outpatient services and supports teams working together to provide an early holistic patient-centred service. Further research is needed to evaluate the effectiveness and feasibility of this approach.

Enhancing the implementation and integration of mHealth interventions in resource-limited settings: a scoping review

BACKGROUND

Although mobile health (mHealth) interventions have shown promise in improving health outcomes, most of them rarely translate to scale. Prevailing mHealth studies are largely small-sized, short-term and donor-funded pilot studies with limited evidence on their effectiveness. To facilitate scale-up, several frameworks have been proposed to enhance the generic implementation of health interventions. However, there is a lack of a specific focus on the implementation and integration of mHealth interventions in routine care in low-resource settings. Our scoping review aimed to synthesize and develop a framework that could guide the implementation and integration of mHealth interventions.

METHODS

We searched the PubMed, Google Scholar, and ScienceDirect databases for published theories, models, and frameworks related to the implementation and integration of clinical interventions from 1st January 2000 to 31st December 2023. The data processing was guided by a scoping review methodology proposed by Arksey and O'Malley. Studies were included if they were i) peer-reviewed and published between 2000 and 2023, ii) explicitly described a framework for clinical intervention implementation and integration, or iii) available in full text and published in English. We integrated different domains and constructs from the reviewed frameworks to develop a new framework for implementing and integrating mHealth interventions.

RESULTS

We identified eight eligible papers with eight frameworks composed of 102 implementation domains. None of the identified frameworks were specific to the integration of mHealth interventions in low-resource settings. Two constructs (skill impartation and intervention awareness) related to the training domain, four constructs (technical and logistical support, identifying committed staff, supervision, and redesigning) from the restructuring domain, two constructs (monetary incentives and nonmonetary incentives) from the incentivize domain, two constructs (organizational mandates and government mandates) from the mandate domain and two constructs (collaboration and routine workflows) from the integrate domain. Therefore, a new framework that outlines five main domains-train, restructure, incentivize, mandate, and integrate (TRIMI)-in relation to the integration and implementation of mHealth interventions in low-resource settings emerged.

CONCLUSION

The TRIMI framework presents a realistic and realizable solution for the implementation and integration deficits of mHealth interventions in low-resource settings.

Implementation of the four habits model in intermediate care services in Norway: a process evaluation

BACKGROUND

Intermediate care (IC) services bridge the transition for older patients from the hospital to the home. Despite the goal of involving individuals in their recovery process, these services often become standardised, leading to communication breakdowns. While evidence-based practices, such as the Four Habits Model (4HM), for effective communication are crucial for enhancing high-quality healthcare, research suggests their integration into routine practice remains limited. In this study, we aimed to investigate the implementation process of the 4HM through a two-day course that engaged healthcare professionals and managers in IC.

METHODS

We conducted a process evaluation employing qualitative and quantitative methods: (i) individual interviews with three managers and two course participants pre-course, (ii) two focus group interviews with course participants (N = 11) and individual interviews with the same three managers post-course, and (iii) the NoMAD questionnaire (Normalisation MeAsure Development) administered four months later to assess the short- and long-term impact on course participants (N = 14). Reflexive thematic analyses were guided by Normalisation Process Theory (NPT), which offers insight into how new interventions become routine practices. The analysis of the NoMAD involved descriptive statistics.

RESULTS

We identified four themes in the qualitative data: (i) Decoding Interactions: Making Sense of the 4HM in IC services, (ii) Fostering Change: Legitimising 4HM Through Staff Engagement, (iii) Harmonising Practice: Integrating 4HM into Complex Situations, and (iv) Embedding Value: Normalising the 4HM into Everyday Work. These themes illustrate the normalisation process of the 4HM course within IC, establishing standard practices. Healthcare professionals and managers highlighted the urgent need to integrate communication skills based on the 4HM into daily care. They noted positive changes in their communication habits following the course. The consistent findings from the NoMAD questionnaire underscore the sustainability of implementing the 4HM programme, as participants continue to utilise it in their clinical practice beyond the initial four-month period.

CONCLUSION

The 4HM course programme was deemed feasible for expansion within IC services. Both managers and staff found its focus on addressing communication breakdowns and readiness for change sensible. The study findings may benefit the stakeholders involved in IC service routines, potentially improving services for older patients and relatives.

The effect of two speech and language approaches on speech problems in people with Parkinson's disease: the PD COMM RCT

Background

Speech impairments are common with Parkinson's disease (reported prevalence 68%), increasing conversational demands, reliance on family and social withdrawal.

Objective(s)

The PD COMM trial compared the clinical and cost-effectiveness of two speech and language therapy approaches: Lee Silverman Voice Treatment LOUD and National Health Service speech and language therapy for the treatment of speech or voice problems in people with Parkinson's disease to no speech and language therapy (control) and against each other.

Design

PD COMM is a phase III, multicentre, three-arm, unblinded, randomised controlled trial. Participants were randomised in a 1 : 1 : 1 ratio to control, National Health Service speech and language therapy or Lee Silverman Voice Treatment LOUD via a central computer-generated programme, using a minimisation procedure with a random element, to ensure allocation concealment. Mixed-methods process and health economic evaluations were conducted.

Setting

United Kingdom outpatient and home settings.

Participants

People with idiopathic Parkinson's disease, with self-reported or carer-reported speech or voice problems. We excluded people with dementia, laryngeal pathology and those within 24 months of previous speech and language therapy.

Interventions

The Lee Silverman Voice Treatment LOUD intervention included maximum effort drills and high-effort speech production tasks delivered over four 50-minute therapist-led personalised sessions per week, for 4 weeks with prescribed daily home practice. National Health Service speech and language therapy content and dosage reflected local non-Lee Silverman Voice Treatment speech and language therapy practices, usually 1 hour, once weekly, for 6 weeks. Trained, experienced speech and language therapists or assistants provided interventions. The control was no speech and language therapy until the trial was completed.

Main outcome measures

Primary outcome: Voice Handicap Index total score at 3 months. Secondary outcomes: Voice Handicap Index subscales, Parkinson's Disease Questionnaire-39; Questionnaire on Acquired Speech Disorders; EuroQol-5D-5L; ICEpop Capabilities Measure for Older Adults; Parkinson's Disease Questionnaire - Carers; resource utilisation; and adverse events. Assessments were completed pre-randomisation and at 3, 6 and 12 months post randomisation.

Results

Three hundred and eighty-eight participants were randomised to Lee Silverman Voice Treatment LOUD (n = 130), National Health Service speech and language therapy (n = 129) and control (n = 129). The impact of voice problems at 3 months after randomisation was lower for Lee Silverman Voice Treatment LOUD participants than control [-8.0 (99% confidence interval: -13.3, -2.6); p = 0.001]. There was no evidence of improvement for those with access to National Health Service speech and language therapy when compared to control [1.7 (99% confidence interval: -3.8, 7.1); p = 0.4]. Participants randomised to Lee Silverman Voice Treatment LOUD reported a lower impact of their voice problems than participants randomised to National Health Service speech and language therapy [99% confidence interval: -9.6 (-14.9, -4.4); p < 0.0001]. There were no reports of serious adverse events. Staff were confident with the trial interventions; a range of patient and therapist enablers of implementing Lee Silverman Voice Treatment LOUD were identified. The economic evaluation results suggested Lee Silverman Voice Treatment LOUD was more expensive and more effective than control or National Health Service speech and language therapy but was not cost-effective with incremental cost-effectiveness ratios of £197,772 per quality-adjusted life-year gained and £77,017 per quality-adjusted life-year gained, respectively.

Limitations

The number of participants recruited to the trial did not meet the pre-specified power.

Conclusions

People that had access to Lee Silverman Voice Treatment LOUD described a significantly greater reduction in the impact of their Parkinson's disease-related speech problems 3 months after randomisation compared to people that had no speech and language therapy. There was no evidence of a difference between National Health Service speech and language therapy and those that received no speech and language therapy. Lee Silverman Voice Treatment LOUD resulted in a significantly lower impact of voice problems compared to National Health Service speech and language therapy 3 months after randomisation which was still present after 12 months; however, Lee Silverman Voice Treatment LOUD was not found to be cost-effective.

Future work

Implementing Lee Silverman Voice Treatment LOUD in the National Health Service and identifying alternatives to Lee Silverman Voice Treatment LOUD for those who cannot tolerate it. Investigation of less costly alternative options for Lee Silverman Voice Treatment delivery require investigation, with economic evaluation using a preference-based outcome measure that captures improvement in communication.

Study registration

This study is registered as ISRCTN12421382.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 10/135/02) and is published in full in Health Technology Assessment; Vol. 28, No. 58. See the NIHR Funding and Awards website for further award information.