Methodological approaches to study context in intervention implementation studies: an evidence gap map

Modifiable determinants of older adults' physical activity and sedentary behavior in community and healthcare settings: a DE-PASS systematic review and meta-analysis

OBJECTIVES

To identify the modifiable determinants targeted in interventions involving older adults, and to determine which of these interventions effectively increased physical activity (PA) and/or reduced sedentary behaviour (SB). Additionally, to explore whether the effects of these interventions vary based on the implementation setting.

METHODS

A search of randomized controlled trials (RCTs) and controlled trials (CTs) was performed in Medline, APA PsycArticles, SPORTDiscus, and Web of Science. Risk of bias assessment was performed with Cochrane's tool. Modifiable determinants were narratively synthesized, and random-effects models were performed to meta-analyse studies reporting device-measured physical activity or sedentary behaviour. Moderator analyses were performed to investigate the role of implementation setting. Standardized between-group mean difference (SMD) with 95% confidence interval (CI) was used to indicate effect sizes.

RESULTS

From 31,727 individual records, 52 eligible studies published between 2012-2022 were identified, 30 and 22 studies from community and health care settings, respectively. Determinants within the category physical health and wellbeing (n = 23) were most frequently reported while only one study reported determinants within a social or cultural context. Eighteen studies were included in the meta-analysis. Interventions targeting physical health and wellbeing revealed an increase in steps (SMD = 0.46; 95%CI: 0.15 to 0.77) and minutes of moderate-to-vigorous intensity physical activity (SMD = 0.41; 95%CI: 0.19 to 0.64) among intervention participants compared to controls, whereas interventions targeting psychological or behavioural determinants showed no between-group differences in steps (SMD = 0.10; 95%CI: -0.12 to 0.32) and moderate-to-vigorous intensity physical activity (SMD = 0.26; 95%CI: -0.24 to -0.75). Interventions targeting physical health and wellbeing showed significant heterogeneity (p < 0.0001; I2 = 73.10%). Subgroup analyses showed a significant effect on device-measured physical activity for the eight community-based interventions (SMD = 0.42; 95%CI: 0.07 to 0.77), while no significant effect was found for the eight studies performed in healthcare settings (SMD = 0.26; 95%CI; -0.10 to 0.62).

CONCLUSION

Interventions targeting physical health and wellbeing may increase PA in older adults, with community-based studies appearing more effective than studies in healthcare settings. The significant heterogeneity of study findings indicates that further research is needed to fully understand the influence of PA and SB determinants across settings, particularly those related to psychological, behavioural, social, and cultural factors.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42022287606.

The social experience of uncertainty: a qualitative analysis of emergency department care for suspected pneumonia for the design of decision support

BACKGROUND

This study sought to understand the process of clinical decision-making for suspected pneumonia by emergency departments (ED) providers in Veterans Affairs (VA) Medical Centers. The long-term goal of this work is to create clinical decision support tools to reduce unwarranted variation in diagnosis and treatment of suspected pneumonia.

METHODS

Semi-structured qualitative interviews were conducted with 16 ED clinicians from 9 VA facilities demonstrating variation in antibiotic and hospitalization decisions. Interviews of ED providers focused on understanding decision making for provider-selected pneumonia cases and providers' organizational contexts.

RESULTS

Thematic analysis identified four salient themes: i) ED decision-making for suspected pneumonia is a social process; ii) the "diagnosis drives treatment" paradigm is poorly suited to pneumonia decision-making in the ED; iii) The unpredictability of the ED requires deliberate and effortful information management by providers in CAP decision-making; and iv) the emotional stakes and high uncertainty of pneumonia care drive conservative decision making.

CONCLUSIONS

Ensuring CDS reflects the realities of clinical work as a socially organized process with high uncertainty may ultimately improve communication between ED and admitting providers, continuity of care and patient outcomes.

Facilitating person-centered patient participation in kidney care-a process evaluation of a quasi-experimental study incorporating a tool and training of local implementation teams

BACKGROUND

The transfer of innovations into healthcare is laden with challenges. Although healthcare professionals are expected to adopt and fulfil new policies, a more person-centered healthcare with conditions for preference-based patient participation is anticipated.

METHODS

The aim of the study was to evaluate two implementation strategies for person-centered patient participation in kidney care, including dissemination of a clinical toolkit, and additional training and support of internal facilitators. Nine Swedish kidney care units joined the study (August 2019-September 2021), strategically organized into: a control group (three sites, no support); a standard dissemination group (three sites, with a tool for patient participation and guidance disseminated to the site managers); and a facilitated implementation group (three sites, with the tool and guidance disseminated as above, plus a six-month support program for designated internal facilitators). This process evaluation was comprised of repeat interviews with managers (n = 10), internal facilitators (n = 5), recordings, and notes from the interventions, and Alberta Context Tool survey data (n = 78). Hybrid analyses comprised mixed methods: descriptive and comparative statistics, and qualitative descriptive analysis.

RESULTS

None of the control group sites addressed patient participation. While the standard dissemination sites' managers received and appreciated the toolkit, they made no attempts to make further use of it. In the facilitated implementation group, five internal facilitators from three sites engaged in the support program. They welcomed the opportunity to learn about preference-based patient participation, and about implementation, including potentially enhanced opportunities for preference-based patient participation via the tool. Each site's facilitators developed a separate strategy for the dissemination of the tool: the tool was used with a few patients in each site, and only some staff were involved. Although noting a general interest in improving patient participation, the internal facilitators described limited local support. Rather, they suggested a longer support program and more local backing and engagement.

CONCLUSIONS

Facilitating person-centered patient participation is complex, given the need to address attitudes, beliefs, and behaviors. This study indicates slow uptake and change, and more efficient strategies are needed to ensure the fundamentals of care remain accessible to all.

Solving the "last mile" problem in overdose prevention: Lessons from the HEALing Communities Study

The concept of the "last mile," crucial in logistics for its complexity and cost, has a parallel in public health services. The last mile in public health is fraught with issues such as fragmented services, regulatory barriers, and resistance to evidence-based interventions. This commentary draws parallels between the challenges in delivering goods to consumers' doorsteps and the difficulties in delivering interventions to reduce overdoses in the community. The HEALing Communities Study (HCS), a large implementation science research study, provides an example of how to navigate some of these last-mile challenges. HCS used a community-driven process that considered local characteristics and preferences, and engaged people with lived experience to create effective and sustainable solutions. However, the study also encountered significant challenges in building a delivery infrastructure, working with delayed and incomplete data, and overcoming stigma around substance use interventions. Lessons from the logistics sector can help improve the efficiency and equity of overdose prevention efforts, ensuring that people receive the life-saving interventions they need.

Implementing group care in Dutch and Surinamese maternity and child care services: the vital importance of addressing outer context barriers

BACKGROUND

By addressing physical and psychosocial needs, group care (GC) improves health-related behaviours, peer support, parent-provider interactions and may improve birth outcomes. Hence, global implementation of GC is encouraged. Context analyses prior to implementation are vital to elucidate which local factors may support or hinder implementation.

METHODS

Contextual analyses conducted in the Netherlands and Suriname were compared to identify the factors relevant to the implementability of GC as perceived by healthcare professionals (HCPs). 32 semi-structured interviews were conducted with Dutch and Surinamese healthcare professionals. Audio recordings were transcribed verbatim and coded using the Framework approach. The Consolidated Framework for Implementation Research guided the development of the interview guide and of the coding tree.

RESULTS

Outer setting: Concerns regarding funding surfaced in both countries. Due to limited health insurance coverage, additional fees would limit accessibility in Suriname. In the Netherlands, midwives dreaded lower revenue due to reimbursement policies that favour one-on-one care. Inner setting: Appropriate space for GC was absent in one Dutch and three Surinamese facilities. Role division regarding GC implementation was clearer in the Netherlands than in Suriname.

INNOVATION

HCPs from both countries expected increased social support, health knowledge among women, and continuity of care(r). Individuals/innovation deliverers: Self-efficacy and motivation emerged as intertwined determinants to GC implementation in both countries. Individuals/innovation recipients: Competing demands can potentially lower acceptability of GC in both countries. While Dutch HCPs prioritised an open dialogue with mothers, Surinamese HCPs encouraged the inclusion of partners.

PROCESS

Campaigns to raise awareness of GC were proposed. Language barriers were a concern for Dutch but not for Surinamese HCPs.

CONCLUSIONS

While the most striking differences between both countries were found in the outer setting, they trickle down and affect all layers of context. Ultimately, at a later stage, the process evaluation will show if those outer setting barriers we identified prior to implementation actually hindered GC implementation. Changes to the health care systems would ensure sustained implementation in both countries, and this conclusion feeds into a more general discussion: how to proceed when contextual analyses reveal barriers that cannot be addressed with the time and resources available.

Multicomponent processes to identify and prioritise low-value care in hospital settings: a scoping review

OBJECTIVES

This scoping review mapped and synthesised original research that identified low-value care in hospital settings as part of multicomponent processes.

DESIGN

Scoping review.

DATA SOURCES

Electronic databases (EMBASE, PubMed, CINAHL, PsycINFO and Cochrane CENTRAL) and grey literature were last searched 11 July and 3 June 2022, respectively, with no language or date restrictions.

ELIGIBILITY CRITERIA

We included original research targeting the identification and prioritisation of low-value care as part of a multicomponent process in hospital settings.

DATA EXTRACTION AND SYNTHESIS

Screening was conducted in duplicate. Data were extracted by one of six authors and checked by another author. A framework synthesis was conducted using seven areas of focus for the review and an overuse framework.

RESULTS

Twenty-seven records were included (21 original studies, 4 abstracts and 2 reviews), originating from high-income countries. Benefit or value (11 records), risk or harm (10 records) were common concepts referred to in records that explicitly defined low-value care (25 records). Evidence of contextualisation including barriers and enablers of low-value care identification processes were identified (25 records). Common components of these processes included initial consensus, consultation, ranking exercise or list development (16 records), and reviews of evidence (16 records). Two records involved engagement of patients and three evaluated the outcomes of multicomponent processes. Five records referenced a theory, model or framework.

CONCLUSIONS

Gaps identified included applying systematic efforts to contextualise the identification of low-value care, involving people with lived experience of hospital care and initiatives in resource poor contexts. Insights were obtained regarding the theories, models and frameworks used to guide initiatives and ways in which the concept 'low-value care' had been used and reported. A priority for further research is evaluating the effect of initiatives that identify low-value care using contextualisation as part of multicomponent processes.

Long-Acting Injectable Antiretrovirals for HIV Treatment: A Multi-Site Qualitative Study of Clinic-Level Barriers to Implementation in the United States

Long-acting injectable antiretroviral therapy (LAI ART) has the potential to address adherence obstacles associated with daily oral ART, leading to enhanced treatment uptake, adherence, and viral suppression among people living with HIV (PLWH). Yet, its potential may be limited due to ongoing disparities in availability and accessibility. We need a better understanding of the organizational context surrounding the implementation of LAI ART, and to inform its widespread rollout, we conducted 38 in-depth interviews with medical and social service providers who offer HIV care at private and hospital-based clinics across six US cities. Our findings highlight real-world implementation barriers outside of clinical trial settings. Providers described ongoing and anticipated barriers across three stages of LAI ART implementation: (1) Patient enrollment (challenges registering patients and limited insurance coverage), (2) medication delivery (insufficient personnel and resources), and (3) leadership and management (lack of interprofessional coordination and a lack of programming guidelines). Providers described how these barriers would have a disproportionate impact on under-resourced clinics, potentially exacerbating existing disparities in LAI ART access and adherence. Our findings suggest strategies that clinic leadership, policymakers, and other stakeholders can pursue to promote rapid and equitable LAI ART implementation in clinics across the United States. Resource and staffing investments could support clinics to begin, sustain, and scale up LAI ART delivery; additionally, the establishment of guidelines and tools could facilitate wider adoption of LAI ART across clinical settings. These efforts are crucial to promote resourced, standardized, and equitable implementation of LAI ART and maximize its potential to help end the HIV epidemic.

Improving the inclusion of an under-served group in trials: development and implementation of the INCLUDE Impaired Capacity to Consent Framework

BACKGROUND

For the potential benefits of trials to reach all that they should, trials must be designed to ensure that those taking part reflect the population who will receive the intervention. However, adults with impaired capacity to consent are frequently excluded from trials - partly because researchers are unfamiliar with the legal and ethical frameworks and lack the necessary methodological expertise. Researchers identified a need for guidance on designing more inclusive trials. Building on the NIHR INCLUDE initiative, we developed the INCLUDE Impaired Capacity to Consent Framework to help researchers design inclusive trials.

METHODS

The framework was developed over five phases: (1) establishing the scope and content of the framework and adapting the INCLUDE Ethnicity Framework for this population; (2) scoping the relevance of the framework to different populations and piloting in a range of trials; (3) consulting people living with impairing conditions and carers to explore their views about the framework and identify missing content areas; (4) refining the framework; and (5) the development of an implementation toolkit of resources to support researchers using the framework.

RESULTS

The framework has two parts: a set of four key questions to help researchers identify who should be included in their trial, and a series of worksheets covering intervention design, recruitment and consent processes, data collection and analysis, and public involvement and dissemination. It is supported by a summary of the ethical and legal frameworks and a website of resources on capacity and consent. Implementation resources include infographics and animations, a library of completed frameworks, and facilitated workshops for researchers. The framework and toolkit were launched at a webinar (November 2022), with polling demonstrating an increase in attendees' awareness about research involving adults lacking capacity. A post-webinar survey found that stakeholders viewed the framework and toolkit as valuable tools to facilitate greater inclusion of this under-served population in trials. The framework is available online: https://www.capacityconsentresearch.com/include-impaired-capacity-to-consent-framework.html .

CONCLUSIONS

The INCLUDE Impaired Capacity to Consent Framework and implementation toolkit can support researchers to design more inclusive trials and other types of research studies. Further engagement, including with funders who are key to ensuring uptake, and evaluation is needed.

Tailored implementation of the FICUS multicomponent family support intervention in adult intensive care units: findings from a mixed methods contextual analysis

BACKGROUND

The Family in Intensive Care UnitS (FICUS) trial investigates the clinical effectiveness of a multicomponent, nurse-led interprofessional family support intervention (FSI) and explores its implementation in intensive care units (ICUs). The local context of each ICU strongly influences intervention performance in practice. To promote FSI uptake and to reduce variation in intervention delivery, we aimed to develop tailored implementation strategies.

METHODS

A mixed method contextual analysis guided by the Consolidated Framework for Implementation Research (CFIR) was performed from March to June 2022 on eight ICUs assigned to the intervention group. ICU key clinical partners were asked to complete a questionnaire on CFIR inner setting measures (i.e., organizational culture, resources, learning climate and leadership engagement) and the Organizational Readiness for Implementing Change (ORIC) scale prior to group interviews, which were held to discuss barriers and facilitators to FSI implementation. Descriptive analysis and pragmatic rapid thematic analysis were used. Then, tailored implementation strategies were developed for each ICU.

RESULTS

In total, 33 key clinical partners returned the questionnaire and 40 attended eight group interviews. Results showed a supportive environment, with CFIR inner setting and ORIC measures each rated above 3 (scale: 1 low-5 high value), with leadership engagement scoring highest (median 4.00, IQR 0.38). Interview data showed that the ICU teams were highly motivated and committed to implementing the FSI. They reported limited resources, new interprofessional information exchange, and role adoption of nurses as challenging.

CONCLUSION

We found that important pre-conditions for FSI implementation, such as leadership support, a supportive team culture, and a good learning climate were present. Some aspects, such as available resources, interprofessional collaboration and family nurses' role adoption were of concern and needed attention. An initial set of implementation strategies were relevant to all ICUs, but some additions and adaptation to local needs were required. Multi-component interventions are challenging to implement within complex systems, such as ICUs. This pragmatic, theory-guided, mixed methods contextual analysis demonstrated high readiness and commitment to FSI implementation in the context of a clinical trial and enabled the specification of a tailored, multifaceted implementation strategy.

Anticipated benefits and challenges of implementing group care in Suriname's maternity and child care sector: a contextual analysis

BACKGROUND

Suriname is a uppermiddle-income country with a relatively high prevalence of preventable pregnancy complications. Access to and usage of high-quality maternity care services are lacking. The implementation of group care (GC) may yield maternal and child health improvements. However, before introducing a complex intervention it is pivotal to develop an understanding of the local context to inform the implementation process.

METHODS

A context analysis was conducted to identify local needs toward maternity and postnatal care services, and to assess contextual factor relevant to implementability of GC. During a Rapid Qualitative Inquiry, 63 online and face-to-face semi-structured interviews were held with parents, community members, on-and off-site healthcare professionals, policy makers, and one focus group with parents was conducted. Audio recordings were transcribed in verbatim and analysed using thematic analysis and Framework Method. The Consolidated Framework for Implementation Research served as a base for the coding tree, which was complemented with inductively derived codes.

RESULTS

Ten themes related to implementability, one theme related to sustainability, and seven themes related to reaching and participation of the target population in GC were identified. Factors related to health care professionals (e.g., workload, compatibility, ownership, role clarity), to GC, to recipients and to planning impact the implementability of GC, while sustainability is in particular hampered by sparse financial and human resources. Reach affects both implementability and sustainability. Yet, outer setting and attitudinal barriers of health professionals will likely affect reach.

CONCLUSIONS

Multi-layered contextual factors impact not only implementability and sustainability of GC, but also reach of parents. We advise future researchers and implementors of GC to investigate not only determinants for implementability and sustainability, but also those factors that may hamper, or facilitate up-take. Practical, attitudinal and cultural barriers to GC participation need to be examined. Themes identified in this study will inspire the development of adaptations and implementation strategies at a later stage.