Being pragmatic about healthcare complexity: our experiences applying complexity theory and pragmatism to health services research

Application of behavioural theories, models, and frameworks in pharmacy practice research based on published evidence: a scoping review

BACKGROUND

Pharmacy practice research often focuses on the design, implementation and evaluation of pharmacy services and interventions. The use of behavioural theory in intervention research allows understanding of interventions' mechanisms of action and are more likely to result in effective and sustained interventions.

AIM

To collate, summarise and categorise the reported behavioural frameworks, models and theories used in pharmacy practice research.

METHOD

PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science and EBSCO (CINAHL PLUS, British Education index, ERIC) were systematically searched to capture all pharmacy practice articles that had reported the use of behavioural frameworks, theories, or models since inception of the database. Results were filtered to include articles published in English in pharmacy practice journals. Full-text screening and data extraction were independently performed by two reviewers. A narrative synthesis of the data was adopted. Studies were reviewed for alignment to the UK Medical Research Council (MRC) framework to identify in which phase(s) of the research that the theory/model/framework had been employed.

RESULTS

Fifty articles met the inclusion criteria; a trend indicating an increasing frequency of behavioural theory/frameworks/models within pharmacy practice research was identified; the most frequently reported were Theory of Planned Behaviour and Theoretical Domains Framework. Few studies provided explicit and comprehensive justification for adopting a specific theory/model/framework and description of how it underpinned the research was lacking. The majority were investigations exploring determinants of behaviours, or facilitators and barriers to implementing or delivering a wide range of pharmacy services and initiatives within a variety of clinical settings (aligned to Phase 1 UK MRC framework).

CONCLUSION

This review serves as a useful resource for future researchers to inform their investigations. Greater emphasis to adopt a systematic approach in the reporting of the use of behavioural theories/models/frameworks will benefit pharmacy practice research and will support researchers in utilizing behavioural theories/models/framework in aspects of pharmacy practice research beyond intervention development.

Preliminary adaptation of the systems thinking for everyday work cue card set in a US healthcare system: a pragmatic and participatory co-design approach

INTRODUCTION

Healthcare is a highly complex adaptive system, requiring a systems approach to understand its behaviour better. We adapt the Systems Thinking for Everyday Work (STEW) cue cards, initially introduced as a systems approach tool in the UK, in a US healthcare system as part of a study investigating the feasibility of a systems thinking approach for front-line workers.

METHODS

The original STEW cards were adapted using consensus-building methods with front-line staff and safety leaders.

RESULTS

Each card was examined for relevance, applicability, language and aesthetics (colour, style, visual cues and size). Two sets of cards were created due to the recognition that systems thinking was relatively new in healthcare and that the successful use of the principles on the cards would need initial facilitation to ensure their effective application. Six principles were agreed on and are presented in the cards: Your System outlines the need to agree that problems belong to a system and that the system must be defined. Viewpoints ensure that multiple voices are heard within the discussion. Work Condition highlights the resources, constraints and barriers that exist in the system and contribute to the system's functions. Interactions ask participants to understand how parts of the system interact to perform the work. Performance guides users to understand how work can be performed daily. Finally, Understanding seeks to promote a just cultural environment of appreciating that people do what makes sense to them. The two final sets of cards were scored using a content validity survey, with a final score of 1.

CONCLUSIONS

The cards provide an easy-to-use guide to help users understand the system being studied, learn from problems encountered and understand the everyday work involved in providing excellent care. The cards offer a practical 'systems approach' for use within complex healthcare systems.

A person-centred care transition support for people with stroke/TIA: A study protocol for effect and process evaluation using a non-randomised controlled design

INTRODUCTION

Care transitions following a stroke call for integrated care approaches to reduce death and disability. The proposed research described in this study protocol aims to evaluate the effectiveness of a person-centred multicomponent care transition support and the process in terms of contextual moderators, implementation aspects and mechanisms of impact.

METHODS

A non-randomized controlled trial design will be used. The intervention includes person-centred dialogue intended to permeate all patient-provider communication, various pedagogical modes of information, a person-centred care and rehabilitation plan, and a bridging e-meeting to prepare patients for homecoming. Patients with stroke or TIA who are to be discharged from the participating hospitals to home and referred to a neurorehabilitation team for continued rehabilitation will be included. Follow-ups will be conducted at one week, 3 months and 12 months. Data will be collected on the primary outcome of perceived quality of the care transition, and on the secondary outcomes of health literacy, medication adherence, and perceived person-centeredness. Data for process evaluation will be collected through semi-structured interviews, focus groups, participatory observations, and the Normalisation Measure Development Questionnaire.

DISCUSSION

The study will provide insights on implementation, mechanisms of impact, contextual moderators, and effectiveness of a care transition support, targeting a poorly functioning part of the care trajectory for people with stroke and TIA.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05646589.

Patient-planetary health co-benefit prescribing in a circumpolar health region: a qualitative study of physician voices from the Northwest Territories, Canada

BACKGROUND

Despite climate change being described as a code red for humanity, health systems have been particularly slow in both climate mitigation and adaptation responses. The effects of climate change on health and health systems will not be felt equally, with underserved and marginalised communities disproportionately impacted. The circumpolar region is warming at 3-4 times the global rate, amplifying already existing socioeconomic barriers and health inequities, with particular amplified effects for the substantial Indigenous population in the area.

OBJECTIVES AND SETTING

We therefore sought to explore perspectives of physicians around patient-planetary health (P-PH) co-benefit prescribing in a circumpolar region in the Northwest Territories (NWT), Canada, known to be one of the ground zero levels for climate change.

METHODS

Thirteen semi-structured physician interviews were carried out in the NWT region between May 2022 and March 2023 using purposive sampling. Interviews were transcribed verbatim and reflexive thematic analysis was carried out to identify key themes.

RESULTS

There were three main themes identified including (1) current healthcare system does not support planetary health, (2) supporting patient-planetary health is currently difficult for clinicians and (3) considering change in the NWT to support patient-planetary health. Participants noted key opportunities to move planetary health forward, with the NWT having the potential to be an innovative model for planetary health-informed change for other health systems.

CONCLUSION

The NWT health system has unique features due to its rural and remote nature and smaller population base. Despite this, our study identified some key opportunities for advancing P-PH co-benefit efforts. The identified opportunities may be considered in future intervention, organisational change and policy-making efforts with potential relevance in other settings.

Building a Program Theory of Implementation Using Process Evaluation of a Complex Quality Improvement Trial in Nursing Homes

BACKGROUND AND OBJECTIVES

Significant quality problems exist in long-term care (LTC). Interventions to improve care are complex and often have limited success. Implementation remains a black box. We developed a program theory explaining how implementation of a complex intervention occurs in LTC settings-examining mechanisms of impact, effects of context on implementation, and implementation outcomes such as fidelity.

RESEARCH DESIGN AND METHODS

Concurrent process evaluation of Safer Care for Older Persons in residential Environments (SCOPE)-a frontline worker (care aide) led improvement trial in 31 Canadian LTC homes. Using a mixed-methods exploratory sequential design, qualitative data were analyzed using grounded theory to develop a conceptual model illustrating how teams implemented the intervention and how it produced change. Quantitative analyses (mixed-effects regression) tested aspects of the program theory.

RESULTS

Implementation fidelity was moderate. Implementation is facilitated by (a) care aide engagement with core intervention components; (b) supportive leadership (internal facilitation) to create positive team dynamics and help negotiate competing workplace priorities; (c) shifts in care aide role perceptions and power differentials. Mixed-effects model results suggest intervention acceptability, perceived intervention benefits, and leadership support predict implementation fidelity. When leadership support is high, fidelity is high regardless of intervention acceptability or perceived benefits.

DISCUSSION AND IMPLICATIONS

Our program theory addresses important knowledge gaps regarding implementation of complex interventions in nursing homes. Results can guide scaling of complex interventions and future research.

Workforce Perspectives of Sustaining the Utilisation of a Harm Reduction Instrument in a Mental Health Residential Setting

PURPOSE

This exploratory study investigated worker experiences of utilising the Before During After (BDA) harm reduction instrument to engage well with service users in a residential mental health service setting. Stakeholder interviews were conducted with a purposive sample of two senior nurses and one senior allied health staff at the study site to explore the impacts of BDA implementation on their work after 3 years of its use. A thematic analysis was conducted, including two-level coding. Five major themes were discussed. Of particular interest, and the focus of this paper, are the themes of effect on service users and effect on staff. The study found improved engagement between staff and service users, reduced stigma and more holistic care that was collaborative. In regard to staff, it was found that staff knowledge and confidence increased in addressing harm reduction issues with consumers and this was sustained over 3 years. Use of the BDA clinical instrument and package was reported to enhance worker engagement, knowledge and confidence in dual diagnosis work with service users.

We're implementing AI now, so why not ask us what to do? - How AI providers perceive and navigate the spread of diagnostic AI in complex healthcare systems

Despite high expectations of artificial intelligence (AI) in medical diagnostics, predictions of its extensive and rapid adoption have so far not been matched by reality. AI providers seeking to promote and perpetuate the use of this technology are faced with the complex reality of embedding AI-enabled diagnostics across variable implementation contexts. In this study, we draw upon a complexity science approach and qualitative methodology to understand how AI providers perceive and navigate the spread of AI in complex healthcare systems. Using semi-structured, one-to-one interviews, we collected qualitative data from 14 providers of AI-enabled diagnostics. We triangulated the data by complementing the interviews with multiple sources, including a focus group of physicians with experience using these technologies. The notion of embedding allowed us to connect local implementation efforts with systemic diffusion. Our study reveals that AI providers self-organise to increase their adaptability when navigating the variable conditions and unpredictability of complex healthcare contexts. In addition to the tensions perceived by AI providers within the sociocultural, technological, and institutional subsystems of healthcare, we illustrate the practices emerging among them to mitigate these tensions: stealth science, agility, and digital ambidexterity. Our study contributes to the growing body of literature on the spread of AI in healthcare by capturing the view of technology providers and adding a new theoretical perspective through the lens of complexity science.

Exploring Australian night shift workers' food experiences within and outside of the workplace: a qualitative photovoice study

OBJECTIVE

Night shift workers are at a 20 to 40 % increased risk of metabolic diseases, which may be associated with their disrupted eating patterns. This qualitative study explores factors that influence night shift workers' eating habits, within and outside of the workplace, to identify target areas for health promotion strategies.

PARTICIPANTS AND SETTING

Eligible participants resided in Australia, working at least three overnight shifts per month.

DESIGN

The photovoice method was used, whereby participants were asked to take photos that represent their typical eating habits. These photos were incorporated as prompts in a semi-structured interview, which explored factors influencing eating habits on night shifts and days-off and perceptions and enablers to healthy eating.

RESULTS

Ten participants completed the study. Thematic analysis generated four main themes, which were mapped onto the Social Ecological Model (SE Model). Aligned with the SE Model, our results show night shift workers' eating habits are influenced by intrapersonal, interpersonal and (work) organisational levels. Participants reported that at work, appropriate food preparation facilities are required to enable healthy food choices. Poor shift work rostering leads to prolonged fatigue on days-off, limiting their ability and motivation to engage in healthy eating. Consequently, night shift workers seem to require additional supports from their social networks and enhanced food literacy skills, in order to adopt/ maintain healthy eating behaviours.

CONCLUSIONS

Night shift work creates individual and environmental barriers to healthy eating, which are present during and outside of work. Health promotion strategies for this population should include multiple approaches to address these barriers.

Equilibrium in the governance of cross-sectoral policies: how does it translate into practice?

BACKGROUND

There is growing interest from health researchers in the governance of Health in All Policies (HiAP). Furthermore, the COVID-19 pandemic has re-ignited managers' interest in HiAP governance and in health prevention activities that involve actors from outside health ministries. Since the dynamics of these multi-actor, multi-sectoral policies are complex, the use of systems theory is a promising avenue toward understanding and improving HiAP governance. We focus on the concept of equilibrium within systems theory, especially as it points to the need to strike a balance between actors that goes beyond synergies or mimicry-a balance that is essential to HiAP governance.

METHOD

We mobilized two sources of data to understand how the concept of equilibrium applies to HiAP governance. First, we reviewed the literature on existing frameworks for collaborative governance, both in general and for HiAP specifically, in order to extract equilibrium-related elements. Second, we conducted an in-depth case study over three years of an HiAP implemented in Quebec, Canada.

RESULTS

In total, we identified 12 equilibrium-related elements relevant to HiAP governance and related to knowledge, actors, learning, mindsets, sustainability, principles, coordination, funding and roles. The equilibria were both operational and conceptual in nature.

CONCLUSIONS

We conclude that policy makers and policy implementers could benefit from mobilizing these 12 equilibrium-related elements to enhance HiAP governance. Evaluators of HiAP may also want to consider and integrate them into their governance assessments.

What Stops Fairness from Emerging in Assessment? The Forces on a Complex Adaptive System

Introduction

Workplace-based assessment occurs in authentic, dynamic clinical environments where reproducible, measurement-based assessments can often not be implemented. In these environments, research approaches that respect these multiple dynamic interactions, such as complexity perspectives, are encouraged. Previous research has shown that fairness in assessment is a nonlinear phenomenon that emerges from interactions between its components and behaves like a complex adaptative system. The aim of this study was to understand the external forces on the complex adaptive system which may disrupt fairness from emerging.

Methods

We conducted online focus groups with a purposeful sample of nineteen academic leaders in the Netherlands. We used an iterative approach to collection, analysis and coding of the data and interpreted the results using a lens of complexity, focusing on how individual elements of fairness work in concert to create systems with complex behaviour.

Results

We identified three themes of forces which can disrupt fairness: forces impairing interactivity, forces impairing adaption and forces impairing embeddedness. Within each of these themes, we identified subthemes: assessor and student forces, tool forces and system forces.

Discussion

Consistent with complexity theory, this study suggests there are multiple forces which can hamper the emergence of fairness. Whilst complexity thinking does not reduce the scale of the challenge, viewing forces through this lens provides insight into why and how these forces are disrupting fairness. This allows for more purposeful, meaningful changes to support the use of fair judgement in assessment in dynamic authentic clinical workplaces.

The role of the physical environment in stroke recovery: Evidence-based design principles from a mixed-methods multiple case study

Hospital design can impact patient outcomes, but there is very little healthcare design evidence specific to stroke rehabilitation facilities. Our aim was to explore, from the patient perspective, the role of the physical environment in factors crucial to stroke recovery, namely, stroke survivor activity (physical, cognitive, social), sleep, emotional well-being, and safety. We conducted a mixed-methods multiple-case study at two inpatient rehabilitation facilities in Victoria, Australia, (n = 20 at Case 1, n = 16 at Case 2) using "walk-through" semi-structured interviews, behavioural mapping, questionnaires, and retrospective audit. Four interrelated themes emerged: 1) entrapment and escape; 2) power, dependency, and identity in an institutional environment; 3) the rehabilitation facility is a shared space; and 4) the environment should be legible and patient-centred. Quantitative data revealed patterns in patient activity; stroke survivors spent over 75% of their time in bedrooms and were often inactive. Convergent mixed methods analysis was used to generate a new conceptual model of the role of the physical environment in stroke survivors' behaviour and well-being, highlighting the importance of variety and interest, privacy without isolation, and patient-centred design. This model can be used by designers, healthcare providers, and policy makers to inform the design of rehabilitation environments.

Using sociotechnical theory to understand medication safety work in primary care and prescribers' use of clinical decision support: a qualitative study

OBJECTIVES

The concept of safety work draws attention to the intentional work of ensuring safety within care systems. Clinical decision support (CDS) has been designed to enhance medication safety in primary care by providing decision-making support to prescribers. Sociotechnical theory understands that healthcare settings are complex and dynamically connected systems of fluid networks, human agents, changing relationships and social processes. This study aimed to understand the relationship between safety work and the use of CDS.

DESIGN AND SETTING

This qualitative study took place across nine different general practices in England. Stakeholders included general practitioners (GPs) and general practice-based pharmacists and nurse prescribers. Semi-structured interviews were conducted to illicit how the system was used by the participants in the context of medication safety work. Data analysis conducted alongside data collection was thematic and drew on socio-technical theory.

PARTICIPANTS

Twenty-three interviews were conducted with 14 GPs, three nurse prescribers and three practice pharmacists between February 2018 and June 2020.

RESULTS

Safety work was contextually situated in a complex network of relationships. Three interconnected themes were interpreted from the data: (1) the use of CDS within organisational and social practices and workflows; (2) safety work and the use of CDS within the interplay between prescribers, patients and populations; and (3) the affordances embedded in CDS systems.

CONCLUSION

The use of sociotechnical theory here extends current thinking in patient safety particularly in the ways that safety work was co-constituted with the use of CDS alerts. This has implications for implementation and use to ensure that the contexts into which such CDS systems are implemented are taken into account. Understanding how alerts can adapt safety culture will help improve the efficacy of CDS systems, enhance prescribing safety and help to further understand how safety work is achieved in primary care.

Improving Engagement in Antenatal Health Behavior Programs-Experiences of Women Who Did Not Attend a Healthy Lifestyle Telephone Coaching Program

Living Well during Pregnancy (LWdP) is a telephone-based antenatal health behavior intervention that has been shown to improve healthy eating behaviors and physical activity levels during pregnancy. However, one-third of eligible, referred women did not engage with or dropped out of the service. This study aimed to explore the experiences and perceptions of women who were referred but did not attend or complete the LWdP program to inform service improvements and adaptations required for scale and spread and improve the delivery of patient-centered antenatal care. Semi-structured telephone interviews were conducted with women who attended ≤2 LWdP appointments after referral. The interviews were thematically analyzed and mapped to the Theoretical Domains Framework and Behavior Change Wheel/COM-B Model to identify the barriers and enablers of program attendance and determine evidence-based interventions needed to improve service engagement and patient-centered antenatal care. Three key themes were identified: (1) the program content not meeting women's expectations and goals; (2) the need for flexible, multimodal healthcare; and (3) information sharing throughout antenatal care not meeting women's information needs. Interventions to improve women's engagement with LWdP and patient-centered antenatal care were categorized as (1) adaptations to LWdP, (2) training and support for program dietitians and antenatal healthcare professionals, and (3) increased promotion of positive health behaviors during pregnancy. Women require flexible and personalized delivery of the LWdP that is aligned with their individual goals and expectations. The use of digital technology has the potential to provide flexible, on-demand access to and engagement with the LWdP program, healthcare professionals, and reliable health information. All healthcare professionals are vital to the promotion of positive health behaviors in pregnancy, with the ongoing training and support necessary to maintain clinician confidence and knowledge of healthy eating, physical activity, and weight gain during pregnancy.

Using Relational Community Engagement within the Digital Health Intervention (DHI) to Improve Access and Retention among People Living with HIV (PLWH): Findings from a Mixed-Method Study in Cambodia

We examined the impact of COVID-19-associated restrictive measures on the HIV care system in Cambodia through a complexity lens and aimed to use the findings to integrate social and relational processes into the design and implementation of proposed solutions that could support program outcomes during these times. Through a mixed-method design, we generated data on the strength of connection and quality of relationships between stakeholders and how this, in turn, provided a more holistic understanding of the challenges experienced during a pandemic. We interviewed 43 HIV care providers and 13 patients from eight HIV clinics and 13 policy-level stakeholders from relevant institutions involved in HIV care from April to May 2021. We identified several challenges, as well as an opportunity to improve HIV care access that built upon a strong foundation of trust between the HIV care providers and receivers in Cambodia. Trusting relationships between providers and patients provided the basis for intervention development aiming to improve the care experience and patients' engagement in care. Iterative research processes could better inform the intervention, and communication resources provided through relational skills training are key to their application and sustainability.

Impact of a social prescribing intervention in North East England on adults with type 2 diabetes: the SPRING_NE multimethod study

Background

Link worker social prescribing enables health-care professionals to address patients’ non-medical needs by linking patients into various services. Evidence for its effectiveness and how it is experienced by link workers and clients is lacking.

Objectives

To evaluate the impact and costs of a link worker social prescribing intervention on health and health-care costs and utilisation and to observe link worker delivery and patient engagement.

Data sources

Quality Outcomes Framework and Secondary Services Use data.

Design

Multimethods comprising (1) quasi-experimental evaluation of effects of social prescribing on health and health-care use, (2) cost-effectiveness analysis, (3) ethnographic methods to explore intervention delivery and receipt, and (4) a supplementary interview study examining intervention impact during the first UK COVID-19 lockdown (April–July 2020).

Study population and setting

Community-dwelling adults aged 40–74 years with type 2 diabetes and link workers in a socioeconomically deprived locality of North East England, UK.

Intervention

Link worker social prescribing to improve health and well-being-related outcomes among people with long-term conditions.

Participants

(1) Health outcomes study, approximately n = 8400 patients; EuroQol-5 Dimensions, five-level version (EQ-5D-5L), study, n = 694 (baseline) and n = 474 (follow-up); (2) ethnography, n = 20 link workers and n = 19 clients; and COVID-19 interviews, n = 14 staff and n = 44 clients.

Main outcome measures

The main outcome measures were glycated haemoglobin level (HbA1c; primary outcome), body mass index, blood pressure, cholesterol level, smoking status, health-care costs and utilisation, and EQ-5D-5L score.

Results

Intention-to-treat analysis of approximately 8400 patients in 13 intervention and 11 control general practices demonstrated a statistically significant, although not clinically significant, difference in HbA1c level (–1.11 mmol/mol) and a non-statistically significant 1.5-percentage-point reduction in the probability of having high blood pressure, but no statistically significant effects on other outcomes. Health-care cost estimates ranged from £18.22 (individuals with one extra comorbidity) to –£50.35 (individuals with no extra comorbidity). A statistically non-significant shift from unplanned (non-elective and accident and emergency admissions) to planned care (elective and outpatient care) was observed. Subgroup analysis showed more benefit for individuals living in more deprived areas, for the ethnically white and those with fewer comorbidities. The mean cost of the intervention itself was £1345 per participant; the incremental mean health gain was 0.004 quality-adjusted life-years (95% confidence interval –0.022 to 0.029 quality-adjusted life-years); and the incremental cost-effectiveness ratio was £327,250 per quality-adjusted life-year gained. Ethnographic data showed that successfully embedded, holistic social prescribing providing supported linking to navigate social determinants of health was challenging to deliver, but could offer opportunities for improving health and well-being. However, the intervention was heterogeneous and was shaped in unanticipated ways by the delivery context. Pressures to generate referrals and meet targets detracted from face-to-face contact and capacity to address setbacks among those with complex health and social problems.

Limitations

The limitations of the study include (1) a reduced sample size because of non-participation of seven general practices; (2) incompleteness and unreliability of some of the Quality and Outcomes Framework data; (3) unavailability of accurate data on intervention intensity and patient comorbidity; (4) reliance on an exploratory analysis with significant sensitivity analysis; and (5) limited perspectives from voluntary, community and social enterprise.

Conclusions

This social prescribing model resulted in a small improvement in glycaemic control. Outcome effects varied across different groups and the experience of social prescribing differed depending on client circumstances.

Future work

To examine how the NHS Primary Care Network social prescribing is being operationalised; its impact on health outcomes, service use and costs; and its tailoring to different contexts.

Trial registration

This trial is registered as ISRCTN13880272.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme, Community Groups and Health Promotion (grant no. 16/122/33) and will be published in full in Public Health Research; Vol. 11, No. 2. See the NIHR Journals Library website for further project information.

Paradoxes, contradictions, and dilemmas: Reflections on the contours of a pandemic and its implications for social work education

Summary

This is a reflective and theoretical article that discusses the impact of COVID-19 on social work practice. The pandemic, which made its presence felt globally from early 2020, continues to have ongoing and significant consequences for lives, livelihoods, public health, and personal freedoms. We argue that, while its specific contours are yet to be comprehensively researched, let alone the final outcomes understood, the pandemic has presented opportunities to develop new ways of thinking about social work and social work education.

Findings

Through a discussion of relevant literature, including a recent work of fiction, we contend that social workers have been able to adapt, to some extent, to the pandemic but in reactive rather than proactive ways. The biopsychosocial and person-in-environment perspectives that characterize social work education, theory, and practice might be greatly enhanced by the introduction of complexity theory in terms of developing new thinking about the theoretical basis of social work, enabling new questions and new strategies to emerge to strengthen social work responses to the challenges posed by COVID-19.

Applications

Arising from this theoretical article, there are many implications for introducing complexity theory within social work education programs. Complexity theory can provide a conceptual frame fit-for-purpose for social work pandemic and post-pandemic theory and practice.

Caregivers' perception of the role of the socio-environment on their extremely preterm child's well-being

PURPOSE

The purpose of this qualitative descriptive study was to explore primary caregivers' perception of how social-environmental characteristics, and their own role as primary caregivers, affected their extremely preterm adolescent's well-being.

METHODS

Participants were 20 mothers who identified as the primary caregiver of an adolescent born extremely prematurely (<28 weeks gestation) enrolled in the ELGAN cohort study. Data was collected through individual interviews and was analyzed using inductive content analysis.

RESULTS

A total of three themes, and five subthemes, were identified. The two main themes were "familial impact to health and well-being," and "contributors and barriers at the community level." This study described specific familial and community contributors to child and caregiver well-being, including: the importance of advocacy, participating in community activities, and social and familial support networks.

CONCLUSIONS

Overall, while there are individual level characteristics that contribute to well-being, a support structure at the family and community level is essential to children born extremely prematurely, and their mother's, well-being.

PRACTICE IMPLICATIONS

Healthcare providers caring for these families should understand that not only are extremely preterm youth affected by prematurity, but caregivers are also deeply impacted. Therefore, it is essential that maternal and family care is emphasized by nurses and healthcare providers.

Gestational diabetes screening from the perspective of consumers: Insights from early in the COVID-19 pandemic and opportunities to optimise experiences

BACKGROUND

Consumer perspectives are a cornerstone of value-based healthcare. Screening and diagnosis of gestational diabetes mellitus (GDM) were among many of the rapid changes to health care recommended during the COVID-19 pandemic. The changes provided a unique opportunity to add information about women's perspectives on the debate on GDM screening.

AIMS

The aim of this qualitative study was to explore women's perspectives and understanding of GDM screening and diagnosis comparing the modified COVID-19 recommendations to standard GDM screening and diagnostic practices.

METHODS

Women who had experienced both the standard and modified GDM screening and diagnostic processes were recruited for telephone interviews. Data analysis used inductive reflexive thematic analysis. Online surveys were disseminated to any registrant not included in interviews to provide an opportunity for all interested participants to provide their perspective.

RESULTS

Twenty-nine telephone interviews were conducted and 19 survey responses were received. Seven themes were determined: (1) information provision from clinicians; (2) acceptability of GDM screening; (3) individualisation of GDM screening methods; (4) safety nets to avoid a missed diagnosis; (5) informed decision making; (6) women want information and evidence; and (7) preferred GDM screening methods for the future.

CONCLUSIONS

Overall, women preferred the modified GDM screening recommendations put in place due to the COVID-19 pandemic. However, their preference was influenced by their prior screening experience and perception of personal risk profile. Women expressed a strong need for clear communication from health professionals and the opportunity to be active participants in decision making.

Understanding dynamic complexity in context-Enriching contextual analysis in implementation science from a constructivist perspective

Context in implementation science includes not only characteristics of a setting in which an intervention will be delivered, but also social systems (e.g., interrelationships). Context is dynamic and interacts with both, the intervention and its implementation. Therefore, contextual analysis is recognized as an indispensable part of implementation science methodology: it provides the foundation for successful and sustainable implementation projects. Yet, driven by the prevailing post-positivist understanding of context, contextual analysis typically focuses on individual characteristics of context i.e., contextual dynamics and interactions go unnoticed. Conducting contextual analysis from a constructivist perspective promotes a multilayered approach, building a more comprehensive understanding of context, and thus facilitating successful implementation. In this article, we highlight the limitations of prevailing perspectives on context and approaches to contextual analysis. We then describe how contextual analysis can be enriched by working from a constructivist perspective. We finish with a discussion of the methodological and practical implications the proposed changes would entail. Emerging literature attempts to address both the concept of context and methods for contextual analysis. Various theories, models and frameworks consider context, however, many of these are reductionistic and do not acknowledge the dynamic nature of context or interactions within it. To complement recent conceptualizations of context, we suggest consider the following five constructivist concepts: 1) social space; 2) social place; 3) agency; 4) sensation; and 5) embodiment. We demonstrate the value of these concepts using COVID-19 vaccination uptake as an example and integrate the concepts in the Context and Implementation of Complex Interventions (CICI) framework-an implementation science framework that pays ample attention to context. To study context from a constructivist perspective, we also suggest additional considerations in view of methodologies for data collection and analysis, e.g., rapid ethnographic methods. A constructivist perspective contributes to a stronger conceptualization of contextual analysis. Considering the five constructivist concepts helps to overcome contextual analysis' current shortcomings, while revealing complex dynamics that usually go unnoticed. Thus, more comprehensive understanding of context can be developed to inform subsequent phases of an implementation project, thereby maximizing an intervention's uptake and sustainability.

"The whole of humanity has lungs, doesn't it? We are not all the same sort of people": patient preferences and choices for an online, self-guided chronic breathlessness supportive intervention: SELF-BREATHE

Introduction

The burden of chronic breathlessness on individuals, family, society and health systems is significant and set to increase exponentially with an ageing population with complex multimorbidity, yet there is a lack of services. This has been further amplified by the coronavirus disease 2019 pandemic. Online breathlessness interventions have been proposed to fill this gap, but need development and evaluation based on patient preferences and choices. This study aimed to explore the preferences and choices of patients regarding the content of an online self-guided chronic breathlessness supportive intervention (SELF-BREATHE).

Methods

Semi-structured telephone interviews were conducted with adults living with advanced malignant and nonmalignant disease and chronic breathlessness (July to November 2020). Interviews were analysed using conventional and summative content analysis.

Results

25 patients with advanced disease and chronic breathlessness (COPD n=13, lung cancer n=8, interstitial lung disease n=3, bronchiectasis n=1; 17 male; median (range) age 70 (47-86) years; median (range) Medical Research Council dyspnoea score 3 (2-5)) were interviewed. Individuals highlighted strong preferences for focused education, methods to increase self-motivation and engagement, interventions targeting breathing and physical function, software capability to personalise the content of SELF-BREATHE to make it more meaningful to the user, and aesthetically designed content using various communication methods including written, video and audio content. Furthermore, they identified the need to address motivation as a key potential determinant of the success of SELF-BREATHE.

Conclusion

Our findings provide an essential foundation for future digital intervention development (SELF-BREATHE) and scaled research.

The science-policy relationship in times of crisis: An urgent call for a pragmatist turn

In this conceptual paper, we argue that at times of crisis, what is sometimes called "evidence-based" or "science-driven" policymaking-establishing scientific truths and then implementing them-must be tempered by a more agile, deliberative and inclusive approach which acknowledges and embraces uncertainty. We offer pragmatism as one potential option, using examples from the UK to illustrate how such an approach might have changed particular crisis decisions and led to better outcomes. We propose that to better prepare for the next public health crisis, five pragmatism-informed shifts are needed in the science-policy relationship: from scientism to science-informed narrative rationality that emerges from practice; from knowledge-then-action to acting judiciously under uncertainty; from hierarchies of evidence to pluralist inquiry; from polarized camps to frame-reflective dialogue; and from an "inside-track" science-policy dialogue to greater participatory democracy. We suggest an agenda for a pragmatist-informed program of applied research on crisis public health policymaking.

What are the active ingredients of 'arts in health' activities? Development of the INgredients iN ArTs in hEalth (INNATE) Framework

Background: There is a scarcity of research concerning what it is about arts engagement that may activate causal mechanisms leading to effects on health and wellbeing: their active ingredients. Further, the limited studies that do exist have tended to be relevant to specific contexts and types of art forms. The aim of this study was to carry out a comprehensive mapping of potential active ingredients, construct a shared language, and propose a framework and toolkit to support the design, implementation, and evaluation of arts in health activities. Methods: Drawing upon Rapid Appraisal techniques and collaborating with 64 participants working in arts in health, we engaged in a three-phase process: 1) scoping review to inform the development of an initial framework; 2) consultation on the initial framework; and 3) analysis and construction of the INNATE framework. Results: The study identified 139 potential active ingredients within the overarching categories of  project, people, and  contexts.  Project components relate directly to the content of the arts activity itself, intrinsic to what the activity is. The  people category denotes how people interact through engagement with the activity and who is involved in this interaction, including activity facilitation.  Contexts relates to the activity setting comprising the aggregate of place(s), things, and surroundings. Aligning with complexity science, ingredients may interconnect or feed into one another to prompt mechanisms, and may not be experienced as distinct by participants. Conclusions: Our mapping exercise is the most extensive to date. In relation to arts in health activities, the INNATE framework can support with: design and implementation, such as co-producing an intervention to meet the needs of a particular population; evaluation, such as facilitating the comparison of different interventions and their efficacy; and replication, scalability, and sustainability through enabling detailed reporting and articulation of what an arts in health activity entails.

What are the active ingredients of ‘arts in health’ activities? Development of the INgredients iN ArTs in hEalth (INNATE) Framework

Background: There is a scarcity of research concerning what it is about arts engagement that may activate causal mechanisms leading to effects on health and wellbeing: their active ingredients. Further, the limited studies that do exist have tended to be relevant to specific contexts and types of art forms. The aim of this study was to carry out a comprehensive mapping of potential active ingredients, construct a shared language, and propose a framework and toolkit to support the design, implementation, and evaluation of arts in health activities.

Methods: Drawing upon Rapid Appraisal techniques and collaborating with 64 participants working in arts in health, we engaged in a three-phase process: 1) scoping review to inform the development of an initial framework; 2) consultation on the initial framework; and 3) analysis and construction of the INNATE framework.

Results: The study identified 139 potential active ingredients within the overarching categories of  project, people, and  contexts.  Project components relate directly to the content of the arts activity itself, intrinsic to what the activity is. The  people category denotes how people interact through engagement with the activity and who is involved in this interaction, including activity facilitation.  Contexts relates to the activity setting comprising the aggregate of place(s), things, and surroundings. Aligning with complexity science, ingredients may interconnect or feed into one another to prompt mechanisms, and may not be experienced as distinct by participants.

Conclusions: Our mapping exercise is the most extensive to date. In relation to arts in health activities, the INNATE framework can support with: design and implementation, such as co-producing an intervention to meet the needs of a particular population; evaluation, such as facilitating the comparison of different interventions and their efficacy; and replication, scalability, and sustainability through enabling detailed reporting and articulation of what an arts in health activity entails.

Indicators for implementation outcome monitoring of reporting and learning systems in hospitals: an underestimated need for patient safety

Objective

We aimed to investigate the perception of the implementation success of reporting and learning systems in German hospitals, the perceived relevance of the implementation outcomes and whether and how these implementation outcomes are monitored. An reporting and learning system is a tool used worldwide for patient safety that identifies and analyses critical events, errors, risks and near misses in healthcare.

Methods

A pretested exploratory cross-sectional online survey was conducted with reporting and learning system experts from 51 acute care hospitals. For communicative validation, the results were discussed in person in an expert panel discussion (N=23).

Results

Fifty-three per cent (n=27) of the participants (N=51) of the online survey perceived that their reporting and learning system was being comprehensively and successfully implemented. However, no service or patient outcomes were reported to ultimately capture the concept of implementation success. Most of the participants reported a (high) relevance of the implementation outcomes’ acceptability and sustainability. In total, 44 measures were provided to monitor implementation outcomes. However, most of the quantitative measures were based on the (relative) number of entered reports. Qualitative measures were reported in relation to the ‘quality of the report’. In general, the measures were poorly specified.

Conclusion

There is an underestimated need to develop validated ‘implementation patient safety indicator(s) (sets)’ to monitor implementation outcomes of reporting and learning systems. We also identified a potential need to facilitate awareness of the concept of implementation success and its relevance for patient safety. Drafts of indicators that could be used as a starting point for the further development of ‘implementation patient safety indicators’ were provided.

Contextual factors influencing complex intervention research processes in care homes: a systematic review and framework synthesis

Background

Care homes are complex settings to undertake intervention research. Barriers to research implementation processes can threaten studies’ validity, reducing the value to residents, staff, researchers and funders. We aimed to (i) identify and categorise contextual factors that may mediate outcomes of complex intervention studies in care homes and (ii) provide recommendations to minimise the risk of expensive research implementation failures.

Methods

We conducted a systematic review using a framework synthesis approach viewed through a complex adaptive systems lens. We searched: MEDLINE, Embase, CINAHL, ASSIA databases and grey literature. We sought process evaluations of care home complex interventions published in English. Narrative data were indexed under 28 context domains. We performed an inductive thematic analysis across the context domains.

Results

We included 33 process evaluations conducted in high-income countries, published between 2005 and 2019. Framework synthesis identified barriers to implementation that were more common at the task and organisational level. Inductive thematic analysis identified (i) avoiding procedural drift and (ii) participatory action and learning as key priorities for research teams. Research team recommendations include advice for protocol design and care home engagement. Care home team recommendations focus on internal resources and team dynamics. Collaborative recommendations apply to care homes’ individual context and the importance of maintaining positive working relationships.

Discussion

Researchers planning and undertaking research with care homes need a sensitive appreciation of the complex care home context. Study implementation is most effective where an intervention is co-produced, with agreed purpose and adequate resources to incorporate within existing routines and care practices.

"You can do it yourself and you can do it at your convenience": internet accessibility and willingness of people with chronic breathlessness to use an internet-based breathlessness self-management intervention during the COVID-19 pandemic

INTRODUCTION

The burden of chronic breathlessness on individuals, family, society and health systems is significant, and set to increase exponentially with population ageing, complex multimorbidity and coronavirus disease 2019 (COVID-19)-related disability. Breathlessness support services are effective; however, reach and access are limited. Delivering online breathlessness interventions may build capacity and resilience within health systems to tackle chronic breathlessness through supported self-management. The aim of this study was to explore accessibility and willingness of patients with chronic breathlessness to use an internet-based breathlessness self-management intervention (SELF-BREATHE).

METHODS

Semi-structured telephone interviews were conducted with adults living with advanced malignant and non-malignant disease and chronic breathlessness (July to November 2020). Interviews were analysed using conventional and summative content analysis.

RESULTS

25 patients (COPD: n=13; lung cancer: n=8; interstitial lung disease (ILD): n=3; bronchiectasis: n=1) were interviewed: 17 male, median (range) age 70 (47-86) years and Medical Research Council dyspnoea score 3 (2-5). 21 patients had internet access. Participants described greater use, acceptance and normalisation of the internet since the advent of the COVID-19 pandemic. They described multifaceted internet use: functional, self-investment (improving health and wellbeing) and social. The concept of SELF-BREATHE was highly valued, and most participants with internet access were willing to use it. In addition to technical limitations, personal choice and perceived value of the internet were important factors that underpinned readiness to use online resources.

CONCLUSION

These findings suggest that patients living with chronic breathlessness that have access to the internet would have the potential to benefit from the online SELF-BREATHE intervention, if given the opportunity.

Using system thinking methodologies to address health care complexities and evidence implementation

BACKGROUND

Despite health care advances, artificial intelligence and government interventions aiming to improve the health and wellbeing of citizens, huge disparities and failures in care provision exist. This is demonstrated by the rising number of medical errors, increase in readmission rates and mortality rates, and the failure of many health systems to successfully cope with events, such as pandemics and natural disasters. This shortfall is in part because of the complexity of the health care system, the interconnectedness of various parts of service, funding models, the complexity of patients' conditions, patient and carer needs, and the clinical processes needed for patients via multiple providers.

OBJECTIVE

The objective of this paper is to describe the use of system thinking methodologies to address complex problems such as those in the public health and health services domains.

METHOD

A description of the system thinking methodology and its associated methods including causal loop diagrams, social network analysis and soft system methodology are described with examples in the health care setting.

RESULTS

There are various models of knowledge translation that have been employed including the Joanna Briggs Institute model of implementation of evidence into practice, the triple C, and the Promoting Action on Research Implementation in Health Services. However, many of these models are neither scalable nor sustainable, and are most effective for localized projects implemented by trained clinicians and champions in relevant settings.System thinking is essentially a modelling process, which aims to create opportunities for change via an appreciation of perspective, and recognition that complex problems are a result of interconnected factors. The article argues that systems thinking applications need to move beyond that of addressing complex health issues pertaining to a population, and rather consider complex problems surrounding the delivery of high-quality health care.

CONCLUSION

It is important that methods to implement systems thinking methodologies in health care settings are developed and tested.

Implementation processes in a cognitive rehabilitation intervention for people with dementia: a complexity-informed qualitative analysis

OBJECTIVES

Healthcare is often delivered through complex interventions. Understanding how to implement these successfully is important for optimising services. This article demonstrates how the complexity theory concept of 'self-organisation' can inform implementation, drawing on a process evaluation within a randomised controlled trial of the GREAT (Goal-oriented cognitive Rehabilitation in Early-stage Alzheimer's and related dementias: a multi-centre single-blind randomised controlled Trial) intervention which compared a cognitive rehabilitation intervention for people with dementia with usual treatment.

DESIGN

A process evaluation examined experiences of GREAT therapists and participants receiving the intervention, through thematic analysis of a focus group with therapists and interviews with participants and their carers. Therapy records of participants receiving the intervention were also analysed using adapted framework analysis. Analysis adopted a critical realist perspective and a deductive-inductive approach to identify patterns in how the intervention operated.

SETTING

The GREAT intervention was delivered through home visits by therapists, in eight regions in the UK.

PARTICIPANTS

Six therapists took part in a focus group, interviews were conducted with 25 participants and 26 carers, and therapy logs for 50 participants were analysed.

INTERVENTION

A 16-week cognitive rehabilitation programme for people with mild-to-moderate dementia.

RESULTS

'Self-organisation' of the intervention occurred through adaptations made by therapists. Adaptations included simplifying the intervention for people with greater cognitive impairment, and extending it to meet additional needs. Relational work by therapists produced an emergent outcome of 'social support'. Self-organised aspects of the intervention were less visible than formal components, but were important aspects of how it operated during the trial. This understanding can help to inform future implementation.

CONCLUSIONS

Researchers are increasingly adopting complexity theory to understand interventions. This study extends the application of complexity theory by demonstrating how 'self-organisation' was a useful concept for understanding aspects of the intervention that would have been missed by focusing on formal intervention components. Analysis of self-organisation could enhance future process evaluations and implementation studies.

TRIAL REGISTRATION NUMBER

ISRCTN21027481.

Confronting complexity and supporting transformation through health systems mapping: a case study

INTRODUCTION

Health systems are a complex web of interacting and interconnected parts; introducing an intervention, or the allocation of resources, in one sector can have effects across other sectors and impact the entire system. A prerequisite for effective health system reorganisation or transformation is a broad and common understanding of the current system amongst stakeholders and innovators. Chronic obstructive pulmonary disease (COPD) and heart failure (HF) are common chronic diseases with high health care costs that require an integrated health system to effectively treat.

STUDY DESCRIPTION

This case study documents the first phase of system transformation at a regional level in Ontario, Canada. In this first phase, visual representations of the health system in its current state were developed using a collaborative co-creation approach, and a focus on COPD and HF. Multiple methods were used including focus groups, open-ended questionnaires, and document review, to develop a series of graphical and visual representations; a health care ecosystem map.

RESULTS

The ecosystem map identified key sectoral components, inter-component interactions, and care requirements for patients with COPD and HF and inventoried current programs and services available to deliver this care. Main findings identified that independent system-wide navigation for this vulnerable patient group is limited, primary care is central to the accessibility of nearly half of the identified care elements, and resources are not equitably distributed. The health care ecosystem mapping helped to identify care gaps and illustrates the need to resource the primary care provider and the patient with system navigation resources and interdisciplinary team care.

CONCLUSION

The co-created health care ecosystem map brought a collective understanding of the health care system as it applies to COPD and HF. The map provides a blueprint that can be adapted to other disease states and health systems. Future transformation will build on this foundational work, continuing the robust interdisciplinary co-creation strategies, exploring predictive health system modelling and identifying areas for integration.

Bibliometric analysis confirms expected trends in consumer health information publications

BACKGROUND

This study provides an overview of consumer health information (CHI) scholarly communication trends.

OBJECTIVES

To explore CHI publications trends, journal citations, prolific authors, countries of origin, and distribution of CHI publications.

METHODS

A bibliometric analysis was used; 8953 records from the Web of Science (WoS) and peer-reviewed journal articles from databases, including LISA, MEDLINE, ERIC, PREMEDLINE and EMBASE were analysed.

RESULTS

Publications on CHI rapidly increased from 1980 to 2019, especially during the 1990s and 2000s. Most journals that have published CHI research are based in North America and Europe.

CONCLUSION

The increase in the CHI literature corresponds with that in Internet usage in the 2000s, and explains the availability of CHI content online. This trend is associated with the widespread adoption of personal computers (PCs) and other Internet-enabled gadgets.

Context and Complexity in Telemedicine Evaluation: Work Domain Analysis in a Surgical Setting

Many promising telemedicine innovations fail to be accepted and used over time, and there are longstanding questions about how to best evaluate telemedicine services and other health information technologies. In response to these challenges, there is a growing interest in how to take the sociotechnical complexity of health care into account during design, implementation, and evaluation. This paper discusses the methodological implications of this complexity and how the sociotechnical context holds the key to understanding the effects and outcomes of telemedicine. Examples from a work domain analysis of a surgical setting, where a telemedicine service for remote surgical consultation was to be introduced, are used to show how abstracted functional modeling can provide a structured and rigorous means to analyze and represent the implementation context in complex health care settings.

Continuing to enhance the quality of case study methodology in health services research

Case study methodology has grown in popularity within Health Services Research (HSR). However, its use and merit as a methodology are frequently criticized due to its flexible approach and inconsistent application. Nevertheless, case study methodology is well suited to HSR because it can track and examine complex relationships, contexts, and systems as they evolve. Applied appropriately, it can help generate information on how multiple forms of knowledge come together to inform decision-making within healthcare contexts. In this article, we aim to demystify case study methodology by outlining its philosophical underpinnings and three foundational approaches. We provide literature-based guidance to decision-makers, policy-makers, and health leaders on how to engage in and critically appraise case study design. We advocate that researchers work in collaboration with health leaders to detail their research process with an aim of strengthening the validity and integrity of case study for its continued and advanced use in HSR.

Characterising the outcomes, impacts and implementation challenges of advanced clinical practice roles in the UK: a scoping review

OBJECTIVES

In response to demographic and health system pressures, the development of non-medical advanced clinical practice (ACP) roles is a key component of National Health Service workforce transformation policy in the UK. This review was undertaken to establish a baseline of evidence on ACP roles and their outcomes, impacts and implementation challenges across the UK.

DESIGN

A scoping review was undertaken following JBI methodological guidance.

METHODS

13 online databases (Medline, CINAHL, ASSIA, Embase, HMIC, AMED, Amber, OT seeker, PsycINFO, PEDro, SportDiscus, Osteopathic Research and PenNutrition) and grey literature sources were searched from 2005 to 2020. Data extraction, charting and summary was guided by the PEPPA-Plus framework. The review was undertaken by a multi-professional team that included an expert lay representative.

RESULTS

191 papers met the inclusion criteria (any type of UK evidence, any sector/setting and any profession meeting the Health Education England definition of ACP). Most papers were small-scale descriptive studies, service evaluations or audits. The papers reported mainly on clinical aspects of the ACP role. Most papers related to nursing, pharmacy, physiotherapy and radiography roles and these were referred to by a plethora of different titles. ACP roles were reported to be achieving beneficial impacts across a range of clinical and health system outcomes. They were highly acceptable to patients and staff. No significant adverse events were reported. There was a lack of cost-effectiveness evidence. Implementation challenges included a lack of role clarity and an ambivalent role identity, lack of mentorship, lack of continuing professional development and an unclear career pathway.

CONCLUSION

This review suggests a need for educational and role standardisation and a supported career pathway for advanced clinical practitioners (ACPs) in the UK. Future research should: (i) adopt more robust study designs, (ii) investigate the full scope of the ACP role and (iii) include a wider range of professions and sectors.

That's how it should work: the perceptions of a senior management on the value of decentralisation in a service delivery organisation

PURPOSE

Decentralisation in health care has been proposed as a way to make services more responsive to local needs and by that improve patient care. This study analyses how the senior management team conceptualised and implemented a decentralised management model within a large public health care delivery organisation.

DESIGN/METHODOLOGY/APPROACH

Data from in-depth interviews with a senior management team were used in a directed content analysis. Underlying assumptions and activities in the decentralisation process are presented in the logic model and scrutinised in an a priori logic analysis using relevant scientific literature.

FINDINGS

The study found support in the scientific literature for the underlying assumptions that increased responsibility will empower managers as clinical directors know their local prerequisites best and are able to adapt to patient needs. Top management should function like an air traffic control tower, trust and loyalty improve managerial capacity, increased managerial skills release creativity and engagement and a system perspective will support collaboration and learning.

ORIGINALITY/VALUE

To the authors' knowledge this is the first a priori logic analysis of a decentralised management model in a healthcare delivery organisation in primary and community care. It shows that the activities consist with underlying assumptions, supported by evidence, and timely planned give managers decision space and ability to use their delegated authority, not disregarding accountability and fostering necessary organisational and individual capacities to avoid suboptimisation.

Acceptability of employment readiness measures in youth and young adults on the autism spectrum: a mixed-methods study

PURPOSE

Reliable, valid, and pragmatic measures are essential for monitoring and evaluating employment readiness and comparing the effectiveness of alternative implementation strategies. The Work Readiness Inventory (WRI) and Ansell-Casey Life Skills Assessment (ACLSA) are valid measures of employment readiness in neurotypical populations; however, their acceptability (i.e., user perception of measure as agreeable/satisfactory) for persons on the autism spectrum is not yet known. This investigation assesses the acceptability of the WRI and a modified ACLSA (ACLSA-M) in measuring employment readiness in youth/young adults on the spectrum.

METHODS

A concurrent triangulation mixed-methods study design utilizing quantitative pre-post measurement of a community-based employment readiness program alongside qualitative survey assessment was employed to determine concurrent acceptability. For robustness, further explication through peer debriefing of experts evaluated the retrospective acceptability via interview and acceptability-rate assessment.

RESULTS

Findings indicated that both measures are acceptable, although individual- and job-specific item modifications are advised, particularly due to disability-specific needs. Significant change in employment readiness in youth/young adults on the spectrum supports concurrent acceptability. Peer debriefing provided rich data on retrospective acceptability. Acceptability-rates of 0.84 and 0.91 confirm broad acceptability of these measures.

CONCLUSIONS

Implications are presented for clinicians and researchers, highlighting the relevance for autism-specific measurement development and acceptability.Implications for rehabilitationGiven the lower labor force participation of persons on the autism spectrum, a combination of measures should be used in the assessment of an individual's employment readiness.In youth and young adults on the spectrum, employment readiness can be measured using the Work Readiness Inventory (WRI) and a modified version of the Ansell-Casey Life Skills Assessment (ACLSA-M).In clinical practice and research, modifying the contents of these measures may be advised to minimize language complexity, and maximize ease in self report.When designing, developing, and testing new measures in rehabilitation practice or research, the intent should be broadened by involving diverse representation from the project outset, by engaging both those on the spectrum and neurotypical populations.

Delivering screening programmes in primary care: protocol for a scoping and systematic mixed studies review

INTRODUCTION

Screening programmes represent a considerable amount of healthcare activity. As complex interventions, they require careful delivery to generate net benefit. Much screening work occurs in primary care. Despite intensive study of intervention delivery in primary care, there is currently no synthesis of the delivery of screening programmes in this setting. The purpose of this review is to describe and critically evaluate the delivery of screening programmes in general practice and community services.

METHODS AND ANALYSIS

We will use scoping review methods to explore which components of screening programmes are delivered in primary care and systematic review methods to locate and synthesise evidence on how screening programmes can be delivered in primary care, including barriers, facilitators and strategies. We will include empirical studies of any design which consider screening programmes in high-income countries, based in part or whole in primary care. We will search 20 information sources from 1 January 2000, including those relating to health (eg, MEDLINE, Embase, CINAHL), management (eg, Rx for change database) and grey literature (eg, OpenGrey, screening committee websites). Two reviewers will screen citations and full texts of potentially eligible studies and assess these against inclusion criteria. Qualitative and quantitative data will be extracted in duplicate and synthesised using a best fit framework approach. Within the systematic review, the mixed methods appraisal tool will be used to assess risk of bias.

ETHICS AND DISSEMINATION

No ethics approval is required. We will disseminate findings to academics through publication and presentation, to decision-makers through national screening bodies, to practitioners through professional bodies, and to the public through social media.

PROSPERO REGISTRATION NUMBER

CRD42020215420.

A dynamic systems view of clinical genomics: a rich picture of the landscape in Australia using a complexity science lens

Background

Clinical genomics represents a paradigm shifting change to health service delivery and practice across many conditions and life-stages. Introducing this complex technology into an already complex health system is a significant challenge that cannot be managed in a reductionist way. To build robust and sustainable, high quality delivery systems we need to step back and view the interconnected landscape of policymakers, funders, managers, multidisciplinary teams of clinicians, patients and their families, and health care, research, education, and philanthropic institutions as a dynamic whole. This study holistically mapped the landscape of clinical genomics within Australia by developing a complex graphic: a rich picture. Using complex systems theory, we then identified key features, challenges and leverage points of implementing clinical genomics.

Methods

We used a multi-stage, exploratory, qualitative approach. We extracted data from grey literature, empirical literature, and data collected by the Australian Genomic Health Alliance. Nine key informants working in clinical genomics critiqued early drafts of the picture, and validated the final version.

Results

The final graphic depicts 24 stakeholder groups relevant to implementation of genomics into Australia. Clinical genomics lies at the intersection of four nested systems, with interplay between government, professional bodies and patient advocacy groups. Barriers and uncertainties are also shown. Analysis using complexity theory showed far-reaching interdependencies around funding, and identified unintended consequences.

Conclusion

The rich picture of the clinical genomic landscape in Australia is the first to show key stakeholders, agencies and processes and their interdependencies. Participants who critiqued our results were instantly intrigued and engaged by the graphics, searching for their place in the whole and often commenting on insights they gained from seeing the influences and impacts of other stakeholder groups on their own work. Funding patterns showed unintended consequences of increased burdens for clinicians and inequity of access for patients. Showing the system as a dynamic whole is the only way to understand key drivers and barriers to largescale interventions. Trial Registration: Not applicable

Supplementary Information

The online version contains supplementary material available at 10.1186/s12920-021-00910-5.

A Sustainability Model for Family-Focused Practice in Adult Mental Health Services

BACKGROUND

Translating evidence-based practice to routine care is known to take significant time and effort. While many evidenced-based family-focused practices have been developed and piloted in the last 30 years, there is little evidence of sustained practice in Adult Mental Health Services. Moreover, many barriers have been identified at both the practitioner and organizational level, however sustainability of practice change is little understood. What is clear, is that sustained use of a new practice is dependent on more than individual practitioners' practice.

DESIGN AND METHOD

Drawing on research on sustaining Let's Talk about Children in adult mental health services and in the field of implementation science, this article proposes a model for sustaining family focused practice in adult mental health services.

SUSTAINABILITY MODEL FOR FAMILY-FOCUSED PRACTICE

An operational model developed from key elements for sustaining Let's Talk about Children identifies six action points for Adult Mental Health Services and their contexts to support the sustainability of family-focused practices. The model aims to support Services to take action in the complexity of real-world sustainability, providing action points for engaging with service users and practitioners, aligning intra-organizational activities, and the wider context.

CONCLUSION

The model for sustaining family-focused practice draws attention to the importance of sustainability in this field. It provides a practical framework for program developers, implementers, adult mental health services and policy-makers to consider both the components that support the sustainability and their interconnection. The model could be built on to develop implementation guides and measures to support its application.

We Need to Talk About Complexity in Health Research: Findings From a Focused Ethnography

There is increasing focus on complexity-informed approaches across health disciplines. This attention takes several forms, but commonly involves framing research topics as "complex" to justify use of particular methods (e.g., qualitative). Little emphasis is placed on how divergent and convergent ways of knowing complexity become negotiated within academic communities. Drawing on findings from a focused ethnography of an international workshop, we illustrate how health researchers employ "boundary-ordering devices" to navigate different meanings ascribed to complexity while they attempt to sustain interdisciplinary communication and collaboration. These include (a) surfacing (but not resolving) tensions between philosophical grounding of knowledge claims and need for practical purchase, (b) employing techniques of representation and abstraction, and (c) drawing on the fluid, ongoing accomplishment of complexity for different audiences and purposes. Our findings have implications for progressing complexity-informed health research, particularly with respect to qualitative approaches.

Programme theory and linked intervention strategy for large-scale change to improve hospital care in a low and middle-income country - A Study Pre-Protocol

In low and middle-income countries (LMIC) general hospitals are important for delivering some key acute care services. Neonatal care is emblematic of these acute services as averting deaths requires skilled care over many days from multiple professionals with at least basic equipment. However, hospital care is often of poor quality and large-scale change is needed to improve outcomes. In this manuscript we aim to show how we have drawn upon our understanding of contexts of care in Kenyan general hospital NBUs, and on social and behavioural theories that offer potential mechanisms of change in these settings, to develop an initial programme theory guiding a large scale change intervention to improve neonatal care and outcomes.  Our programme theory is an expression of our assumptions about what actions will be both useful and feasible.  It incorporates a recognition of our strengths and limitations as a research-practitioner partnership to influence change. The steps we employ represent the initial programme theory development phase commonly undertaken in many Realist Evaluations. However, unlike many Realist Evaluations that develop initial programme theories focused on pre-existing interventions or programmes, our programme theory informs the design of a new intervention that we plan to execute. Within this paper we articulate briefly how we propose to operationalise this new intervention. Finally, we outline the quantitative and qualitative research activities that we will use to address specific questions related to the delivery and effects of this new intervention, discussing some of the challenges of such study designs. We intend that this research on the intervention will inform future efforts to revise the programme theory and yield transferable learning.

Programme theory and linked intervention strategy for large-scale change to improve hospital care in a low and middle-income country - A Study Pre-Protocol

In low and middle-income countries (LMIC) general hospitals are important for delivering some key acute care services. Neonatal care is emblematic of these acute services as averting deaths requires skilled care over many days from multiple professionals with at least basic equipment. However, hospital care is often of poor quality and large-scale change is needed to improve outcomes. In this manuscript we aim to show how we have drawn upon our understanding of contexts of care in Kenyan general hospital NBUs, and on social and behavioural theories that offer potential mechanisms of change in these settings, to develop an initial programme theory guiding a large scale change intervention to improve neonatal care and outcomes.  Our programme theory is an expression of our assumptions about what actions will be both useful and feasible.  It incorporates a recognition of our strengths and limitations as a research-practitioner partnership to influence change. The steps we employ represent the initial programme theory development phase commonly undertaken in many Realist Evaluations. However, unlike many Realist Evaluations that develop initial programme theories focused on pre-existing interventions or programmes, our programme theory informs the design of a new intervention that we plan to execute. Within this paper we articulate briefly how we propose to operationalise this new intervention. Finally, we outline the quantitative and qualitative research activities that we will use to address specific questions related to the delivery and effects of this new intervention, discussing some of the challenges of such study designs. We intend that this research on the intervention will inform future efforts to revise the programme theory and yield transferable learning.

Exploring the emotional experience of lean

PURPOSE

This research aims to contribute to the literature on Lean implementation in healthcare by studying the emotional experiences of the relevant actors related to a Rapid Process Improvement Workshop (RPIW) in a UK healthcare context. The purpose of this study was to go beyond what people think about Lean and towards an exploration of their subjective, emotional and "feeling" experience and whether that emotional experience influenced Lean implementation.

DESIGN/METHODOLOGY/APPROACH

A phenomenological and symbolic interactionist qualitative case study was undertaken. Data related to participants' emotional experience were collected through non-participant observation and semi-structured interviews. Data were analysed using thematic network analysis.

FINDINGS

This paper provides novel insights into the emotional experience of Lean as experienced through an RPIW. The findings reveal that participation in an RPIW is much more than a technical process. It influences how people feel about themselves, is based on relationships with others, and requires mental, physical and emotional effort. All of these factors influence engagement with, initiation of and sustainability of the RPIW.

RESEARCH LIMITATIONS/IMPLICATIONS

A new conceptual framework for the planning and implementation of RPIWs has been developed. However, because of the chosen research approach, the results may lack generalisability. Therefore, researchers are encouraged to test the framework and proposed practice implications.

ORIGINALITY/VALUE

Despite emotions being an integral part of individual and social everyday life, emotional experience has not been studied in relation to Lean. This study is the first to explore emotions in relation to Lean, with implications for practice as to how RPIWs are managed with a new framework for implementation being proposed.

Publication and related bias in quantitative health services and delivery research: a multimethod study

Background

Bias in the publication and reporting of research findings (referred to as publication and related bias here) poses a major threat in evidence synthesis and evidence-based decision-making. Although this bias has been well documented in clinical research, little is known about its occurrence and magnitude in health services and delivery research.

Objectives

To obtain empirical evidence on publication and related bias in quantitative health services and delivery research; to examine current practice in detecting/mitigating this bias in health services and delivery research systematic reviews; and to explore stakeholders’ perception and experiences concerning such bias.

Methods

The project included five distinct but interrelated work packages. Work package 1 was a systematic review of empirical and methodological studies. Work package 2 involved a survey (meta-epidemiological study) of randomly selected systematic reviews of health services and delivery research topics (n = 200) to evaluate current practice in the assessment of publication and outcome reporting bias during evidence synthesis. Work package 3 included four case studies to explore the applicability of statistical methods for detecting such bias in health services and delivery research. In work package 4 we followed up four cohorts of health services and delivery research studies (total n = 300) to ascertain their publication status, and examined whether publication status was associated with statistical significance or perceived ‘positivity’ of study findings. Work package 5 involved key informant interviews with diverse health services and delivery research stakeholders (n = 24), and a focus group discussion with patient and service user representatives (n = 8).

Results

We identified only four studies that set out to investigate publication and related bias in health services and delivery research in work package 1. Three of these studies focused on health informatics research and one concerned health economics. All four studies reported evidence of the existence of this bias, but had methodological weaknesses. We also identified three health services and delivery research systematic reviews in which findings were compared between published and grey/unpublished literature. These reviews found that the quality and volume of evidence and effect estimates sometimes differed significantly between published and unpublished literature. Work package 2 showed low prevalence of considering/assessing publication (43%) and outcome reporting (17%) bias in health services and delivery research systematic reviews. The prevalence was lower among reviews of associations than among reviews of interventions. The case studies in work package 3 highlighted limitations in current methods for detecting these biases due to heterogeneity and potential confounders. Follow-up of health services and delivery research cohorts in work package 4 showed positive association between publication status and having statistically significant or positive findings. Diverse views concerning publication and related bias and insights into how features of health services and delivery research might influence its occurrence were uncovered through the interviews with health services and delivery research stakeholders and focus group discussion conducted in work package 5.

Conclusions

This study provided prima facie evidence on publication and related bias in quantitative health services and delivery research. This bias does appear to exist, but its prevalence and impact may vary depending on study characteristics, such as study design, and motivation for conducting the evaluation. Emphasis on methodological novelty and focus beyond summative assessments may mitigate/lessen the risk of such bias in health services and delivery research. Methodological and epistemological diversity in health services and delivery research and changing landscape in research publication need to be considered when interpreting the evidence. Collection of further empirical evidence and exploration of optimal health services and delivery research practice are required.

Study registration

This study is registered as PROSPERO CRD42016052333 and CRD42016052366.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 33. See the NIHR Journals Library website for further project information.

Evaluation of systems reform in public hospitals, Victoria, Australia, to improve access to antenatal care for women of refugee background: An interrupted time series design

INTRODUCTION

Inequalities in maternal and newborn health persist in many high-income countries, including for women of refugee background. The Bridging the Gap partnership programme in Victoria, Australia, was designed to find new ways to improve the responsiveness of universal maternity and early child health services for women and families of refugee background with the codesign and implementation of iterative quality improvement and demonstration initiatives. One goal of this 'whole-of-system' approach was to improve access to antenatal care. The objective of this paper is to report refugee women's access to hospital-based antenatal care over the period of health system reforms.

METHODS AND FINDINGS

The study was designed using an interrupted time series analysis using routinely collected data from two hospital networks (four maternity hospitals) at 6-month intervals during reform activity (January 2014 to December 2016). The sample included women of refugee background and a comparison group of Australian-born women giving birth over the 3 years. We describe the proportions of women of refugee background (1) attending seven or more antenatal visits and (2) attending their first hospital visit at less than 16 weeks' gestation compared over time and to Australian-born women using logistic regression analyses. In total, 10% of births at participating hospitals were to women of refugee background. Refugee women were born in over 35 countries, and at one participating hospital, 40% required an interpreter. Compared with Australian-born women, women of refugee background were of similar age at the time of birth and were more likely to be having their second or subsequent baby and have four or more children. At baseline, 60% of refugee-background women and Australian-born women attended seven or more antenatal visits. Similar trends of improvement over the 6-month time intervals were observed for both populations, increasing to 80% of women at one hospital network having seven or more visits at the final data collection period and 73% at the other network. In contrast, there was a steady decrease in the proportion of women having their first hospital visit at less than 16 weeks' gestation, which was most marked for women of refugee background. Using an interrupted time series of observational data over the period of improvement is limited compared with using a randomisation design, which was not feasible in this setting.

CONCLUSIONS

Accurate ascertainment of 'harder-to-reach' populations and ongoing monitoring of quality improvement initiatives are essential to understand the impact of system reforms. Our findings suggest that improvement in total antenatal visits may have been at the expense of recommended access to public hospital antenatal care within 16 weeks of gestation.

Publication and related biases in health services research: a systematic review of empirical evidence

Background

Publication and related biases (including publication bias, time-lag bias, outcome reporting bias and p-hacking) have been well documented in clinical research, but relatively little is known about their presence and extent in health services research (HSR). This paper aims to systematically review evidence concerning publication and related bias in quantitative HSR.

Methods

Databases including MEDLINE, EMBASE, HMIC, CINAHL, Web of Science, Health Systems Evidence, Cochrane EPOC Review Group and several websites were searched to July 2018. Information was obtained from: (1) Methodological studies that set out to investigate publication and related biases in HSR; (2) Systematic reviews of HSR topics which examined such biases as part of the review process. Relevant information was extracted from included studies by one reviewer and checked by another. Studies were appraised according to commonly accepted scientific principles due to lack of suitable checklists. Data were synthesised narratively.

Results

After screening 6155 citations, four methodological studies investigating publication bias in HSR and 184 systematic reviews of HSR topics (including three comparing published with unpublished evidence) were examined. Evidence suggestive of publication bias was reported in some of the methodological studies, but evidence presented was very weak, limited in both quality and scope. Reliable data on outcome reporting bias and p-hacking were scant. HSR systematic reviews in which published literature was compared with unpublished evidence found significant differences in the estimated intervention effects or association in some but not all cases.

Conclusions

Methodological research on publication and related biases in HSR is sparse. Evidence from available literature suggests that such biases may exist in HSR but their scale and impact are difficult to estimate for various reasons discussed in this paper.

Systematic review registration

PROSPERO 2016 CRD42016052333.