Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies

Essential competencies of nurses working with AI-driven lifestyle monitoring in long-term care: A modified Delphi study

BACKGROUND

As more and more older adults prefer to stay in their homes as they age, there's a need for technology to support this. A relevant technology is Artificial Intelligence (AI)-driven lifestyle monitoring, utilizing data from sensors placed in the home. This technology is not intended to replace nurses but to serve as a support tool. Understanding the specific competencies that nurses require to effectively use it is crucial. The aim of this study is to identify the essential competencies nurses require to work with AI-driven lifestyle monitoring in long-term care.

METHODS

A three round modified Delphi study was conducted, consisting of two online questionnaires and one focus group. A group of 48 experts participated in the study: nurses, innovators, developers, researchers, managers and educators. In the first two rounds experts assessed clarity and relevance on a proposed list of competencies, with the opportunity to provide suggestions for adjustments or inclusion of new competencies. In the third round the items without consensus were bespoken in a focus group.

FINDINGS

After the first round consensus was reached on relevance and clarity on n = 46 (72 %) of the competencies, after the second round on n = 54 (83 %) of the competencies. After the third round a final list of 10 competency domains and 61 sub-competencies was finalized. The 10 competency domains are: Fundamentals of AI, Participation in AI design, Patient-centered needs assessment, Personalisation of AI to patients' situation, Data reporting, Interpretation of AI output, Integration of AI output into clinical practice, Communication about AI use, Implementation of AI and Evaluation of AI use. These competencies span from basic understanding of AI-driven lifestyle monitoring, to being able to integrate it in daily work, being able to evaluate it and communicate its use to other stakeholders, including patients and informal caregivers.

CONCLUSION

Our study introduces a novel framework highlighting the (sub)competencies, required for nurses to work with AI-driven lifestyle monitoring in long-term care. These findings provide a foundation for developing initial educational programs and lifelong learning activities for nurses in this evolving field. Moreover, the importance that experts attach to AI competencies calls for a broader discussion about a potential shift in nursing responsibilities and tasks as healthcare becomes increasingly technologically advanced and data-driven, possibly leading to new roles within nursing.

Supervised Toothbrushing Programmes: Understanding Barriers and Facilitators to Implementation

OBJECTIVES

Supervised toothbrushing programmes (STPs), whereby children brush their teeth at nursery or school with a fluoride toothpaste under staff supervision, are a clinically and cost-effective intervention to reduce dental caries. However, uptake is varied, and the reasons unknown. The aim was to use an implementation science approach to explore the perspectives of key stakeholders on the barriers and facilitators at each level of implementation of STPs.

METHODS

This qualitative study involved individual interviews and focus groups with a purposive sample of stakeholders involved at all levels of implementation of STPs: (1) policymakers; (2) providers of STPs; (3) nursery/school staff; (4) parents/carers; and (5) children (aged 2-6 years old) across England. Data collection and analysis were guided by the Consolidated Framework for Implementation Research (CFIR).

RESULTS

A total of 159 stakeholders were interviewed (40 individual interviews and 17 focus groups) across all levels of implementation. Barriers and facilitators to STP implementation were identified across 35 of the 39 CFIR constructs. Four themes were identified that determined STP implementation: (1) acceptability of STPs; (2) external 'make or break' conditions; (3) the importance of engagement across the system; and (4) desire for centralised support.

CONCLUSIONS

This is the first study to qualitatively explore the barriers and facilitators to STP at all levels of implementation underpinned by an implementation science framework. The findings have strong implications for policymakers who wish to implement STPs, highlighting the need for careful consideration of the adaptability of the programmes, the role of formal and informal engagement systems, and the need for centralised support. This work has facilitated the co-design and piloting of a supervised toothbrushing implementation toolkit, which provides a central hub of resources and good practice to optimise implementation of STPs at scale.

Effect and acceptability of an mHealth smoking cessation intervention 'Stopcoach' combined with smoking cessation counseling for people from multiple levels of socioeconomic position: a multi-methods study

INTRODUCTION

Smoking cessation interventions tend to be less effective for people of lower socioeconomic position (SEP) compared to those of higher SEP. Mobile phone-based interventions have been shown to increase abstinence from smoking. Stopcoach is an mHealth smoking cessation intervention that specifically targets people with a lower SEP. A pilot study showed the potential and feasibility of Stopcoach but as yet no research exists that assesses the effectiveness of Stopcoach.

OBJECTIVE

This study aims to evaluate whether using Stopcoach in combination with group-based smoking cessation counselling (SCC; intervention group) increases short- and long-term abstinence compared to SCC alone (control groups). Secondarily, this study aims to assess acceptability of Stopcoach as perceived by people who smoke and SCC group coaches.

METHODS

This multi-methods study was originally designed comparing an intervention group (n = 242; 2020-2022) to a historical control group (n = 3362; 2018-2020) that did not use Stopcoach. However, the COVID-19 pandemic hampered realistic comparison due to declining abstinence rates. Therefore, a COVID-era control group was added (n = 312; 2020-2021). All participants enrolled in professionally led SCC groups. The primary outcome was abstinence at four weeks and one year after quit date. In the intervention group, usability, acceptability and usefulness were also measured. In a qualitative assessment, eight SCC trainers were interviewed to explore acceptance by trainers and integration of Stopcoach into SCC.

RESULTS

Due to the COVID-19 related overall decline in abstinence rates, the intervention group had lower abstinence rates compared to the pre-COVID control group (73.6% vs. 78.2% p < 0.001). However, the COVID-era control group revealed that Stopcoach, as addition to accredited SCC, was associated with higher abstinence rates after four weeks than SCC alone (73.6% vs. 57.1%, p < 0.001). This difference was sustained in the lower SEP subgroup (65.6% vs. 49.6%, p = 0.043). No overall significant differences in 1-year abstinence rates were found between the intervention group and both control groups. Participants rated usability, acceptability and usefulness highly positive, irrespective of SEP. Qualitative measures showed most trainers welcomed adding Stopcoach to their SCC.

CONCLUSION

Addition of the Stopcoach app to SCC appears effective and feasible. Importantly, this also holds for the lower SEP subgroup. This makes Stopcoach one of the few smoking cessation mHealth interventions that also meets the needs of people with lower SEP who smoke.

Advancing the selection of implementation science theories, models, and frameworks: a scoping review and the development of the SELECT-IT meta-framework

BACKGROUND

Theories, models, and frameworks (TMFs) are central to implementation practice and research. Selecting one or more TMF(s) for a project remains challenging due to numerous options and limited guidance. This study aimed to (1) identify and categorize the reported purposes and attributes of TMFs, as well as the practical considerations of TMF users, and (2) synthesize these findings into a meta-framework that supports implementation practitioners and researchers in selecting TMFs.

METHODS

A scoping review was conducted using Joanna Briggs Institute guidelines. Medline, Embase, and CINAHL were searched to identify articles on the selection of TMFs. Articles were selected and data extracted using Covidence. Inductive thematic analysis was used to refine and categorize purposes, attributes and practical considerations. The meta-framework was developed by mapping these categories onto a sequential process, pilot-testing through case studies, and iteratively refining it based on team feedback.

RESULTS

Of 9,276 records, 43 articles (2005-2024) were included. Most articles reported TMF purposes (41 articles), followed by attributes (30) and practical considerations (13). Seven distinct purposes were identified: (1) enhancing conceptual clarity, (2) anticipating change and guiding inquiry, (3) guiding the implementation process, (4) guiding identification of determinants, (5) guiding design and adaptation of strategies, (6) guiding evaluation and causal explanation, and (7) guiding interpretation and dissemination. Additionally, 24 TMF attributes were grouped into five domains: clarity and structure, scientific strength and evidence, applicability and usability, equity and sociocultural responsiveness, and system and partner integration. Ten practical considerations were grouped into three domains: team expertise and readiness, resource availability, and project fit. These findings informed the development of the Systematic Evaluation and Selection of Implementation Science Theories, Models and Frameworks (SELECT-IT) meta-framework, comprising four steps: (1) determine the purpose(s) of using TMF(s); (2) identify potential TMFs; (3) evaluate short-listed TMFs against attributes; and (4) assess practical considerations of using TMF(s) within the project context. A worked example and two user-friendly worksheets illustrate its utility.

CONCLUSIONS

This study advances understanding of the selection of implementation science TMFs by distinguishing inherent TMF attributes from practical considerations. The SELECT-IT meta-framework offers a structured, context-sensitive approach for selecting appropriate TMFs. Future research should evaluate its validity and utility across diverse contexts.

Clinical effectiveness and cost-effectiveness of the rehabilitation enablement in chronic heart failure facilitated self-care rehabilitation intervention for people with heart failure with preserved ejection fraction and their caregivers: rationale and protocol for a multicentre randomised controlled trial - REACH-HFpEF trial

INTRODUCTION

Heart failure with preserved ejection fraction (HFpEF) is common and causes functional limitation, poor health-related quality of life (HRQoL) and impairs prognosis. Exercise-based cardiac rehabilitation is a promising intervention for HFpEF, but there is currently insufficient evidence to support its routine use. This trial will assess the clinical and cost-effectiveness of a 12-week health professional-facilitated, home-based rehabilitation intervention (REACH-HF), in people with HFpEF, for participants and their caregivers.

METHODS AND ANALYSIS

REACH-HFpEF is a parallel two group multicentre randomised controlled trial with 1:1 individual allocation to the REACH-HF intervention plus usual care (intervention group) or usual care alone (control group) with a target sample size of 372 participants with HFpEF and their caregivers recruited from secondary care centres in United Kingdom. Outcome assessment and statistical analysis will be performed blinded; outcomes will be assessed at baseline and 4-month and 12-month follow-up. The primary outcome measure will be patients' disease-specific HRQoL, measured using the Minnesota Living with Heart Failure questionnaire, at 12 months. Secondary outcomes include patient's exercise capacity, psychological well-being, level of physical activity, generic HRQoL, self-management, frailty, blood biomarkers, mortality, hospitalisations, and serious adverse events, and caregiver's HRQoL and burden. A process evaluation and substudy will assess the fidelity of intervention delivery and adherence to the home-based exercise regime and explore potential mediators and moderators of changes in HRQoL with the intervention. Qualitative studies will describe facilitators' experiences of delivery of the intervention. A cost-effectiveness analysis (CEA) of the REACH-HF intervention in participants with HFpEF will estimate incremental cost per quality-adjusted life year at 12 months. The CEA will be conducted from a UK NHS and Personal Social Services perspective and a wider societal perspective. The adequacy of trial recruitment in an initial 6-month internal pilot period will also be checked.

ETHICS AND DISSEMINATION

The study is approved by the West of Scotland Research Ethics Committee (ref 21/WS/0085). Results will be disseminated via peer-reviewed journal publication and conference presentations to researchers, service users and policymakers.

TRIAL REGISTRATION NUMBER

ISRCTN47894539.

Triple cardiovascular disease detection with an artificial intelligence-enabled stethoscope (TRICORDER): design and rationale for a decentralised, real-world cluster-randomised controlled trial and implementation study

INTRODUCTION

Early detection of cardiovascular disease in primary care is a public health priority, for which the clinical and cost-effectiveness of an artificial intelligence-enabled stethoscope that detects left ventricular systolic dysfunction, atrial fibrillation and cardiac murmurs is unproven but potentially transformative.

METHODS AND ANALYSIS

TRICORDER is a pragmatic, two-arm, multi-centre (decentralised), cluster-randomised controlled trial and implementation study. Up to 200 primary care practices in urban North West London and rural North Wales, UK, will be randomised to usual care or to have artificial intelligence-enabled stethoscopes available for use. Primary care clinicians will use the artificial intelligence-enabled stethoscopes at their own discretion, without patient-level inclusion or exclusion criteria. They will be supported to do so by a clinical guideline developed and approved by the regional health system executive board. Patient and outcome data will be captured from pooled primary and secondary care records, supplemented by qualitative and quantitative clinician surveys. The coprimary endpoints are (i) difference in the coded incidence (detection) of heart failure and (ii) difference in the ratio of coded incidence of heart failure via hospital admission versus community-based diagnostic pathways. Secondary endpoints include difference in the incidence of atrial fibrillation and valvular heart disease, cost-consequence differential, and prescription of guideline-directed medical therapy.

ETHICS AND DISSEMINATION

This trial has ethical approval from the UK Health Research Authority (23/LO/0051). Findings from this trial will be disseminated through publication of peer-reviewed manuscripts, presentations at scientific meetings and conferences with local and national stakeholders.

TRIAL REGISTRATION NUMBER

NCT05987670.

How to Implement Digital Clinical Consultations in UK Maternity Care: the ARM@DA Realist Review

Background

Digital transformation is a key component within the National Health Service Maternity Transformation Programme. The COVID-19 pandemic led to an acceleration of digital innovation, in particular, the use of digital clinical consultations (telephone/video consultations). The ways in which digital clinical consultations can be optimised and utilised alongside the traditional maternity care pathway remains unclear, however, with particular concerns about the potential for digital care to exacerbate inequalities.

Objective

To explore how digital clinical consultations can be implemented in a clinically safe, appropriate and acceptable way within UK maternity services? For whom? In what settings? And for what purposes?

Design

A realist synthesis combining an evidence review of diverse sources (2010 to the present) from Organisation for Economic Co-operation and Development countries with insights from key stakeholder groups (healthcare professionals, service users and community organisations).

Data sources

There were three main sources: (1) published primary and secondary research; (2) grey literature (such as policy documents and maternity safety reports); and (3) stakeholder insights.

Methods

A realist synthesis adopts a theory-driven approach which seeks to understand how a complex programme works, for whom and under what circumstances. The review had three iterative phases: (1) refining the review focus and developing initial programme theories; (2) retrieval of evidence for data extraction and analysis (using on a realist logic to identify key contexts, mechanisms and outcomes); and (3) testing and refining the programme theories.

Results

The final synthesis included 93 evidence sources (reviews, reports and 77 primary studies), with priority given to UK-focused studies. Study samples included a focus on healthcare professionals (n = 17), women (n = 45, of which 14 focused on vulnerable groups) or both (n = 15). Clinical and safety-related outcomes were reported in 12 studies. Fifteen programme theories were developed. A conceptual framework was produced that illustrates the inter-relationship between key contexts in maternity care through which different interactions activate mechanisms to produce outcomes of interest. The findings suggest that digital clinical consultations can be acceptable and appropriate if implementation includes personalisation and informed choice for women, as well as support and autonomy for staff. The relationship and connection between women and their healthcare professional are proposed as key mechanisms that support safety and engagement in care.

Limitations

Some of the evidence lacked details regarding specific settings, interventions or sample characteristics. This limits the extent to which findings can be applied to micro-level contexts. Stakeholder groups contributed key insights to the review at all stages. In spite of efforts to achieve diversity within these groups, there may have been experiences or identities that were missed.

Conclusions

Four 'CORE' implementation principles were identified to guide future practice and research: C - Creating the right environment, infrastructure and support for staff; O - Optimising consultations to be responsive, flexible and personalised to different needs and preferences; R - Recognising the importance of access and inclusion; and E - Enabling quality and safety through relationship-focused connections.

Future work

Future research should embed equity considerations and should focus on understanding digital clinical consultation within specific maternity systems (like triage/helplines), services (such as specialist outpatient clinics) or groups of women (e.g. with digital literacy or communication needs).

Funding

This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research as award number NIHR134535.

Optimising digital advance care planning implementation in palliative and end-of-life care: a multi-phase mixed-methods national research programme and recommendations

BACKGROUND

Digital advance care planning (DACP) is increasingly used globally for patients with life-limiting conditions to support real-time documentation and the sharing of preferences for care. There has been low engagement with DACP systems, with patients often having information about their care preferences documented late in their illness trajectory or not at all. To optimise implementation, the Optimal Care research programme sought to understand DACP system use from multiple perspectives to guide their development and evaluation.

METHODS

Between 2020 and 2023, our mixed-methods research programme sought an understanding of DACP implementation from multiple perspectives, including (i) national online survey of end-of-life care commissioning leads in England; (ii) online survey of community and hospital-based health and care professionals in two geographical regions; (iii) semi-structured interviews with a sample of survey respondents; (iv) focus groups and interviews with patients with life-limiting illness and their carers and (v) regional and national Theory of Change workshops. Findings were organised by five phases of a conceptual model of DACP generated during the programme and further categorised using the Non-adoption, Abandonment, Scale-up, Spread and Sustainability (NASSS) framework.

RESULTS

A total of 788 stakeholders participated. Twenty evidence-based recommendations were distilled from data collected across the research programme to guide the implementation of DACP in routine care. Considerations are provided across the five phases of DACP implementation (system design, recognition of clinical need for DACP, documentation processes, health and care professional engagement with DACP and DACP evaluation). Recommendations prioritise a focus on end-user needs and experiences, alongside highlighting the requisite need for DACP systems to support information exchange across settings involved in the care of people with life-limiting conditions.

CONCLUSIONS

As currently designed and implemented, DACP systems may be falling short of their potential and are not working as intended for patients, carers and health and care professionals. The application of the recommendations should ensure consideration of the wider ecosystem in which DACP is being implemented, prioritising end-user experiences. Future research should prioritise developing approaches that target health and care professional DACP system engagement, alongside developing and evaluating patient and carer access to DACP systems.

Exploring people with stroke's perceptions of digital technologies in post-stroke rehabilitation - a qualitative study

PURPOSE

Stroke survivors often report unmet rehabilitation needs. Digital care has become increasingly prevalent, but limited research has explored its role in stroke rehabilitation, particularly from perspectives of people with chronic stroke. This study aims to explore how people with stroke perceive the usage of digital technologies in post-stroke rehabilitation.

METHODS

A qualitative study was conducted from June 2022 to January 2023, encompassing semi-structured interviews with 17 stroke participants recruited from a Norwegian rehabilitation hospital. Reflexive thematic analysis was applied.

RESULTS

Two themes were generated 1) "Still digitally connected" Digitalisation and its impact on everyday life and rehabilitation services, and 2) "To bring people closer" The need for personal contact and responsibility in digital rehabilitation services. Participants continued using digital technologies in rehabilitation and recognised digital self-management tools as beneficial for exercising and gaining information in the stroke process. They used various technologies to stay connected to the rehabilitation network, such as video-consultations, apps and exergaming.

CONCLUSIONS

This study highlights the importance of digital tools in managing the individuals' rehabilitation post-stroke. Digital technologies have the potential to deliver an interactive and person-centred rehabilitation service between healthcare professionals and people with stroke, but evaluation of technology use challenges after stroke is emphasised.

The use of implementation science theoretical approaches in hybrid effectiveness-implementation type 1 randomised trials of healthcare interventions: A scoping review

BACKGROUND

Hybrid type 1 effectiveness-implementation randomised controlled trials (RCTs) aim to accelerate the translation of proven clinical interventions into routine care by concurrently investigating the effectiveness of clinical interventions and the context for real-world implementation. Hybrid type 1 RCTs can make use of implementation science theoretical approaches (i.e., theories, models, and frameworks) to understand barriers and facilitators to sustainable implementation of clinical interventions; however, the extent to which these approaches have been used in hybrid type 1 RCTs has not been systematically investigated. This scoping review aimed to investigate the extent to which implementation science theoretical approaches have been used in hybrid type 1 RCTs of healthcare interventions and describe which approaches have been reported and how they have been used.

METHODS

The review was conducted in accordance with the pre-registered protocol ( https://doi.org/10.17605/OSF.IO/CJ8A7 ). Searches of six electronic databases were conducted for published hybrid type 1 RCTs evaluating any clinical intervention in any healthcare setting. The included trials were full-text, peer-reviewed primary research articles written in English, and reporting the findings of hybrid type 1 RCTs of healthcare interventions. Non-English language reports, reviews, protocols without a linked trial results report, methodological papers, opinion pieces, commentaries, books/book chapters, dissertations, and conference abstracts were excluded. Two reviewers independently selected studies, extracted data, and assessed use of theoretical approach/es.

RESULTS

We identified 8,878 citations, screened 673 full-text records, and included 37 trials. Most trials were conducted in North America (68%), investigating clinical interventions for mental health problems (32%) in adults (43%). Twenty-eight (76%) trials cited use of at least one theoretical approach. The most common was the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework (43%). Theoretical approaches were most often applied (62%) to justify the implementation study design, guide selection of study materials or analyse implementation outcomes.

CONCLUSION

The majority of published hybrid type 1 effectiveness-implementation RCTs of healthcare interventions report using at least one theoretical approach to explore the context for implementation. Use of implementation science theories, models, and/or frameworks to understand the barriers and facilitators to implementation and sustainability of proven clinical interventions is likely to accelerate future translation of evidence-based practices into routine care and thus optimise patient outcomes.

Experiences Receiving and Delivering Virtual Health Care For Women: Qualitative Evidence Synthesis

BACKGROUND

Persisting sex- and gender-based disparities in access to high-quality, personalized health care in the United States can lead to devastating outcomes with long-lasting consequences. Strategic use of virtual resources could expand equitable health care access for women. However, optimal approaches and timing for individualized, virtually delivered health care for women are unclear.

OBJECTIVE

This study aims to conduct a detailed analysis of the current literature to answer the following question: "According to women and their health care teams, what are the reported successes and challenges in accessing, delivering, and participating in synchronous virtual health care for women?"

METHODS

We conducted a qualitative evidence synthesis using a best-fit framework approach based on the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework and concepts from the Public Health Critical Race Praxis. We searched MEDLINE, Embase, and CINAHL from January 1, 2010, to October 10, 2022, using a combination of database-specific, relevant, controlled vocabulary terms and keywords; this search was updated in MEDLINE through January 2024. Additional citations were identified through handsearching. Our eligibility criteria were developed using the Sample, Phenomenon of Interest, Design, Evaluation, Research type tool to identify qualitative studies addressing synchronous virtual care for women. Citations were screened in duplicate, and eligible articles were abstracted. An iterative thematic synthesis approach was used to identify descriptive themes related to the successes and challenges related to delivering high-quality virtual care. Data reduction was performed using inductive and deductive reasoning. Quality assessment was conducted using the Critical Appraisal Skills Program and certainty of evidence using Confidence in the Evidence from Reviews of Qualitative Research approaches.

RESULTS

Of 85 eligible articles, we sampled 51 (60%) for data extraction based on representation of patient and clinician perspectives, marginalized voices, and relevance to a variety of clinical contexts. We identified themes across NASSS domains, including difficulty building rapport and emotional connections in the virtual setting, the amplification of barriers for women with preexisting challenges (eg, language barriers, limited transportation, and family and social commitments), and differing perceptions of privacy and safety related to virtual care depending on patient home context. Themes found to have high confidence included the value of convenience and cost savings offered by virtual care, the importance of patient choice in visit modality, the potential for negative impact on user well-being, considering the clinical context of modality choice, the importance of technology usability, and the value of virtual care for women located in regions without adequate supply of clinical offerings.

CONCLUSIONS

The benefits of virtual care for health care access may be more acutely felt by women, especially those with preexisting challenges. Strategic incorporation of virtual modalities into health care delivery for women could improve equitable access to high quality, patient-centered care.

TRIAL REGISTRATION

PROSPERO CRD42021283791; https://www.crd.york.ac.uk/PROSPERO/view/CRD42021283791.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1089/heq.2023.0089.

Evaluating for learning and sustainability (ELS) framework: a realist synthesis

BACKGROUND

Learning Health Systems (LHS), in which continuous and equitable improvements support optimization of healthcare practices, outcomes, experience, and costs, offer enormous potential for health system transformation. Within the LHS model, evaluation of health innovations assists in question identification, data collection, and targeted action, which facilitates continuous improvement. Evaluation that catalyzes learning may contribute to health innovation implementation, refinement, and sustainability, however, there is little consensus as to why certain evaluations support learning, while others impede it.

METHODS

Embedded in the implementation science literature, we conducted a realist synthesis to understand evaluative contextual factors and underlying mechanisms that best support health system learning and sustainable implementation of innovations. We sought to understand whether evaluations can 'work' to support learning and sustainability, in which contexts, for whom, and why. Working with an Expert Committee comprised of leaders in evaluation, innovation, sustainability, and realist methodology, we followed a five-stage process of: 1. Scoping the Review, 2. Building Theories, 3. Identifying the Evidence, 4. Evidence Selection and Appraisal, and 5.

DATA EXTRACTION AND SYNTHESIS

Our Review Team and Expert Committee participated in iterative cycles of results interpretation and feedback.

RESULTS

Our synthesis includes 60 articles capturing the mechanisms and contextual factors driving learning and sustainability through evaluation. We found that evaluations that support learning and sustainability incorporate favourable organizational preconditions and focus on implementing rapid cyclical feedback loops that contribute to a culture of innovation and evaluation sustainability. Our findings have been organized into 6 Context-Mechanism-Outcome Configurations (CMOCs): 1. Embracing Risk & Failure; 2. Increasing Capacity for Evaluation; 3. Co-Producing Evaluation; 4. Implementing Learning Feedback Loops; 5. Creating Sustainability Culture; and 6. Becoming a Learning Organization. We have also translated findings into a series of Action Strategies for evaluation implementation to support health systems learning and sustainability.

CONCLUSIONS

We identified key contextual factors and underlying mechanisms that make evaluations 'work' (or 'not work') to support learning and sustainability. Findings support the operationalization of LHS by translating CMOCs into Action Strategies for those tasked with completing evaluations with a view toward health system learning and innovation sustainability.

Using a Robot to Address the Well-Being, Social Isolation, and Loneliness of Care Home Residents via Video Calls: Qualitative Feasibility Study

Background

About 40,000 people are living in Norwegian care homes, where a majority are living with a dementia diagnosis. Social isolation and loneliness are common issues affecting care home residents' quality of life. Due to visitation restrictions during the pandemic, residents and family members started using digital solutions to keep in contact. There is no framework or guidelines to inform the uptake and use of technologies in the care home context, and this often results in non-adoption and a lack of use after the introduction phase. Hence, there is a great need for research on the feasibility of a robot that can facilitate video communication between residents and family members.

Objective

This study aimed to (1) introduce video communication through a robot to address social isolation and loneliness in a care home during a period of 6 weeks and (2) identify elements central to the feasibility concerning testing and evaluating the use of the robot.

Methods

Three focus group interviews were undertaken: 1 with family members (n=4) and 2 with care staff (n=2 each). The informants were purposely selected to ensure that they had the proper amount of experience with the robot to have the ability to inform this study's objectives. The focus group interviews were tape-recorded and transcribed verbatim, then subsequently analyzed using systematic text condensation.

Results

The data analysis of focus group interviews and individual interviews resulted in three categories: (1) organizing the facilitation of video calls, (2) using a robot in dementia care, and (3) user experience with the robot.

Conclusions

Video communication in care homes is a feasible alternative to face-to-face interactions, but it depends on organizational factors such as information flow, resources, and scheduling. In dementia care, the user-friendly robot supports person-centered care through tailored social interaction. Both family members and staff express enthusiasm for video calls as an option and see its potential for future use.

Technology-enabled CONTACT tracing in care homes in the COVID-19 pandemic: the CONTACT non-randomised mixed-methods feasibility study

Background

Coronavirus disease 2019 devastated lives in care homes for older people, where residents faced higher mortality risks than the general population. Infection prevention and control decisions were critical to protect these vulnerable residents. Infection prevention and control measures like 'lockdowns' had their own risks, such as social isolation, alongside assumed benefits. A key non-pharmaceutical intervention for managing infections is contact tracing. Traditional contact tracing, which relies on recalling contacts, is not feasible in care homes where approximately 70% of residents have cognitive impairments. The CONtact TrAcing in Care homes using digital Technology intervention introduces Bluetooth-enabled wearable devices for automated contact tracing. We provided structured reports (scheduled regularly and in reaction to positive COVID-19 cases) on contact patterns to homes to support better-informed infection prevention and control decisions and potentially reduce blanket restrictive measures. We also partnered with the PROTECT COVID-19 research team to examine air quality in two of our homes.

Methods

CONTACT was a non-randomised mixed-method feasibility study in four English care homes. Recruitment was via care home research networks, with individual consent. Data collection included routine device data, case report forms, qualitative interviews, field observations of care home activity and an adapted Normalisation Measure Development questionnaire survey to explore implementation using normalisation process theory. Quantitative data were analysed using descriptive statistical methods, and qualitative data were thematically analysed using normalisation process theory. Intervention and study delivery were evaluated against predefined progression criteria.

Results

Of 156 eligible residents, 105 agreed to wear a device, with 102 (97%) starting the intervention. Of 225 eligible staff, 82.4% (n = 178) participated. Over 2 months, device loss and battery failure were significant: residents lost 11% of devices, with half replaced. Staff lost fewer devices, just 6.5%, but < 10% were replaced. Fob wearables needed more battery changes than card-type devices (15% vs. 0%). Homes variably understood structured and reactive feedback but were unlikely to act on it. Researcher support for interpreting reports was valued. Homes found information useful when it confirmed rather than challenged preconceived contact patterns. Staff privacy concerns were a barrier to adoption. Study procedures added to existing work, making participation burdensome. The perceived burden of participation, amplified by the pandemic context, outweighed the benefits. CONTACT did not meet its quantitative or qualitative progression criteria.

Limitations

Researchers had to pragmatically adapt procedures, resulting in suboptimal implementation choices from an implementation science perspective. Future research should co-design interventions with homes, focusing on implementation and wearability as much as technical effectiveness.

Conclusion

A definitive trial of CONTACT was not feasible or acceptable to care homes, partly due to the shifting pandemic context and demands on homes. With more effective implementation, Bluetooth-enabled wearable systems as part of 'Internet of Things' in homes could be used to: (1) better understand airborne transmission risks, ventilation and air quality and (2) make important relational aspects of care quality and residents' quality of life more transparent.

Future work

We will continue to explore the possibilities of Bluetooth-enabled wearables for modelling social networks, movement, infection risks and quality in care homes with academic and care partners.

Funding

This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR132197.

Technology-enabled community pharmacies: qualitative evaluation of a framework for assessing technology solutions

OBJECTIVES

Optimal provision of pharmacists' professional services requires integrated digital health platforms and ideally an evaluation framework to guide implementation and adoption. The Technology Evaluation Key (TEK) framework, which combines three published models describing technology usage behaviour, had not been applied to identify technological needs for community pharmacists to enable practice. This research aimed to describe pharmacists' needs relating to information communication technology (ICT) platforms and apply the findings to refine the TEK framework.

METHODS

This study was conducted in Australia between June and July 2022 (approval number HRE2022-0249). A systematic scoping review, face and content validation, and field testing guided the development of the interview tool. Semi-structured online interviews were conducted with participants until data saturation, where no new themes emerged. Following Braun and Clarke's six-step reflexive thematic analysis, a deductive-to-inductive approach was utilised to identify themes, which were applied to the TEK framework to refine domains. Coding was conducted by [A.O.] and confirmed by consensus with the other authors.

KEY FINDINGS

Twenty-four pharmacists were interviewed. Thematic analysis identified technological needs that included greater system integration, interoperability, and increased user access to nationally commissioned ICT systems. The TEK framework was refined from nine to eight domains accordingly (healthcare system, organisation, practitioner, ICT, user experience, logistics and operations, system integrity, and clinical impact).

CONCLUSIONS

This study highlighted areas for improvement in implementing ICT platforms to meet the needs of community pharmacists as users of these technologies. The refined TEK framework can guide ICT development, implementation, and evaluation.

Medical preparedness for bioterrorism and chemical warfare: A public health integration review

Global public health faces a major danger from chemical and biological weapon-related terrorism which requires comprehensive emergency preparedness and response strategies. This review investigates present-day public health measures against bioterrorism by focusing on an all-hazards framework which unifies traditional and nontraditional threats. The review evaluates federal programs that boost state and local health systems through funding, distribution and team-based partnerships and technological innovation. The primary emergency response elements consist of identifying outbreaks early and improving surveillance together with using state-of-the-art diagnostic tools to detect biological and chemical agents. The review emphasizes the necessity of maintaining healthcare provider education alongside preparations of full medical readiness plans as well as strategic approaches for safeguarding defenseless groups. This paper investigates resource constraints and governmental agency coordination challenges during biowarfare emergencies. The review examines nucleic-acid-based diagnostic and sensor network innovations as vital components for real-time biological agent detection systems. The review emphasizes the vital role of community involvement together with psychological resistance training in addition to continued pathogen behavior study and protection research. The review demonstrates that successful bioterrorism risk reduction depends on advanced integrated protection strategies which combine state agency collaboration with state of the art monitoring techniques and strengthened public health systems.

Clinician views on acupuncture for acute pain care in a busy urban emergency department

INTRODUCTION

Opioid misuse and dependence remain critical public health issues in the U.S., contributing significantly to reduced life expectancy. Emergency departments (EDs) are key settings for implementing opioid reduction strategies when treating acute pain, such as nonpharmacologic treatment options like acupuncture. This study explored clinician-related factors influencing the integration of the Pain Elimination through Acupuncture Research and Learning (PEARL) program for pain reduction within a high-volume urban ED.

METHODS

This study employed a sequential mixed methods design, involving surveys and interviews with ED clinicians. An 11-item electronic survey was administered annually to assess clinician attitudes related to appropriateness and effectiveness of integrating acupuncture into the ED's comprehensive care plan for treatment of pain. Near the end of the 3rd year of the PEARL program, semi-structured interviews were conducted to gather in-depth insights into clinician knowledge and perceptions of the program.

RESULTS

Quantitative survey data from 99 eligible ED clinicians indicated positive perceptions of the program's appropriateness and effectiveness, and improved understanding of acupuncture referral procedures. Analysis of qualitative interviews conducted with 16 ED clinicians revealed five key themes: acupuncture as an acceptable analgesic strategy to reduce the use of opioids, patient benefits, program presence in the ED, integration challenges, and the need for continued education.

CONCLUSION

Strong acceptance of acupuncture as a feasible nonpharmacologic addition to the comprehensive pain care plan used in the ED was observed. Dedicated space, expanded acupuncture staff and hours, and ongoing training of ED staff will require institutional support to sustain acupuncture as a nonpharmacologic treatment option for ED patients.

Differences in the Use and Perception of Telehealth Across Four Mental Health Professions: Insights From a Secondary Analysis of Qualitative Data

There is growing evidence that the uptake and use of telehealth is influenced by the distinct specialty area or type of healthcare service provided, with mental health services presenting particular challenges. However, little is known about how telehealth use differs between different mental health professions, and no qualitative research has explored variations in telehealth use and perspectives at the profession level within Australian mental health services. To address this gap, we analyzed transcripts from 19 semi-structured interviews conducted with mental healthcare professionals in a local health district within New South Wales, Australia. A secondary analysis of the data revealed the distinct ways in which different mental health professions perceive and engage with telehealth depending on their specific role and approach to practice. Application of a systems theory lens highlighted the challenges each profession faces at different levels of telehealth engagement, and the macro-systemic power dynamics and hierarchies that shape profession-specific differences in telehealth use.

Novel algorithms & blood-based biomarkers: Dementia detection and care transitions for persons living with dementia in the emergency department

Persons Living with Dementia (PLWD), diagnosed or undiagnosed, have high Emergency Department (ED) use. Identification of such patients poses significant challenges for emergency clinicians with considerable downstream implications on patients, care partners, and healthcare systems. With the advent of Geriatric Emergency Departments (GEDs) there is an opportunity to understand and improve care of PLWDs in EDs with effective allocation of resources and the development of novel techniques to better support detecting those at risk, communicating findings, and coordinating care for such patients. Advances have been made leveraging Electronic Health Record (EHR) data to risk stratify patients for dementia in the hope that those at high-risk may benefit from further evaluation. The promise of multiple blood-base biomarkers (BBM) as a future modality to improve detection of those at risk of dementias, will also have the potential to advance the delivery of care of PLWD and their care partners in EDs. HIGHLIGHTS: EDs have an integral role in delivering care for Person Living with Dementia and their care partners. High acuity and fast paced ED environment and other barriers makes it difficult to identify Person Living with Dementia. EHR-based risk stratification algorithms can identify patients at risk for Dementia in ED and outpatient settings. Use of Blood-Based Biomarkers in the ED setting is novel and considerations of its use and implications need to be studied. EHR based risk stratification algorithm and Blood Based Biomarkers when used judiciously have the potential to overcome some of the known barriers to identify and improve care for Person Living with Dementia as they transition through EDs.

Integrating a Mobile App to Enhance Atrial Fibrillation Care: Key Insights From an Implementation Study Guided by the Consolidated Framework for Implementation Research

BACKGROUND

Despite the growing use of mobile health apps in managing chronic heart disease, their integration into routine care remains challenging due to dynamic, context-specific barriers.

OBJECTIVE

This study aimed to identify the key enablers and challenges of implementing a mobile app for cardiac rehabilitation and healthy lifestyles in patients with atrial fibrillation at an Australian cardiology clinic.

METHODS

We interviewed both clinicians and patients to understand their perspectives about the mobile app and what factors affected the implementation. The two semistructured interview guides used, one for clinicians and one for patients, were developed based on the Consolidated Framework for Implementation Research (CFIR) and nonadoption abandonment, scale-up, spread, and sustainability complexity assessment tool. All interviews were recorded and transcribed, and the transcripts were analyzed inductively to generate codes using a constructionist perspective. These codes were subsequently mapped onto the constructs within the CFIR across its five domains. This framework analysis was followed by examining the interconnections among the constructs to understand their collective impact on the implementation process, thereby identifying key enablers and challenges for the integration efforts.

RESULTS

We interviewed 24 participants including 18 patients, whose mean age was 69 (SD 9.2) years, and 6 clinicians, comprising 4 specialist cardiac electrophysiologists and 2 nurses. Patient engagement with the app varied: 3 participants completed the cardiac rehabilitation plan, 1 participant was still actively engaged, 2 participants had partial use, 10 participants downloaded but never used the app, and 2 participants did not download the app. We identified a complex interplay between key determinants across all five CFIR domains, collectively impacting two main elements in the implementation process: (1) acceptability and user engagement with the app and (2) the clinic's implementation readiness. The app was more likely to be accepted and used by patients who needed to establish healthy lifestyle habits. Those with established healthy lifestyle habits did not indicate that the app provided sufficient added value to justify adoption. Interoperability with other devices and design issues, for example, limited customization options, also negatively impacted the uptake. The clinic's implementation readiness was limited by various challenges including limited staff availability, insufficient internal communication processes, the absence of an implementation evaluation plan, and lack of clarity around who is funding the app's use beyond the initial trial. Despite the clinician's overall inclination toward technology use, diverse opinions on the evidence for short-term cardiac rehabilitation programs in atrial fibrillation critically reduced their commitment to app integration.

CONCLUSIONS

Mobile health apps have seen rapid expansion and offer clear benefits, yet their integration into complex health systems remains challenging. Whilst our findings are from a single app implementation, they highlight the importance of embedding contextual analysis and proactive strategic planning in the integration process.

Investigating the effective factors on telemedicine in Iran of 2030: A futuristic approach

BACKGROUND

Telemedicine is influenced by several factors. Increase of recent changes, the emergence of new issues presence of societies in the future world, discontinuous events, and the existence of uncertainties, it seems necessary to plan for the successful. Identifying key effective factors, their role, and mutual relationship can enhance the decision-making and planning process in the country. This study endeavors to find the key effective factors on telemedicine to achieve a better future for the implementation of this technology in Iran.

MATERIALS AND METHODS

In terms of its nature, this research is based on the new methods of futurology is analytical-exploratory, and in terms of purpose it is applied, and in terms of the type of research is descriptive survey. The time horizon of 1410 is the basis of this study. This study was performed in Iran based on STEEP and using MICMAC software (Calculate from matrix of direct influence (MDI) and matrix of indirect influence (MII) include: direct influence/dependence map, direct influence graph, and indirect influence graph).

RESULTS

Data collection was performed through reviewing sources. The prioritization of primary variables was performed through a questionnaire to determine the importance, which led to the identification of 22 important factors. Next, to identify the nature of different factors and explanation the key factors, the matrix of cross-impact and MICMAC software were used. Finally, 13 key factors were defined.

CONCLUSION

Political factors have the greatest contribution as the main key factors and have a greater impact on the future of telemedicine, which highlights the need for authorities to consider this field for the effective implementation of technology in the future.

Application of a Sociotechnical Framework to Uncover Factors That Influence Effective User Engagement With Digital Mental Health Tools in Clinical Care Contexts: Scoping Review

BACKGROUND

Digital health tools such as mobile apps and patient portals continue to be embedded in clinical care pathways to enhance mental health care delivery and achieve the quintuple aim of improving patient experience, population health, care team well-being, health care costs, and equity. However, a key issue that has greatly hindered the value of these tools is the suboptimal user engagement by patients and families. With only a small fraction of users staying engaged over time, there is a great need to better understand the factors that influence user engagement with digital mental health tools in clinical care settings.

OBJECTIVE

This review aims to identify the factors relevant to user engagement with digital mental health tools in clinical care settings using a sociotechnical approach.

METHODS

A scoping review methodology was used to identify the relevant factors from the literature. Five academic databases (MEDLINE, Embase, CINAHL, Web of Science, and PsycINFO) were searched to identify pertinent articles using key terms related to user engagement, mental health, and digital health tools. The abstracts were screened independently by 2 reviewers, and data were extracted using a standardized data extraction form. Articles were included if the digital mental health tool had at least 1 patient-facing component and 1 clinician-facing component, and at least one of the objectives of the article was to examine user engagement with the tool. An established sociotechnical framework developed by Sittig and Singh was used to inform the mapping and analysis of the factors.

RESULTS

The database search identified 136 articles for inclusion in the analysis. Of these 136 articles, 84 (61.8%) were published in the last 5 years, 47 (34.6%) were from the United States, and 23 (16.9%) were from the United Kingdom. With regard to examining user engagement, the majority of the articles (95/136, 69.9%) used a qualitative approach to understand engagement. From these articles, 26 factors were identified across 7 categories of the established sociotechnical framework. These ranged from technology-focused factors (eg, the modality of the tool) and the clinical environment (eg, alignment with clinical workflows) to system-level issues (eg, reimbursement for physician use of the digital tool with patients).

CONCLUSIONS

On the basis of the factors identified in this review, we have uncovered how the tool, individuals, the clinical environment, and the health system may influence user engagement with digital mental health tools for clinical care. Future work should focus on validating and identifying a core set of essential factors for user engagement with digital mental health tools in clinical care environments. Moreover, exploring strategies for improving user engagement through these factors would be useful for health care leaders and clinicians interested in using digital health tools in care.

Decision-Making Process of Home and Social Care Professionals Using Telemonitoring of Activities of Daily Living for Risk Assessment: Embedded Mixed Methods Multiple-Case Study

BACKGROUND

Older adults with cognitive deficits face difficulties in recalling daily challenges and lack self-awareness, impeding home care clinicians from obtaining reliable information on functional decline and home care needs and possibly resulting in suboptimal service delivery. Activity of daily living (ADL) telemonitoring has emerged as a tool to optimize evaluation of ADL home care needs. Using ambient sensors, ADL telemonitoring gathers information about ADL behaviors such as preparing meals and sleeping. However, there is a significant gap in understanding on how ADL telemonitoring data can be integrated into clinical reasoning to better target home care services.

OBJECTIVE

This paper aims to describe (1) how ADL telemonitoring data are used by clinicians to maintain care recipients with cognitive deficits at home and (2) the impact of ADL telemonitoring on home care service delivery.

METHODS

We used an embedded mixed methods multiple-case study design to examine 3 health institutions located in the greater Montreal region in Quebec that offer public home care services. An ADL telemonitoring system-Innovative Easy Assistance System-Support for Older Adults' Autonomy (Soutien à l'autonomie des personnes âgées in French)-was deployed within these 3 health institutions for 4 years. Subcases (care recipient, informal caregiver, and clinicians) were embedded within each case. For this paper, we used the data collected during interviews (45-60 min) with clinicians only. Quantitative metadata were also collected on each service provided to care recipients before and after the implementation of NEARS-SAPA to triangulate the qualitative data.

RESULTS

We analyzed 27 subcases comprising 29 clinicians who completed 57 postimplementation interviews concerning 147 telemonitoring reports. Data analysis showed a 4-step decision-making process used by clinicians: (1) extraction of relevant telemonitoring data, (2) comparison of telemonitoring data with other sources of information, (3) risk assessment of the care recipient's ADL performance and ability to remain at home, and (4) maintenance or modification of the intervention plan. Quantitative data reporting the number of services received allowed the triangulation of qualitative data pertaining to step 4. Overall, the results suggest a stabilization in monthly services after the introduction of the ADL telemonitoring system, particularly in cases where the number of services were increasing before its implementation. This is consistent with qualitative data indicating that, in light of the telemonitoring data, most clinicians decided to maintain the current intervention plan rather than increase or reduce services.

CONCLUSIONS

Results suggest that ADL telemonitoring contributed to service optimization on a case-by-case basis. ADL telemonitoring may have an important role in reassuring clinicians about their risk management and the appropriateness of service delivery, especially when questions remain regarding the relevance of services. Future studies may further explore the benefits of ADL telemonitoring for public health care systems with larger-scale implementation studies.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/52284.

Examining the challenges in sustaining user engagement with a mobile app to enhance multidrug-resistant tuberculosis (MDR-TB) care in Vietnam and its implications for implementing person-centred mHealth interventions

Digital health technologies, especially mobile application (mHealth), offer great potential for enhancing person-centred care and managing MDR-TB. The rapid expansion of digital infrastructure in Vietnam presents a valuable opportunity for such interventions. This qualitative study examines user experiences to explain reported reduction in engagement with (i.e. use of) a smartphone app which is being trialed to improve early detection and management of adverse events (AEs) among MDR-TB patients in Vietnam (VSMART trial). We conducted 37 in-depth interviews with patients and healthcare workers (HCWs) and thematically analyzed the data. Initially, patients were motivated to use the app seeing it as a promise of the provision of 'good care' from trusted healthcare workers, and over-estimated its functional capacity. However, as patients realized its functional limitations for AE reporting and management they reverted to communicating with HCWs through existing communication channels. While the app empowered patients to communicate with HCWs for AE reporting, it inadvertently increased HCWs' workloads which became difficult to manage. This resulted in a paradox where the app was used because of its social value, in spite of its limited functional value. This study reveals how relational and socially mediated effects of technology may complicate mHealth design and implementation, illuminating why 'acceptable' technologies within pilot/projects could struggle to sustain engagement a scale. To support attention to this process, we propose an explanatory framework that captures the social-functional dynamics of mHealth interventions which can guide much needed qualitative evaluation to support the design of mHealth technologies to align with stakeholders' needs and suited for integration into local healthcare systems.

Mental health practitioners' perceptions and adoption intentions of AI-enabled technologies: an international mixed-methods study

BACKGROUND

As mental health disorders continue to surge, exceeding the capacity of available therapeutic resources, the emergence of technologies enabled by artificial intelligence (AI) offers promising solutions for supporting and delivering patient care. However, there is limited research on mental health practitioners' understanding, familiarity, and adoption intentions regarding these AI technologies. We, therefore, examined to what extent practitioners' characteristics are associated with their learning and use intentions of AI technologies in four application domains (diagnostics, treatment, feedback, and practice management). These characteristics include medical AI readiness with its subdimensions, AI anxiety with its subdimensions, technology self-efficacy, affinity for technology interaction, and professional identification.

METHODS

Mixed-methods data from N = 392 German and US practitioners, encompassing psychotherapists (in training), psychiatrists, and clinical psychologists, was analyzed. A deductive thematic approach was employed to evaluate mental health practitioners' understanding and familiarity with AI technologies. Additionally, structural equation modeling (SEM) was used to examine the relationship between practitioners' characteristics and their adoption intentions for different technologies.

RESULTS

Qualitative analysis unveiled a substantial gap in familiarity with AI applications in mental healthcare among practitioners. While some practitioner characteristics were only associated with specific AI application areas (e.g., cognitive readiness with learning intentions for feedback tools), we found that learning intention, ethical knowledge, and affinity for technology interaction were relevant across all four application areas, underscoring their relevance in the adoption of AI technologies in mental healthcare.

CONCLUSION

In conclusion, this pre-registered study underscores the importance of recognizing the interplay between diverse factors for training opportunities and consequently, a streamlined implementation of AI-enabled technologies in mental healthcare.

Digital stress perception and associations with work- and health-related outcomes among general practitioners in Germany: a quantitative study

BACKGROUND

Digital technologies are increasingly being integrated into healthcare settings, including the ambulatory sector of general practitioners, with potential improvement in everyday work life. Although the changes sound very promising, the adoption of new technologies can also introduce additional stressors for medical staff, potentially resulting in negative impacts on work performance and health. This study seeks to identify the stressors and resources associated with digitization among general practitioners in Germany, explore their effects on work and health variables, and uncover potential preventive measures to mitigate these stressors.

METHODS

This mixed methods study combined quantitative and qualitative approaches. An online questionnaire was used to examine the relationships between technostress creators, inhibitors, and the perception of technostress, as well as the measures of burnout, job satisfaction, and general health among 114 general practitioners in Germany's ambulatory care setting. The study was carried out between March and June 2024. Several validated instruments were employed, including the Technostress Model and selected items from the Copenhagen Psychosocial Questionnaire (COPSOQ III). Exploratory assumptions were evaluated using descriptive statistics and multiple regression analyses.

RESULTS

The study found medium levels of technostress perception among the participating general practitioners (n = 114) along with a substantial level of technostress inhibitors. The general practitioners surveyed in this study reported experiencing burnout symptoms occasionally, expressed a moderate level of job satisfaction, and generally described their health status as good. The relationships between stressors and work- and health-related outcomes were analyzed.

CONCLUSIONS

This study offers a preliminary overview of the persistence of techno-stressors, technostress inhibitors, and technostress levels and their impact on health- and work-related outcomes among general practitioners in Germany. The findings indicate that using information and communication technologies can lead to heightened stress, increased burnout symptoms, and reduced job satisfaction. As the workload for general practitioners is expected to grow in the upcoming years, the study highlights the critical need for additional preventive strategies to mitigate stress and improve well-being among general practitioners.

Exploring telemedicine and organizational challenges in the healthcare system: a qualitative analysis using Grounded Theory

PURPOSE

Telemedicine is a context-specific intervention that implies significant procedural changes in a health organization. The objective of the study is to explore healthcare professionals' usage of and perceptions towards telemedicine technology and identify the perceived factors and related process change, influencing the effective adoption of telemedicine from an organizational perspective.

DESIGN/METHODOLOGY/APPROACH

The study includes multi-disciplinary commentaries of a purposive sample of 31 healthcare professionals, conducted through semi-structured qualitative interviews and employs Grounded Theory and Thematic Analysis techniques to analyze the data.

FINDINGS

Telemedicine is perceived as a highly beneficial digital intervention in healthcare, focusing on the delivery of effective healthcare, and promoting healthcare equity. Healthcare professionals showed their willingness to assimilate technology into clinical decision-making, resulting in better treatment outcomes, and recommended its' adoption into mainstream healthcare as a viable approach to providing remote healthcare. The key organizational issues with telemedicine adoption were system requirements, network connectivity, non-standardized medical records, and legal bottlenecks, that can be addressed by improving infrastructural convenience, optimizing service processes, imparting training, and adopting better technical measures.

ORIGINALITY/VALUE

The focus is on exploring factors significant for the adoption of telemedicine technology from the perspective of multi-specialties in a health organization, rather than a specific specialty, as studied in previous scholarly work. This study contributes to the theory by proposing a conceptual framework on critical factors for telemedicine adoption, integrating the theory of planned behavior (TPB) and diffusion of innovation (DOI).

Ethical Design of Data-Driven Decision Support Tools for Improving Cancer Care: Embedded Ethics Review of the 4D PICTURE Project

Oncology patients often face complex choices between treatment regimens with different risk-benefit ratios. The 4D PICTURE (Producing Improved Cancer Outcomes Through User-Centered Research) project aims to support patients, their families, and clinicians with these complex decisions by developing data-driven decision support tools (DSTs) for patients with breast cancer, prostate cancer, and melanoma as part of care path redesign using a methodology called MetroMapping. There are myriad ethical issues to consider as the project will create data-driven prognostic models and develop conversation tools using artificial intelligence while including patient perspectives by setting up boards of experiential experts in 8 different countries. This paper aims to review the key ethical challenges related to the design and development of DSTs in oncology. To explore the ethics of DSTs in cancer care, the project adopted the Embedded Ethics approach-embedding ethicists into research teams to sensitize team members to ethical aspects and assist in reflecting on those aspects throughout the project. We conducted what we call an embedded review of the project drawing from key literature on topics related to the different work packages of the 4D PICTURE project, whereas the analysis was an iterative process involving discussions with researchers in the project. Our review identified 13 key ethical challenges related to the development of DSTs and the redesigning of care paths for more personalized cancer care. Several ethical aspects were related to general potential issues of data bias and privacy but prompted specific research questions, for instance, about the inclusion of certain demographic variables in models. Design methodology in the 4D PICTURE project can provide insights related to design justice, a novel consideration in health care DSTs. Ethical points of attention related to health care policy, such as cost-effectiveness, financial sustainability, and environmental impact, were also identified, along with challenges in the research process itself, emphasizing the importance of epistemic justice, the role of embedded ethicists, and psychological safety. This viewpoint highlights ethical aspects previously neglected in the digital health ethics literature and zooms in on real-world challenges in an ongoing project. It underscores the need for researchers and leaders in data-driven medical research projects to address ethical challenges beyond the scientific core of the project. More generally, our tailored review approach provides a model for embedding ethics into large data-driven oncology research projects from the start, which helps ensure that technological innovations are designed and developed in an appropriate and patient-centered manner.

AI Applications for Chronic Condition Self-Management: Scoping Review

BACKGROUND

Artificial intelligence (AI) has potential in promoting and supporting self-management in patients with chronic conditions. However, the development and application of current AI technologies to meet patients' needs and improve their performance in chronic condition self-management tasks remain poorly understood. It is crucial to gather comprehensive information to guide the development and selection of effective AI solutions tailored for self-management in patients with chronic conditions.

OBJECTIVE

This scoping review aimed to provide a comprehensive overview of AI applications for chronic condition self-management based on 3 essential self-management tasks, medical, behavioral, and emotional self-management, and to identify the current developmental stages and knowledge gaps of AI applications for chronic condition self-management.

METHODS

A literature review was conducted for studies published in English between January 2011 and October 2024. In total, 4 databases, including PubMed, Web of Science, CINAHL, and PsycINFO, were searched using combined terms related to self-management and AI. The inclusion criteria included studies focused on the adult population with any type of chronic condition and AI technologies supporting self-management. This review was conducted following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines.

RESULTS

Of the 1873 articles retrieved from the search, 66 (3.5%) were eligible and included in this review. The most studied chronic condition was diabetes (20/66, 30%). Regarding self-management tasks, most studies aimed to support medical (45/66, 68%) or behavioral self-management (27/66, 41%), and fewer studies focused on emotional self-management (14/66, 21%). Conversational AI (21/66, 32%) and multiple machine learning algorithms (16/66, 24%) were the most used AI technologies. However, most AI technologies remained in the algorithm development (25/66, 38%) or early feasibility testing stages (25/66, 38%).

CONCLUSIONS

A variety of AI technologies have been developed and applied in chronic condition self-management, primarily for medication, symptoms, and lifestyle self-management. Fewer AI technologies were developed for emotional self-management tasks, and most AIs remained in the early developmental stages. More research is needed to generate evidence for integrating AI into chronic condition self-management to obtain optimal health outcomes.

Identification and Categorization of the Distinct Purposes Underpinning the Use of Digital Health Care Self-Monitoring: Qualitative Study of Stakeholders in the Health Care Ecosystem

BACKGROUND

Digital health care self-monitoring has gained prominence as a tool to address various challenges in health care, including patient autonomy, data-informed decision-making, and organizational improvements. However, integrating self-monitoring solutions across a diverse ecosystem of stakeholders-patients, health care providers, policy makers, and industry-can be complicated by differing priorities and needs.

OBJECTIVE

This study aimed to identify and categorize the distinct purposes underpinning the use of digital health care self-monitoring. By mapping these purposes, the research seeks to clarify how technology design and implementation can be better aligned with stakeholder expectations, thereby enhancing adoption and impact.

METHODS

A qualitative design was used, drawing on 31 in-depth, semistructured interviews conducted with stakeholders in the Swedish health care ecosystem. Participants included patients, advocacy groups, health care professionals, policy makers, pharmaceutical representatives, and technology developers. Data were analyzed thematically using an inductive coding approach supported by NVivo 12 (Lumivero). Emerging themes were refined through iterative discussion among the research team and validated by presentation to health care practitioners.

RESULTS

A total of 8 distinct purposes of digital health care self-monitoring emerged: (1) emancipate (enhance patient autonomy), (2) learn (understand health behaviors), (3) improve (enhance patient health), (4) engage (bolster patient involvement), (5) control (manage adherence and symptoms), (6) evaluate (assess health parameters), (7) innovate (advance interventions and processes), and (8) generate (drive new initiatives). These purposes form three categories of value creation: (1) improving the patient-provider link, (2) leveraging big data analytics for knowledge creation, and (3) using digital infrastructure to develop new care processes.

CONCLUSIONS

Our findings demonstrate that digital health care self-monitoring serves multifaceted aims, ranging from individual patient empowerment to ecosystem-wide innovation. Designing and implementing these tools with an explicit understanding of all stakeholders' "why" can help address potential conflicts (eg, balancing patient autonomy with clinical control) and facilitate more holistic adoption. Ultimately, this study underscores the importance of clear, purpose-driven approaches to promote better health outcomes, knowledge generation, and care process improvements.

Value of a Nationwide University Network in scaling up telemonitoring: a qualitative study

OBJECTIVES

The adoption and subsequent implementation of telemonitoring across university hospital settings is a challenging task. This study provides insight into the perceived value of using a nationwide network to support scaling up telemonitoring in university hospitals.

METHODS

A qualitative approach was used to evaluate the role of the National eHealth network 'Citrien eHealth programme Implementation and Upscaling (Citrien-2)'. In phase 1, an inventory questionnaire was used to identify successes and lessons learnt. Phase 2 consisted of a semi-structured group interview to develop a deeper understanding about the potential value of the network. Subsequently, we conducted a qualitative content analysis and results were organised into key themes of the non-adoption, abandonment, scale-up, spread and sustainability framework.

RESULTS

In total, 20 participants responded to our questionnaire, and 7 participants participated in our semistructured group interview. Qualitative analysis revealed 28 themes. The network's key value is the collaboration and structured approach it promotes. This serves as a foundation for exchanging ideas, identifying both temporary and sustainable funding, and establishing a robust stakeholder position, all of which serve to act as a catalyst for implementation and scaling up of telemonitoring.

DISCUSSION

Our findings align with known barriers to digital innovation, such as funding and legal issues. Our study shows the value of a nationwide network in overcoming these barriers.

CONCLUSIONS

The Citrien-2 nationwide network contributes to scaling up telemonitoring across university settings. Therefore, we recommend that governments and their funding agencies recognise and embrace the power of these nationwide networks in scaling up digital initiatives.

Multi Perspective Considerations for Health Smart Home: Early Phase Exploratory Study

AIMS

This study engaged key stakeholders-older adults, family caregivers, home care support workers, nurses, and home healthcare leaders-to explore perspectives on essential components and integration into home care models, and to explore the role of their technology readiness for health smart homes adoption.

DESIGN

A qualitative methodology with a quantitative component, early-phase exploratory design.

METHODS

Semi-structured interviews underwent qualitative thematic analysis, with cross-case analysis comparing stakeholder perspectives to identify convergences and divergences. Descriptive statistics were used to analyse Technology Readiness Index (TRI 2.0) survey data to provide background and context to the qualitative findings.

RESULTS

Among 18 participants-older adults (n = 6), family caregivers (n = 2), nurses (n = 7), and support workers/healthcare leaders (n = 3)-findings reflected optimism for health smart home adoption and its potential to support ageing in place. Nurses and care workers saw health smart home as a tool for improving care coordination and quality of life. Key adoption considerations included education, data visualisation, privacy, and security. Technology readiness scores were moderate, with nurses scoring highest (3.52), followed by caregivers (3.41), support workers (3.13), and older adults (3.10).

CONCLUSION

While stakeholders were open to integrating health smart home into home care, concerns around usability, security, and training must be addressed to facilitate adoption.

IMPLICATIONS FOR THE PROFESSION

Findings suggest that while health smart home technology holds promise for enhancing ageing in place, varying levels of technology readiness across stakeholders highlight the need for tailored education and support strategies to ensure successful implementation.

PROBLEM ADDRESSED

Despite a strong preference for ageing in place among older adults, integrating health smart home technologies into home care remains challenging. Key issues include ensuring intuitive functionality, protecting privacy, and clarifying the roles of caregivers and healthcare professionals in a technology-enhanced care model. This study addresses the critical gap in understanding how health smart home solutions can be effectively tailored to support the diverse needs of older adults, family caregivers, and home care nurses and support workers.

MAIN FINDINGS

Stakeholders were generally optimistic about health smart home technologies supporting ageing in place and improving quality of life. Nurses and support workers highlighted the need for tailored data visualisations, alert parameters, and clear role guidelines. A novel finding was that older adults and family caregivers viewed health smart home as a way to reduce intrusive monitoring, promote independence, and maintain a familiar living environment. Family caregivers valued the ability to stay involved remotely through activity data, offering reassurance and peace of mind. Across all groups, privacy safeguards were seen as essential, with strong concerns about data security, transparent usage policies, and user control over data sharing.

IMPACT

Findings have implications for community-dwelling older adults, family caregivers, home care professionals, researchers, and technology developers. Insights from this study can inform the design of user-friendly health smart home technologies, shape future research, and guide tailored implementation strategies in home care settings.

PATIENT OR PUBLIC CONTRIBUTION

An advisory group of community-dwelling older adults in Western Australia provided input on study design and methodology. Their recommendations led to the use of one-on-one interviews to ensure accessibility and relevance for older adults when exploring technology readiness and smart home integration. While the advisory group did not contribute to the data itself or its analysis, their feedback shaped the method of engagement to ensure its relevance and accessibility to potential participants.

Developing the Workplace Learning Social System: considerations for genomics implementation and workforce preparedness

Innovations, such as genomics, are expected to transform the practice of the healthcare workforce. Workplace learning is an established and fundamental component of healthcare workforce training. We propose that it can be leveraged to facilitate workforce preparedness to adopt innovations relevant to practice. To explore this, this study aimed to develop a workplace learning framework premised on primary literature. Four databases were systematically searched to identify and synthesize contemporary research articles investigating doctors' workplace learning, with an additional focus on genetics/genomics. From the articles included, factors influencing workplace learning were extracted. Informed by structuration and workplace learning theories, thematic analysis was conducted on these factors to generate the framework. Despite the lack of articles on doctors' genetics/genomics workplace learning, 50 articles on doctors' workplace learning were included. Extracted influencing factors were synthesized into five major domains, across three social system levels and the agentic learner, to generate the Workplace Learning Social System framework. Innovations in healthcare require its workforce to change work practices. The Workplace Learning Social System framework holistically conceptualizes workplace learning based on contemporary literature. It provides pragmatic insights to inform workforce development when implementing innovations as part of system-wide change.

Changing practice in cystic fibrosis: Implementing objective medication adherence data at every consultation, a learning health system and quality improvement collaborative

Background

Medication adherence data are an important quality indicator in cystic fibrosis (CF) care, yet real-time objective data are not routinely available. An online application (CFHealthHub) has been designed to deliver these data to people with CF and their clinical team. Adoption of this innovation is the focus of an National Health Service England-funded learning health system and Quality Improvement Collaborative (QIC). This study applies the capability, opportunity, and motivation model of behavior change to assess whether the QIC had supported healthcare professionals' uptake of accessing patient adherence data.

Method

This was a mixed-method study, treating each multidisciplinary team as an individual case. Click analytic data from CFHealthHub were collected between January 1, 2018, and September 22, 2019. Thirteen healthcare practitioners participated in semi-structured interviews, before and after establishing the QIC. Qualitative data were analyzed using the behavior change model.

Results

The cases showed varied improvement trajectories. While two cases reported reduced barriers, one faced persistent challenges. Participation in the QIC led to enhanced confidence in the platform's utility. Reduced capability, opportunity, and motivation barriers correlated with increased uptake, demonstrating value in integrating behavior change theory into QICs.

Conclusion

QICs can successfully reduce barriers and enable uptake of e-health innovations such as adherence monitoring technology. However, ongoing multi-level strategies are needed to embed changes. Further research should explore sustainability mechanisms and their impact on patient outcomes.

Digital divide or digital exclusion? Do allied health professionals' assumptions drive use of telehealth?

IntroductionTelehealth use within allied health services currently lacks structure and consistency, ultimately affecting who can, and cannot, access services. This study aimed to investigate the factors influencing allied health professionals' (AHP) selection of consumers and appointments for telehealth.MethodsThis study was conducted across 16 allied health departments from four Australian hospitals. Semi-structured focus groups were conducted with 58 AHPs. Analysis was underpinned by Qualitative Description methodology with inductive coding guided by Braun and Clarke's thematic analysis approach.ResultsSix themes were identified that influenced AHPs' evaluation of telehealth suitability and selection of consumers. These included the following: (1) ease, efficiency and comfort of telehealth for clinicians; (2) clear benefits of telehealth for the consumer, yet the consumers were not always given the choice; (3) consumers' technology access and ability; (4) establishing and maintaining effective therapeutic relationships via telehealth; (5) delivering clinically appropriate and effective care via telehealth; and (6) external influences on telehealth service provision. A further theme of 'assumption versus reality' was noted to pervade all six themes.DiscussionClinicians remain the key decision makers for whether telehealth is offered within allied health services. Ease and efficiency of use is a major driver in AHP's willingness to use telehealth. Assumptions and pre-conceived frames-of-reference often underpin decisions to not offer telehealth and present major barriers to telehealth adoption. The development of evidence-based, decision-support frameworks that engage the consumer and clinician in determining when telehealth is used is required. Services need to actively pursue joint decision-making between the clinician and consumer about service delivery preferences.

Between-Visit Asthma Symptom Monitoring With a Scalable Digital Intervention: A Randomized Clinical Trial

Importance

Asthma affects an estimated 7.7% of the US population and 262 million people worldwide. Symptom monitoring has demonstrated benefits but has not achieved widespread use.

Objective

To assess the effect of a scalable asthma symptom monitoring intervention on asthma outcomes.

Design, Setting, and Participants

This randomized clinical trial was conducted between July 2020 and March 2023 at 7 primary care clinics affiliated with an academic medical center (Brigham and Women's Hospital in Boston, Massachusetts). Candidate patients with a diagnosis of asthma over a 20-month recruitment period (July 2020 to March 2022) were identified and categorized into tiers of varying disease activity based on electronic health record data. Eligible patients were adults (aged ≥18 years) and had a primary care practitioner in 1 of the 7 participating clinics.

Intervention

Intervention group patients were asked to use a mobile health app to complete weekly symptom questionnaires; track notes, peak flows, and triggers; and view educational information. Patients who reported worsening or severe symptoms were offered clinical callback requests. App data were available in the electronic health record. Usual care group patients received general asthma guidance.

Main Outcomes and Measures

The primary outcome was the mean change in Mini Asthma Quality of Life Questionnaire (MiniAQLQ) score for the intended 12-month study period. A change of 0.5 on a scale of 1 to 7 was considered a minimally important change. The secondary outcome was the mean number of asthma-related health care utilization events (urgent care visits, emergency department visits, or hospitalizations). Mean differences for all outcomes between groups were compared using robust linear regression models (generalized estimating equations) with treatment group as the only covariate.

Results

Baseline questionnaires were completed by 413 patients (mean [SD] age, 52.2 [15.4] years; 321 women [77.7%]). Of these, 366 patients completed final questionnaires and were included in the primary analysis. MiniAQLQ scores increased 0.34 (95% CI, 0.19-0.49) in the intervention group and 0.11 (95% CI, -0.11 to 0.33) in the usual care group from baseline to final questionnaire completion (adjusted difference-in-difference, 0.23 [95% CI, 0.06-0.40]; P = .01); although the difference was statistically significant, it did not reach the threshold for a minimally important change. Intervention subgroups showed positive differences in MiniAQLQ scores relative to the usual care group, with noteworthy increases among individuals aged 18 to 44 years (adjusted difference-in-difference, 0.40 [95% CI, 0.13-0.66]), those with low baseline patient activation (adjusted difference-in-difference, 0.77 [95% CI, 0.30-1.24]), those with a low baseline MiniAQLQ score (adjusted difference-in-difference, 0.33 [95% CI, 0.07-0.59]), and those with uncontrolled asthma at baseline (adjusted difference-in-difference, 0.30 [95% CI, 0.05-0.54]). The intervention group had a mean of 0.59 (95% CI, 0.42-0.77) nonroutine asthma-related utilization events compared with 0.76 (95% CI, 0.55-0.96) in the usual care group (adjusted effect size, -0.16 [95% CI, -0.42 to 0.17]; P = .23).

Conclusions and Relevance

In this randomized clinical trial of a scalable symptom monitoring intervention, the increase in asthma-related quality of life did not reach the threshold for a minimally important change. Exploratory analyses suggest possible benefits for patients with low levels of activation.

Trial Registration

ClinicalTrials.gov Identifier: NCT04401332.

Bright visions, shady days: Exploring hospital staff expectations and early experiences with a new EHR system in Norway

Background: The preparation phase of an IT implementation may have consequences for the outcomes. To increase the chance of a successful implementation, many organisations invest in preparing the organisation through organisational readiness projects and similar activities. Objective: To determine how hospital staff in Central Norway were prepared for a new electronic health record (EHR) system and how expectations were met during the go-live and early use phase. Methods: Semi-structured interviews with the implementation team and staff members of a University hospital. Results: Preparations were carefully planned, but the staff considered them insufficient. The staff were positive towards the aim of the new EHR but found the training and practical preparations inadequate, resulting in unmet expectations and frustrations. Conclusion: Readiness activities in socio-technical implementations should emphasise to users that the information system presents opportunities, not necessarily fixed-use recipes, and is continuously evolving. Contextual information can help users align their expectations with the possibilities.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

PUBLIC AND PATIENT CONTRIBUTION

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

A field study to explore user experiences with socially assistive robots for older adults: emphasizing the need for more interactivity and personalisation

Older adults often desire to remain in their homes for as long as possible, and Socially Assistive Robots (SARs) can play a role in supporting this goal. However, the acceptance and adoption rates of SARs remain relatively low, suggesting that current designs may not fully address all user needs. Field studies in Human-Robot Interaction, particularly those involving multiple end-users, remain limited. Nevertheless, such studies are crucial for identifying factors that shape the user experience with SARs, potentially improving their acceptance and adoption in healthcare settings. Therefore, this study aims to explore user perspectives, referred to as factors, that could guide design considerations for SAR development. We conducted a field study with 90 participants across Italy, Switzerland, and the Netherlands to identify these factors and their implications for improving the SAR user experience for older adults and their formal and informal caregivers. SARs were placed in the homes of older adults, and interviews were conducted with the three groups of primary end-users, at the beginning, midpoint, and end of the two-to six-week trial period. We initially focused on four factors (personalisation, interactivity, embodiment, and ethical considerations), identified in earlier design phases of the related 3-year Guardian project. Our findings confirmed the importance of these factors while uncovering additional ones. Personalisation and interactivity emerged as the most important ones among these factors. Based on our insights, we recommend involving all primary end-users in SAR research and design process and prioritising field studies to refine design elements. In conclusion, our study identified six factors for SAR design that can enhance the user experience: personalisation, interactivity, embodiment, ethical considerations, connectedness, and dignity. These findings provide valuable guidance for developing SARs that may better address the needs of older adults and their caregivers.

Opportunities to Digitally Enable Falls Prevention in Older Adults

Falls are a serious problem confronting older adults. Evidence demonstrates that multifactorial interventions that target multiple risk factors can reduce falls. However, resource and access constraints affect intervention uptake and sustainability. In comparison, digitally enabled interventions have the potential to provide greater support and convenience whilst being tailored to an individual. Although digital advancements present an opportunity to improve access, scalability, and sustainability, there is limited knowledge on how to digitally enable traditional interventions. In this article, we summarize the academic literature on digital falls prevention and propose future research directions for digital falls prevention. We examine barriers and enablers to digital falls prevention in aged care, although, given the scarcity of evidence, we draw on lessons from other digital healthcare innovations.

Theory-informed process evaluation protocol to assess a rapid-access outpatient model of care in South East Queensland, Australia

INTRODUCTION

Chronic diseases place a large burden on health systems globally. While long-term planned care is essential for their management, episodes of deterioration are common. The emergence of rapid access to outpatient care has proliferated in response to increased resource pressures on acute health services. It is anticipated that these new models of care may prevent hospitalisations and reduce the burden on emergency departments. While some evidence supports the clinical effectiveness of these models, little is known about the core components and key attributes of these services. This paper outlines the protocol of a theory-driven, pragmatic process evaluation embedded within a new rapid-access outpatient service for chronic disease in South East Queensland, Australia.

METHODS AND ANALYSIS

This mixed-methods process evaluation will be conducted across three phases: (1) context assessment to identify programme characteristics and core components; (2) evaluation of key service processes and development of service improvement strategies and (3) sustainability assessment, with a focus on programme embedding and the resources associated with service evaluation. Each phase will be guided using implementation science frameworks and/or theory. Participants will include service consumers, service delivery staff, implementation leaders and decision-makers and wider system referrers. Professional stakeholders will be recruited through a direct invitation to participate (using purposeful sampling methods) and will be engaged in interviews at 1-3 data collection time points. Service consumers will be recruited through direct advertisement to participate in interviews. Administrative and clinical data collections will be retrospectively analysed with descriptive and inferential methods and triangulated with qualitative data to yield primary and secondary outcomes.

ETHICS AND DISSEMINATION

Ethical clearance has been obtained from the West Moreton Hospital and Health Service Human Research Ethics Committee. The planned dissemination of results will occur through conferences, abstracts and publications.

TRIAL REGISTRATION NUMBER

Australia and New Zealand Clinical Trials Registry (ANZCTR Trial ID: ACTRN12624000757516).

How theories, models, and frameworks have been used to implement digital health interventions in services for people with severe mental health problems: a scoping review

BACKGROUND

Digital health interventions have the potential to improve the efficacy and accessibility of mental health services for people with severe mental health problems, but their integration into routine practice is a challenge. The real-world implementation of digital health interventions should be considered alongside digital intervention development. However, little is known about the quality of implementation research in this area, including the extent to which implementation science theories, models and frameworks are used. The aim of this review was to synthesise evidence regarding the application of theories, models and frameworks in research investigating the implementation of digital health interventions in services for people with severe mental health problems. Secondary aims were to consider the contexts within which studies had been undertaken and the degree of service user involvement in this research.

METHODS

A scoping review method was employed. Electronic databases were systematically searched for published papers in English and reference lists of included studies were hand searched. Included studies used an implementation science theory, model, or framework to understand, guide or evaluate the implementation of digital health interventions in services for people with severe mental health problems.

RESULTS

Twelve eligible studies were identified. Studies were primarily undertaken in community mental health services with staff participants and there was variation in the types of digital interventions that were investigated. Eight different implementation science theories, models, and frameworks were used and were mainly employed to guide qualitative analysis. Most studies were undertaken in the early exploratory stages of implementation projects and there was little evidence regarding factors affecting the longer-term sustainment of digital health interventions in practice. Only one study reported the inclusion of service users in the design of the implementation study.

CONCLUSIONS

The use of implementation theories, models, and frameworks in efforts to implement digital health interventions in routine care for people with severe mental health problems is limited. Researchers should consider integrating such approaches throughout the research process and ensure service users are involved in this work. Further research regarding implementation processes, and the reach and sustainment of digital health interventions in routine practice, is required.

Human interactions remain at the heart of rehabilitation with advanced technology: a practice-embedded longitudinal qualitative study with allied health clinicians

BACKGROUND

Technology is gaining momentum in rehabilitation. While evidence is emerging, a growing number of rehabilitation facilities are implementing devices, though with variable success. A public-private rehabilitation provider in Australia recently opened a technology therapy centre with robotic and virtual reality devices. This study was embedded in the setting, which saw substantial clinician uptake of devices and presented a unique opportunity to explore clinician experiences, perceptions and factors influencing uptake, implementation and sustainment of advanced technology in practice.

METHODS

A longitudinal qualitative study was conducted, involving interviews with clinicians at three timepoints across the first 16 months of the centre opening. Allied health clinicians in the organisation (n = 119) were invited to participate in interviews, which were audio-recorded, transcribed, coded and analysed using an inductive thematic approach.

RESULTS

In total, 63 interviews were conducted with 25 allied health clinicians across inpatient, outpatient and community rehabilitation services. An overarching finding that human interactions remain at the heart of rehabilitation with advanced technology, comprised three major themes with 12 subthemes. (1) Technology integration involves cognitive and emotional labour for clinicians, stemming from determining the value-add of advanced technology, juggling learning demands and negotiating patients' high expectations of technology. (2) Contextual factors shape clinician uptake and ongoing use of technology, including organisational culture, professional discipline, rehabilitation setting, patient characteristics and device features. (3) Shared understanding and priorities promote technology implementation and sustainment, including understanding advanced technology in relation to conventional therapy, creating a well-designed training model, equipping clinicians to manage patient expectations and maintaining a commitment to evidence-based practice.

CONCLUSIONS

While further high-quality evidence regarding the effectiveness of technology in rehabilitation is required, clinicians in this study perceived advanced technology as an adjunct to conventional therapy, with benefits for enhancing therapy dosage, patient engagement, manual handling and providing objective feedback. Important practice-derived considerations for integrating advanced technologies in rehabilitation include: developing clinician technical, clinical reasoning and interpersonal skills, reducing contextual barriers and fostering a positive organisational culture with strong leadership and targeted initiatives to support clinicians. Successful implementation of advanced rehabilitation technologies relies on clinician buy-in to champion change within an enabling person-centered context.

Legitimacy as Social Infrastructure: A Critical Interpretive Synthesis of the Literature on Legitimacy in Health and Technology

BACKGROUND

As technology is integrated into health care delivery, research on adoption and acceptance of health technologies leaves large gaps in practice and provides limited explanation of how and why certain technologies are adopted and others are not. In these discussions, the concept of legitimacy is omnipresent but often implicit and underdeveloped. There is no agreement about what legitimacy is or how it works across social science disciplines, despite a prolific volume of the literature centering legitimacy.

OBJECTIVE

This study aims to explore the meaning of legitimacy in health and technology as conceptualized in the distinctive disciplines of organization and management studies, science and technology studies, and medical anthropology and sociology, including how legitimacy is produced and used. This allows us to critically combine insights across disciplines and generate new theory.

METHODS

We conducted a critical interpretive synthesis literature review. Searches were conducted iteratively and were guided by preset eligibility criteria determined through thematic analysis, beginning with the selection of disciplines, followed by journals, and finally articles. We selected disciplines and journals in organization and management studies, science and technology studies, and medical anthropology and sociology using results from the Scopus and Web of Science databases and disciplinary expert-curated journal lists, focusing on the depth of legitimacy conceptualization. We selected 30 journals, yielding 796 abstracts.

RESULTS

A total of 97 articles were included. The synthesis of the literature allowed us to produce a novel conceptualization of legitimacy as a form of social infrastructure, approaching legitimacy as a binding fabric of relationships, narratives, and materialities. We argue that the notion of legitimacy as social infrastructure is a flexible and adaptable framework for working with legitimacy both theoretically and practically.

CONCLUSIONS

The legitimacy as social infrastructure framework can aid both academics and decision makers by providing more coherent and holistic explanations for how and why new technologies are adopted or not in health care practice. For academics, our framework makes legitimacy and technology adoption empirically approachable from an ethnographic perspective; for decision makers, legitimacy as social infrastructure allows for a practical, action-oriented focus that can be assessed iteratively at any stage of the technology development and implementation process.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

From Data to Improvement: Social Mechanisms as a Key to Understanding Dashboard Adoption

Research on dashboard adoption has focused on technical and design requirements. Evidence on social mechanisms for successful dashboard adoption is scarce. This study examined 2 quality dashboards in a similar organizational context with different outcomes. The research question was: How do social mechanisms influence the adoption of dashboards in practice? This embedded case study within one Dutch hospital in 2 phases: (1) interviews and observations to identify social mechanisms in the end-user's team and (2) expert focus groups to validate identified mechanisms. Data were transcribed verbatim and analyzed thematically, resulting in the identification of 3 social mechanisms within the team of end-users influencing dashboard adoption: cultivating a supportive team climate, trust, and leadership behavior in end-users' teams. These mechanisms stimulate a learning environment for discussing and improving care quality. They require action from individuals and teams, so dashboards can be used for collective understanding, learning, and improving. Without these social mechanisms, dashboards remain an unadopted "materiality."

Social network intervention for loneliness and social isolation in a community setting: the PALS cluster-RCT

Background

Loneliness and social isolation are associated with adverse mental and physical health outcomes in adults. However, there is a lack of existing research on effective interventions and the contexts in which these could be implemented.

Primary objective

To assess the clinical and cost-effectiveness of a social network intervention compared to usual care among at-risk populations.

Design

A pragmatic, community-based, cluster randomised controlled trial with embedded health economic evaluation, process evaluation and qualitative study. Outcome assessments were conducted at baseline and at 3 and 6 months.

Setting

The study was conducted in collaboration with 44 community-based organisations in two regions in England.

Participants

Adults aged ≥ 18 years at risk of loneliness and social isolation.

Intervention

A facilitated social network tool ('project about loneliness and social networks'; PALS) designed to link people to opportunities for social involvement. First, participants map and reflect on personal social networks. Second, identification of local resources based on individual preferences, available support, and health and wellness needs.

Main outcome measures

The primary outcome was mental wellness at 6-month follow-up, measured by the Short Form questionnaire-12 items mental health component score (MCS). Secondary outcomes included the Short Form questionnaire-12 items Physical Health subscale, loneliness, social isolation, well-being and collective efficacy. Economic measures assessed the cost-effectiveness of the intervention in terms of costs, quality-adjusted life-years and net monetary benefits.

Results

We recruited 469 adults into the study, with 120 withdrawals (25.6%). The main trial results indicate little to no treatment effect of the intervention on either the primary or secondary outcomes compared to usual care. The within-trial economic evaluation found that PALS was inexpensive to deliver but there was no significant difference in quality-adjusted life-years, measures of well-being capability or costs, and the intervention did not lead to demonstrable cost-effectiveness in terms of net monetary benefits. The process evaluation found PALS to be acceptable to all types of community organisations, but low resource availability and capacity to sustain PALS was found across all community organisational contexts. Qualitative interviews (n = 20) highlighted that participants wanted to engage with meaningful social activities but barriers to doing so were psychological (i.e. confidence and competence) and practical (i.e. transport or cost).

Limitations

The timing of COVID-19 and associated restrictions (approximately splitting trial follow-up into thirds of pre-COVID, during the first lockdown, and following the trial reopening) meant its impact on the trial is difficult to assess. There were high levels of missing data (20-30% for most outcomes at 6 months), though methods to handle missing data did not change the conclusions of the trial.

Conclusions

Our findings do not provide strong evidence of the efficacy of the PALS social network intervention to address the complexities of loneliness and social isolation. Although the intervention was acceptable to participants and community organisations who hold the potential to deliver such an intervention, sustainability would require a networked approach between organisations to mitigate against the challenges found in each organisation.

Future work

Future interventions for loneliness would likely benefit from utilising a multistep approach providing tailored psychological, relational and social components.

Trial registration

This trial is registered as Current Controlled Trials ISRCTN19193075.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 16/08/41) and is published in full in Public Health Research; Vol. 13, No. 1. See the NIHR Funding and Awards website for further award information.

The NASSS (Non-Adoption, Abandonment, Scale-Up, Spread and Sustainability) framework use over time: A scoping review

The Non-adoption, Abandonment, Scale-up, Spread, Sustainability (NASSS) framework (2017) was established as an evidence-based, theory-informed tool to predict and evaluate the success of implementing health and care technologies. While the NASSS is gaining popularity, its use has not been systematically described. Literature reviews on the applications of popular implementation frameworks, such as the RE-AIM and the CFIR, have enabled their advancement in implementation science. Similarly, we sought to advance the science of implementation and application of theories, models, and frameworks (TMFs) in research by exploring the application of the NASSS in the five years since its inception. We aim to understand the characteristics of studies that used the NASSS, how it was used, and the lessons learned from its application. We conducted a scoping review following the JBI methodology. On December 20, 2022, we searched the following databases: Ovid MEDLINE, EMBASE, PsychINFO, CINAHL, Scopus, Web of Science, and LISTA. We used typologies and frameworks to characterize evidence to address our aim. This review included 57 studies that were qualitative (n=28), mixed/multi-methods (n=13), case studies (n=6), observational (n=3), experimental (n=3), and other designs (e.g., quality improvement) (n=4). The four most common types of digital applications being implemented were telemedicine/virtual care (n=24), personal health devices (n=10), digital interventions such as internet Cognitive Behavioural Therapies (n=10), and knowledge generation applications (n=9). Studies used the NASSS to inform study design (n=9), data collection (n=35), analysis (n=41), data presentation (n=33), and interpretation (n=39). Most studies applied the NASSS retrospectively to implementation (n=33). The remainder applied the NASSS prospectively (n=15) or concurrently (n=8) with implementation. We also collated reported barriers and enablers to implementation. We found the most reported barriers fell within the Organization and Adopter System domains, and the most frequently reported enablers fell within the Value Proposition domain. Eighteen studies highlighted the NASSS as a valuable and practical resource, particularly for unravelling complexities, comprehending implementation context, understanding contextual relevance in implementing health technology, and recognizing its adaptable nature to cater to researchers' requirements. Most studies used the NASSS retrospectively, which may be attributed to the framework's novelty. However, this finding highlights the need for prospective and concurrent application of the NASSS within the implementation process. In addition, almost all included studies reported multiple domains as barriers and enablers to implementation, indicating that implementation is a highly complex process that requires careful preparation to ensure implementation success. Finally, we identified a need for better reporting when using the NASSS in implementation research to contribute to the collective knowledge in the field.

Global Evidence on the Sustainability of Telemedicine in Outpatient and Primary Care During the First 2 Years of the COVID-19 Pandemic: Scoping Review Using the Nonadoption, Abandonment, Scale-Up, Spread, and Sustainability (NASSS) Framework

BACKGROUND

The rapid implementation of telemedicine during the early stages of the COVID-19 pandemic raises questions about the sustainability of this intervention at the global level.

OBJECTIVE

This research examines the patient experience, health inequalities, and clinician-patient relationship in telemedicine during the COVID-19 pandemic's first 2 years, aiming to identify sustainability factors.

METHODS

This study was based on a prepublished protocol using the Joanna Briggs Institute (JBI) methodology for scoping reviews. We included academic and gray literature published between March 2020 and March 2022 according to these criteria: (1) population (any group); (2) concepts (patient experience, clinician-patient relationship, health inequalities); (3) context (telemedicine in primary and outpatient care); (4) excluding studies pertaining to surgery, oncology, and (inpatient) psychiatry. We searched Ovid Medline/PubMed (January 1, 2022), Web of Science (March 19, 2022), Google/Google Scholar (February and March 2022), and others. The risk of bias was not assessed as per guidance. We used an analysis table for the studies and color-coded tabular mapping against a health care technology adoption framework to identify sustainability (using double-blind extraction).

RESULTS

Of the 134 studies that met our criteria, 49.3% (66/134) reported no specific population group. Regarding the concepts, 41.8% (56/134) combined 2 of the concepts studied. The context analysis identified that 56.0% (75/134) of the studies referred to, according to the definition in the United Kingdom, an outpatient (ambulatory care) setting, and 34.3% (46/134) referred to primary care. The patient experience analysis reflected positive satisfaction and sustained access during lockdowns. The clinician-patient relationship impacts were nuanced, affecting interaction and encounter quality. When mapping to the nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework, 81.3% (109/134) of the studies referenced the innovation's sustainability. Although positive overall, there were some concerns about sustainability based on quality, eHealth literacy, and access to health care for vulnerable migrants and the uninsured.

CONCLUSIONS

We identified confusion between the concepts of patient experience and patient satisfaction; therefore, future research could focus on established frameworks to qualify the patient experience across the whole pathway and not just the remote encounter. As expected, our research found mainly descriptive analyses, so there is a need for more robust evidence methods identifying impacts of changes in treatment pathways. This study illustrates modern methods to decolonize academic research by using gray literature extracts in other languages. We acknowledge that the use of Google to identify gray literature at the global level and in other languages has implications on reproducibility. We did not consider synchronous text-based communication.

TRIAL REGISTRATION

Open Science Framework 4z5ut; https://osf.io/4z5ut/.