Design Implementation Strategies Research Articles

Examining the feasibility of assisted index case testing for HIV case-finding: a qualitative analysis of barriers and facilitators to implementation in Malawi

BackgroundAssisted index case testing (ICT), in which health care workers take an active role in referring at-risk contacts of people living with HIV for HIV testing services, has been widely recognized as an evidence-based intervention with high potential to increase status awareness in people living with HIV. While the available evidence from eastern and southern Africa suggests that assisted ICT can be an effective, efficient, cost-effective, acceptable, and low-risk strategy to implement in the region, it reveals that feasibility barriers to implementation exist. This study aims to inform the design of implementation strategies to mitigate these feasibility barriers by examining “assisting” health care workers’ experiences of how barriers manifest throughout the assisted ICT process, as well as their perceptions of potential opportunities to facilitate feasibility.MethodsIn-depth interviews were conducted with 26 lay health care workers delivering assisted ICT in Malawian health facilities. Interviews explored health care workers’ experiences counseling index clients and tracing these clients’ contacts, aiming to inform development of a blended learning implementation package. Transcripts were inductively analyzed using Dedoose coding software to identify and describe key factors influencing feasibility of assisted ICT. Analysis included multiple rounds of coding and iteration with the data collection team.ResultsParticipants reported a variety of barriers to feasibility of assisted index case testing implementation, including sensitivities around discussing ICT with clients, privacy concerns, limited time for assisted index case testing amid high workloads, poor quality contact information, and logistical obstacles to tracing. Participants also reported several health care worker characteristics that facilitate feasibility (knowledge, interpersonal skills, non-stigmatizing attitudes and behaviors, and a sense of purpose), as well as identified process improvements with the potential to mitigate barriers.ConclusionsMaximizing assisted ICT’s potential to increase status awareness in people living with HIV requires equipping health care workers with effective training and support to address and overcome the many feasibility barriers that they face in implementation. Findings demonstrate the need for, as well as inform the development of, implementation strategies to mitigate barriers and promote facilitators to feasibility of assisted ICT.Trial registrationNCT05343390. Date of registration: April 25, 2022.

How can a behavioral economics lens contribute to implementation science?

BackgroundImplementation science in health is an interdisciplinary field with an emphasis on supporting behavior change required when clinicians and other actors implement evidence-based practices within organizational constraints. Behavioral economics has emerged in parallel and works towards developing realistic models of how humans behave and categorizes a wide range of features of choices that can influence behavior. We argue that implementation science can be enhanced by the incorporation of approaches from behavioral economics.Main bodyFirst, we provide a general overview of implementation science and ways in which implementation science has been limited to date. Second, we review principles of behavioral economics and describe how concepts from BE have been successfully applied to healthcare including nudges deployed in the electronic health record. For example, de-implementation of low-value prescribing has been supported by changing the default in the electronic health record. We then describe what a behavioral economics lens offers to existing implementation science theories, models and frameworks, including rich and realistic models of human behavior, additional research methods such as pre-mortems and behavioral design, and low-cost and scalable implementation strategies. We argue that insights from behavioral economics can guide the design of implementation strategies and the interpretation of implementation studies. Key objections to incorporating behavioral economics are addressed, including concerns about sustainment and at what level the strategies work.ConclusionScholars should consider augmenting implementation science theories, models, and frameworks with relevant insights from behavioral economics. By drawing on these additional insights, implementation scientists have the potential to boost efforts to expand the provision and availability of high quality care.

Patient and pharmacist perspectives on opioid misuse screening and brief interventions in community pharmacies

BackgroundPharmacy-based screening and brief interventions (SBI) offer opportunities to identify opioid misuse and opioid safety risks and provide brief interventions that do not overly burden pharmacists. Currently, such interventions are being developed without patient input and in-depth contextual data and insufficient translation into practice. The purpose of this study is to qualitatively explore and compare patient and pharmacist perceptions and needs regarding a pharmacy-based opioid misuse SBI and to identify relevant SBI features and future implementation strategies.MethodsUsing the Consolidated Framework for Implementation Research, we conducted semi-structured interviews with 8 patients and 11 pharmacists, to explore needs and barriers to participating in a pharmacy-based SBI. We recruited a purposive sample of English-speaking patients prescribed opioids for chronic or acute pain and pharmacists practicing in varied pharmacies (small independent, large-chain, specialty retail) settings. We used an inductive content analysis approach to analyze patient interview data. Then through a template analysis approach involving comparison of pharmacist and patient themes, we developed strategies for SBI implementation.ResultsMost patient participants were white, older, described living in suburban areas, and were long-term opioid users. We identified template themes related to individual, interpersonal, intervention, and implementation factors and inferred applications for SBI design or potential SBI implementation strategies. We found that patients needed education on opioid safety and general opioid use, regardless of opioid use behaviors. Pharmacists described needing patient-centered training, protocols, and scripts to provide SBI. A short-self-reported screening and brief interventions including counseling, naloxone, and involving prescribers were discussed by both groups.ConclusionsThrough this implementation-focused qualitative study, we identified patient needs such as opioid safety education delivered in a private and convenient format and pharmacist needs including training, workflow integration, protocols, and a time-efficient intervention for effective pharmacy-based SBI. Alternate formats of SBI using digital health technologies may be needed for effective implementation. Our findings can be used to develop patient-centered pharmacy-based SBI that can be implemented within actual pharmacy practice.

Thermal Imaging for Burn Wound Depth Assessment: A Mixed-Methods Implementation Study.

Background: Implementing innovations emerging from clinical research can be challenging. Thermal imagers provide an accessible diagnostic tool to increase the accuracy of burn wound depth assessment. This mixed-methods implementation study aimed to assess the barriers and facilitators, design implementation strategies, and guide the implementation process of thermal imaging in the outpatient clinic of a burn centre. Methods: This study was conducted between September 2022 and February 2023 in Beverwijk, The Netherlands. Semi-structured interviews with burn physicians guided by the Consolidated Framework for Implementation Research (CFIR) were conducted to identify barriers and facilitators. Based on the barriers, implementation strategies were developed with the CFIR-ERIC Matching Tool, and disseminated to support the uptake of the thermal imager. Subsequently, thermal imaging was implemented in daily practice, and an iterative RE-AIM approach was used to evaluate the implementation process. Results: Common facilitators for the implementation of the thermal imager were the low complexity, the relative advantage above other diagnostic tools, and benefits for patients. Common barriers were physicians' attitude towards and perceived value of the intervention, the low compatibility with the current workflow, and a lack of knowledge about existing evidence. Six implementation strategies were developed: creating a formal implementation blueprint, promoting adaptability, developing educational materials, facilitation, conducting ongoing training, and identifying early adopters. These strategies resulted in the effective implementation of the thermal imager, reflected by a >70% reach among eligible patients, and >80% effectiveness and adoption. Throughout the implementation process, compatibility, and available resources remained barriers, resulting in low ratings on RE-AIM dimensions. Conclusions: This study developed implementation strategies based on the identified CFIR constructs that impacted the implementation of a thermal imager for burn wound assessment in our outpatient clinic. The experiences and findings of this study could be leveraged to guide the implementation of thermal imaging and other innovations in burn care.

Co-designing strategies to implement long-acting injectable PrEP for sexual minority men in Chicago: a study protocol for an innovation tournament and implementation mapping

BackgroundParticipatory design approaches can improve successful selection and tailoring of implementation strategies by centering the voices of key constituents. To reduce incidence of the human immunodeficiency virus (HIV) in the USA, co-design of implementation strategies is needed for long-acting injectable cabotegravir (CAB-LA), a new form of HIV pre-exposure prophylaxis, among the disproportionately impacted population of sexual minority men (SMM). This manuscript describes the protocol for participatory design approaches (i.e., innovation tournament and implementation mapping) to inform implementation of CAB-LA among SMM (≥ 12 years), particularly Black and Latino populations, in Chicago.MethodsThis research incorporates innovative methods to accomplish two objectives: (1) to crowdsource ideas for the design of implementation strategies for CAB-LA through a virtual innovation tournament and (2) to leverage the ideas from the innovation tournament to operationalize implementation strategies for CAB-LA thorough the systematic process of implementation mapping. A committee of constituents with diverse expertise and perspectives (e.g., SMM, implementation scientists, HIV clinicians, public health leadership, and community partners) will provide input throughout the design process.DiscussionThis research will produce a menu of co-designed implementation strategies, which can guide plans for CAB-LA integration in Chicago and provide insights for other EHE regions. Further, as the first innovation tournament focused on HIV prevention, this research can provide a framework for participatory approaches across the care continuum. Given that the co-design of implementation strategies often does not involve the participation of individuals with lived experiences, this work will center the voices of those who will benefit most.

Learning Innovation based on seTARA daring in the Community Learning Activity Center

This study aims to describe learning innovations based on seTARA daring at (Community Learning Activity Center) PKBM Sunan Kalijaga Lirboyo Kediri, which includes planning, implementation, and evaluation stages, including identifying supporting and inhibiting factors and improvement efforts made. This study used a qualitative approach with a case study. In-depth interviews with leaders, teachers/tutors, and students, as well as observations of the learning process and online classes, were used to gain an in-depth understanding of experiences in the educational environment. Supporting data were obtained from official documents such as the e-learning curriculum, teaching records, and learning outcome evaluation. The results show that the learning innovation based on the seTARA daring application is practical and can benefit the students. At the planning stage, meetings were held to design implementation strategies, discuss policies, and announce the strategies and policies to students. The implementation stage involves implementing the policy and practical guidance and improving tutor innovation. The evaluation stage assessed the success of learning innovations based on the seTARA daring application by collecting feedback from tutors and students, becoming the basis for future improvement and enhancement. This research provides an essential contribution to understanding the challenges and potential solutions to optimize e-learning in the equivalency education program in PKBM.

Bibliometric Exploration of Publication Development in Entrepreneurship Education

This research presents a bibliometric exploration of publication development in entrepreneurship education, aiming to elucidate trends, research focuses, and emerging opportunities within the field. Entrepreneurship education has gained prominence as a crucial discipline in academia and practice, reflecting the growing recognition of entrepreneurship's role in economic and societal advancement. Through bibliometric analysis techniques, including citation analysis, keyword analysis, and visualization methods, a comprehensive examination of scholarly publications related to entrepreneurship education from 1977 to 2023 was conducted. The findings offer insights into publication metrics, such as citation counts, author productivity, and impact indices, providing a nuanced understanding of the scholarly landscape. Visualization of term networks and trends revealed dominant research themes, evolving concepts, and potential research directions within entrepreneurship education. Practical implications derived from this study inform educators, policymakers, practitioners, and other stakeholders about curriculum design, policy formulation, and program implementation strategies to foster collaboration, innovation, and excellence in entrepreneurship education research and practice.

Exploring Consumers' Motivations and Experiences of Engaging as Partners in Cancer Research.

Consumer engagement improves research quality and relevance but can be difficult to implement. This study aimed to explore the motivations and understand the barriers, if any, experienced by consumers before and when partnering with cancer research teams. Semi-structured interviews were conducted with consumers and the results analysed thematically. Two groups were recruited: consumers who were members of the consumer registry and patients who did not have previous experience of being a consumer in a researcher partnership. Twenty-one interviews were conducted with a total of 22 participants aged between 26 and 74 years. Consumers motivation was driven by altruism to help others and personal benefits. Barriers to beginning and maintaining consumer engagement included consumers' perceptions of being appreciated by researchers and meaningful communication between researchers and consumers. Australian policy has made important steps towards consumer engagement in research. This study showed that demonstrating an appreciation for consumers and effective communication are key areas to consider when designing implementation strategies of these policies in the cancer research space in the future.

The ART of Readiness: A Practical Tool for Implementation Tailoring at the Activity Level

AbstractThe field of implementation science has made notable strides to enhance the practice of tailoring through the development of implementation strategy taxonomies (e.g., Expert Recommendations for Implementation Change; Waltz et al., In Implement Sci 10:109, 2015) and numerous tailoring methodologies (e.g., concept mapping, conjoint analysis, group model building, and intervention mapping; Powell et al., In J Behav Health Serv Res 44:177–194, 2017). However, there is growing concern about a widening gap between implementation science research and what is practical in real-world settings, given resource and time constraints (Beidas et al., In Implement Sci 17:55, 2022; Lewis et al., In Implement Sci 13:68, 2018). Overly complex implementation strategies and misalignment with practitioner priorities threaten progress in the field of implementation science. As solutions to the burgeoning threats, implementation science thought leaders have suggested using rapid approaches to contextual inquiry; developing practical approaches to implementation strategy design, selection, and tailoring; and embracing an embedded implementation science researcher model that prioritizes partner needs over researcher interests (Beidas et al., In Implement Sci 17:55, 2022). Aligned with these recommendations, we introduce the Activity Readiness Tool (ART)—a brief, practitioner-friendly survey that assesses discrete determinants of practice through an implementation readiness lens. We illustrate how the tool can be used as a rapid approach to facilitate implementation efforts in a case example involving a national integrated care initiative. The ART can serve as a quick, user-friendly companion to an array of existing evidence-based tailoring methods and tools.

Situating implementation science (IS) in res(IS)tance: a conceptual frame toward the integration of scholarship from the black radical tradition.

This manuscript undertakes a disciplinary self-critique of the field of implementation science, a field which attempts to bridge the gap between evidence-based interventions and their practical application. Despite the heightened emphasis on health equity and racial disparities, the field's current discourse is limited by key epistemic shortcomings. First, even though prevalence of implementation gaps between racialized groups in the United States necessitates a comprehensive understanding of the systems perpetuating these disparities, the field does not operate with a general explanation for disparities not as a failure of systems, but a system historically and structural designed to produce disparities. Second, the field has attempted to address disparities without adequate dialog with a broad tradition of anti-racist and anti-colonial sociology, history and epistemology, and therefore risks a decontextualized analysis of disparities and under-informed approaches to achieving equity. Fortunately, scholarship from the Black radical tradition (BRT), such as the Public Health Critical Race Praxis (PHCRP), Critical Race Theory (CRT), and more broadly conceptual frameworks from post-modern, anti-colonial, Black feminist studies and social epistemology can offer to implementation science frameworks that center power dynamics and racialized oppression. This epistemic re-alignment of implementation research to "center at the margins" can enable the field of implementation science to more critically examine and dismantle systems that perpetuate racial inequalities in access to and utilization of health interventions. For example, normalization and dynamic fit, which are thought to be key mechanisms of implementation, are revealed in the light of this tradition of scholarship to be potentially problematic acquiescence to oppressive systems. Drawing from the concept of resistance anchored in the scholarship of the Black radical tradition as well as contemporary social epistemology such as the work of José Medina and Maria Fricker about epistemic justice, the authors further advance that implementation science could make more substantial contributions to the dismantling of racialized systems and actively work toward health justice through the transdisciplinary lens of resistance. This is a call to action for integrating implementation science with critical philosophical and theoretical perspectives rooted in Black studies and related insights, which have been acquired through the struggle for social justice, to inform the design of implementation strategies and research projects that improve health services and health outcomes for health disparity populations.

Construction of Mineralization Nanostructures in Polymers for Mechanical Enhancement and Functionalization.

Mineralization capable of growing inorganic nanostructures efficiently, orderly, and spontaneously shows great potential for application in the construction of high-performance organic-inorganic composites. As a thermodynamically spontaneous solid-phase crystallization reaction involving dual organic and inorganic components, mineralization allows for the self-assembly of sophisticated and exclusive nanostructures within a polymer matrix. It results in a diversity of functions such as enhanced strength, toughness, electrical conductivity, selective permeability, and biocompatibility. While there are previous reviews discussing the progress of mineralization reactions, many of them overlook the significant benefits of interfacial regulation and functionalization that come from the incorporation of mineralized structures into polymers. Focusing on different means of assembly of mineralized nanostructures in polymer, the work analyzes their design principles and implementation strategies. Then, their different advantages and disadvantages are analyzed by combining nanostructures with organic substrates as well as involving the basis of different functionalizations. It is anticipated to provide insights and guidance for the future development of mineralized polymer composites and their application designs.

IMPLEMENTING AN AREA AGENCY ON AGING COMMUNITY CARE TRANSITION INITIATIVE: FACILITATORS AND BARRIERS

Abstract The Michigan Region VII Area Agency on Aging (AAA) implemented a Community Care Transition Initiative (CCTI) for rural hospitalized older adults at high risk for readmission. After discharge home, AAA CCTI participants received a home visit by an AAA-trained pharmacy technician community health worker (CHW), a telehealth AAA pharmacist medication review, assessments by the CHW and pharmacist, education, primary care follow-up coaching, and referrals. As part of a program evaluation, we conducted six interviews with AAA key informants (e.g., pharmacist, director, CHWs). A semi-structured interview guide was piloted and revised to assess implementation, processes, impact, and future directions. Interviews were conducted via Zoom, recorded, transcribed, and checked for accuracy. Thematic analysis was used to identify implementation facilitators, barriers, and areas for program refinement. Three researchers coded the transcripts, developed a codebook, and resolved discrepancies by consensus. NVivo 14® was used for data management and analysis. Barriers to AAA CCTI implementation included unknowns at project start and need for procedures, anxiety about entering a client’s house, client’s lack of familiarity with technology, lack of perceived pharmacist benefit, limited personnel, and billing or financial reimbursement. Facilitators identified were the AAA’s reputation and backing, relationships built between healthcare providers, referral processes (e.g., community mental health), and pharmacist telehealth visit efficiency. Program refinements included shortened follow-up time and tailored visits to different client situations and needs. The results provide insights into the design of implementation strategies to disseminate the AAA CCTI to meet rural older adults’ health and social needs after hospitalization.

Older people's perceptions and experiences of older people with the Sit-to-stand activity: An ethnographic pre-feasibility study.

the purpose of this pre-feasibility study was to examine perceptions and experiences of a Sit-to-stand activity with urban Brazilian community-dwelling older people in their homes. the exploration method was focused ethnography. Purposive sampling was used to recruit 20 older people. Five means of data generation were used, namely: socio-demographic surveys, participant observations, informal interviews, formal semi-structured interviews, and field notes. Data analysis was qualitative content analysis. the experience of mobility-challenged older people with the Sit-to-stand activity was dependent on their mobility expectations involving many factors that worked together to influence their beliefs and attitudes towards the activity, preferences, behaviors, and cultural perceptions. The participants of this study seemed to find the activity enjoyable; however, the most noticeable shortcomings for their engagement in the Sit-to-stand activity emerged as gaps in their personal and intrapersonal needs. the recommendations generated from the study findings call for the design of implementation strategies for the Sit-to-stand intervention that are tailored to this particular population's needs.

Designing Implementation Strategies for a Digital Suicide Safety Planning Intervention in a Psychiatric Emergency Department: Protocol for a Multimethod Research Project.

Suicide prevention is currently a national health priority in Canada. Emergency departments (EDs) are critical settings for suicide prevention, and in our local psychiatric ED at the Centre for Addiction and Mental Health, we plan to embed an app-based tool called the Hope app to support suicide safety planning intervention. The app is free and available on app stores, and usability tests have been completed. As a next step to embed this new tool into the routine clinical workflow, research is needed to assess determinants of and design strategies for implementation with the end goal of routinization. The purpose of this 2-phased research is to implement the app in the routine clinical workflow in our local psychiatric ED. The specific objectives are as follows: (1) understanding ED clinicians' perceptions and experience of implementing the app in routine practice and identifying barriers to and facilitators of implementation (phase 1) and (2) using findings and outputs from phase 1 and collaborating with service users, families, and ED clinicians to co-design implementation strategies for the app (phase 2). We will use an integrated knowledge translation approach throughout this project. In phase 1, we will conduct interviews with ED clinicians to identify implementation determinants using a behavior change framework. In phase 2, a co-design team comprising clinicians, ED service users, and families will design implementation strategies that align with the determinants identified in phase 1. This protocol presents detailed information about the entire structure of the 2-phased research project. Ethics approval for conducting the qualitative descriptive study (phase 1) has been obtained, and the recruitment and data collection processes will be completed no later than December 2023. Ethics approval for phase 2 is underway. Involving multiple knowledge user groups early in the research and decision-making process is crucial for successful implementation. Although co-designing is commonly practiced during innovation development, there is often a misconception that the responsibility for implementing what has been designed falls on others. This research aims to fill this methodological gap in the health informatics literature. By the end of this project, we will have developed theory-informed implementation strategies to support Centre for Addiction and Mental Health ED clinicians in adopting the Hope app to complete safety planning intervention. These strategies, guided by a behavior change framework, will target clinicians' behavior change and seamlessly integrate the app into the routine clinical workflow. In addition, this research project will provide recommendations on how to involve multiple knowledge user groups and offer insights into how the methodology used can be adapted to other areas within the health informatics literature. PRR1-10.2196/50643.

Prediction of Design Ideas and Implementation Strategies for the Development of New Forms of Maritime English Textbooks

With the further deepening of the "Three Education" reform, the development of new forms of textbooks has become a necessary question for the construction of vocational colleges and talent cultivation in the new era. The construction of a new form of teaching material for Maritime English is centered around paper textbooks, with the principles of "advanced, practical, and applicable". The paper textbooks are organically integrated with high-quality digital resources, and the teaching content is restructured based on job responsibilities to achieve new forms of teaching theory and practice. At the same time, the ideological and political curriculum is organically integrated into the textbooks, in order to explore and practice vocational education teaching reform, Provide valuable experience and reference for promoting the level of textbook construction.

Designing an implementation strategy to increase health-related social needs screening: Applying the PRISM framework in a resource-limited clinical setting.

Despite growing acceptability of health-related social needs (HRSN) screening and increasing policy incentives for adoption, clinical implementation of HRSN screening remains low. HRSN screening has been particularly difficult for Community Health Centers (CHCs), which have limited resources to implement and sustain new workflows. While CHCs provide care to patients with disproportionately high levels of unmet social needs, identifying HRSN screening implementation strategies that take CHC-specific contexts into account remains elusive. This study uses the Practical Robust Implementation and Sustainability Model (PRISM) to design an implementation strategy accounting for the unique context of CHCs. We used Rapid Ethnographic Assessment observations and stakeholder focus groups to identify current workflow barriers and facilitators to HRSN screening, and to develop implementation strategies that include multi-level contexts and perspectives. We identified eight themes contributing to low screening implementation: perceived stigma around screening; need for community-based solutions; re-confirming organizational priorities and values; Electronic Medical Record (EMR) limitations; multi-tasking pressures limiting implementation; staff turnover; limited knowledge of regulatory requirements; and community resource availability for referral. Based on the themes, we identified implementation strategies including non-EMR data collection; integration into the workflow for multiple staff members; creation of new training and educational modules; and identification of peer champions for retraining in real time. Administrative requirements are necessary but not sufficient for implementation of HRSN screening in CHCs. Resource-constrained settings benefit from context-specific stakeholder engagement to improve implementation success. The use of PRISM ensured contextual factors were central to the implementation strategy design.

Improving Neurology Clinical Care With Natural Language Processing Tools.

The integration of natural language processing (NLP) tools into neurology workflows has the potential to significantly enhance clinical care. However, it is important to address the limitations and risks associated with integrating this new technology. Recent advances in transformer-based NLP algorithms (e.g., GPT, BERT) could augment neurology clinical care by summarizing patient health information, suggesting care options, and assisting research involving large datasets. However, these NLP platforms have potential risks including fabricated facts and data security and substantial barriers for implementation. Although these risks and barriers need to be considered, the benefits for providers, patients, and communities are substantial. With these systems achieving greater functionality and the pace of medical need increasing, integrating these tools into clinical care may prove not only beneficial but necessary. Further investigation is needed to design implementation strategies, mitigate risks, and overcome barriers.

Designing implementation strategies for the inclusion of LGBTQIA+ and key populations content in undergraduate nursing curricula in KwaZulu-Natal, South Africa: Protocol for a Multi-Methods Research Project.

Literature suggests that Lesbian, Gay, Bisexual, Transgender, Intersex, Queer and Allied (LGBTQIA+) individuals encounter challenges with access and engagement with health services. Studies have reported that LGBTQIA+ individuals' experiences stigma, discrimination and health workers' micro aggression when accessing healthcare. There is compelling evidence to suggest that the LGBTQIA+ community are faced with disproportionate rates of HIV infection, mental health disorders, substance abuse and other non-communicable diseases. The South African National Strategic Plan (NSP) on HIV/AIDS, TB and STI's (2023-2028) recognises the need for providing affirming LGBTQIA+ health care as part of the country's HIV/AIDS response strategy that is rooted in comprehensive and holistic care underpinned by the principles of community oriented primary healthcare. However, current anecdotal evidence suggests paucity of LGBTQIA+ and key populations health content in the undergraduate health science curricula in South Africa. Moreover, literature reveals a general lack of health worker training regarding the health needs of LGBTQIA+ persons and other key populations such as sex workers, People Who Inject Drugs (PWID) and Men who have Sex with Men (MSM). This protocol paper describes the design of a project that aims at facilitating the inclusion of health content related to the LGBTQIA+ community and other key populations in the undergraduate nursing curricula of KwaZulu-Natal, South Africa. A multi-methods design encompassing collection of primary and secondary data using multiple qualitative designs and quantitative approaches will be used to generate evidence that will inform the co-design, testing and scale-up of strategies to facilitate the inclusion of LGBTQIA+ and key populations content in undergraduate nursing curricula in KwaZulu-Natal, South Africa. Data will be collected using a combination of convenience, purposive and snow ball sampling techniques from LGBTQIA+ persons, academic staff, undergraduate nursing students and other key populations such as MSM, PWID and sex workers. Primary data will be collected through individual in-depth interviews, focus groups discussions and surveys guided by semi-structure and structured data collection tools. Data collection and analysis will be an iterative process guided by the respective research design to be adopted. The continuous quality improvement process to be adopted during data gathering and analysis will ensure contextual relevance and sustainability of the resultant co-designed strategies that are to be scaled-up as part of the overarching objective of this study. The proposed study is designed in response to recent contextual empirical evidence highlighting the multiplicity of health challenges experienced by LGBTQIA+ individuals and key populations in relation to health service delivery and access to healthcare. The potential findings of the study may be appropriate for contributing to the education of nurses as one of the means to ameliorate these problems. This research has potential implications for nursing education in South Africa and worldwide as it addresses up-to-date problems in the nursing discipline as it pertains to undergraduate students' preparedness for addressing the unique needs and challenges of the LGBTQIA+ community and other key populations. The findings may also provide baseline data to inform knowledge transfer to other health sciences disciplines that have not included LGBTQIA+ content in their undergraduate curricula in South Africa.

Aligning intuition and theory: a novel approach to identifying the determinants of behaviours necessary to support implementation of evidence into practice

BackgroundDisentangling the interplay between experience-based intuition and theory-informed implementation is crucial for identifying the direct contribution theory can make for generating behaviour changes needed for successful evidence translation. In the context of ‘clinicogenomics’, a complex and rapidly evolving field demanding swift practice change, we aimed to (a) describe a combined clinician intuition- and theory-driven method for identifying determinants of and strategies for implementing clinicogenomics, and (b) articulate a structured approach to standardise hypothesised behavioural pathways and make potential underlying theory explicit.MethodsInterview data from 16 non-genetic medical specialists using genomics in practice identified three target behaviour areas across the testing process: (1) identifying patients, (2) test ordering and reporting, (3) communicating results. The Theoretical Domains Framework (TDF) was used to group barriers and facilitators to performing these actions. Barriers were grouped by distinct TDF domains, with ‘overarching’ TDF themes identified for overlapping barriers. Clinician intuitively-derived implementation strategies were matched with corresponding barriers, and retrospectively coded against behaviour change techniques (BCTs). Where no intuitive strategies were provided, theory-driven strategies were generated. An algorithm was developed and applied to articulate how implementation strategies address barriers to influence behaviour change.ResultsAcross all target behaviour areas, 32 identified barriers were coded across seven distinct TDF domains and eight overarching TDF themes. Within the 29 intuitive strategies, 21 BCTs were represented and used on 49 occasions to address 23 barriers. On 10 (20%) of these occasions, existing empirical links were found between BCTs and corresponding distinct TDF-coded barriers. Twenty additional theory-driven implementation strategies (using 19 BCTs on 31 occasions) were developed to address nine remaining barriers.ConclusionClinicians naturally generate their own solutions when implementing clinical interventions, and in this clinicogenomics example these intuitive strategies aligned with theoretical recommendations 20% of the time. We have matched intuitive strategies with theory-driven BCTs to make potential underlying theory explicit through proposed structured hypothesised causal pathways. Transparency and efficiency are enhanced, providing a novel method to identify determinants of implementation. Operationalising this approach to support the design of implementation strategies may optimise practice change in response to rapidly evolving scientific advances requiring swift translation into healthcare.

Stigma and Social Determinants of Health Associated With Fidelity to Guideline-Concordant Therapy in Patients With Breast Cancer Living With and Without HIV in Botswana.

Patients with breast cancer in sub-Saharan Africa (SSA) experience a disproportionate burden of mortality. Fidelity to treatment guidelines, defined as receiving optimal dose and frequency of prescribed treatments, improves survival. We sought to identify patient factors associated with treatment fidelity and how this may differ for people with HIV (PWH) and breast cancer. We conducted a qualitative study of women who initiated outpatient treatment for stages I-III breast cancer in Botswana, with deviance sampling of high- and low-fidelity patients. One-on-one interviews were conducted using semi-structured guides informed by the Theory of Planned Behavior. The sample size was determined by thematic saturation. Transcribed interviews were double coded with an integrated analytic approach. We enrolled 15 high- and 15 low-fidelity participants from August 25, 2020 to December 15, 2020, including 10 PWH (4 high, 6 low fidelity). Ninety-three percent had stage III disease. Barriers to treatment fidelity included stigma, social determinants of health (SDOH), and health system barriers. Acceptance and de-stigmatization, peer and other social support, increased knowledge and self-efficacy were identified as facilitators. The COVID-19 pandemic amplified existing socioeconomic stressors. Unique barriers and facilitators identified by PWH included intersectional stigma, and HIV and cancer care integration, respectively. We identified multilevel modifiable patient and health system factors associated with fidelity. The facilitators provide opportunities for leveraging existing strengths within the Botswana context to design implementation strategies to increase treatment fidelity to guideline-concordant breast cancer therapy. However, PWH experienced unique barriers, suggesting that interventions to address fidelity may need to be tailored to specific comorbidities.