Directed Content Analysis Research Articles

Digital health technologies, such as telehealth, remote patient monitoring, and smartphone apps, have the potential to reduce access disparities faced by rural patients with cardiovascular disease, but little is known about rural health care providers' perspectives on adopting digital health in their practice. This study used diffusion of innovations theory as a guiding framework to interpret interview findings on rural and rural-serving health care providers' perspectives on the use of digital health to deliver rural cardiovascular care. We conducted semistructured interviews with rural and rural-serving health care providers, including primary care advanced practice providers and physicians, as well as referring cardiologists from 6 primary care clinics in Alaska, Idaho, and Washington. We performed a directed content analysis of interview data informed by diffusion of innovations theory and identified emergent subthemes related to each of the 5 factors that influence adoption: relative advantage, compatibility, complexity, trialability, and observability. Seventeen health care providers participated in this study. Participants described cycles of adopting and discontinuing the use of digital health in their practice. Participants identified advantages of digital health including reduced patient travel, the ability to leverage nonphysician health care workers, and the availability of objective patient data from remote patient monitoring. Compatibilities included increased patient adherence and follow-up and the ability to involve specialists in patient care. The trialability of digital health was described through experiences with remote patient monitoring and scaled-up use of telehealth during the COVID-19 pandemic, and participants observed the benefits of digital health in other disciplines and as patients. We also identified several disadvantages, incompatibilities, and complexities that may hinder the adoption of digital health technologies in rural practice, most of which were highlighted at the clinic and patient levels. These disadvantages, incompatibilities, and complexities included substandard equipment, inability to perform a physical examination, connectivity issues caused by poor internet and cell phone service, concerns about patient age and technical abilities, concerns about proper fit and distribution of remote patient monitoring equipment, and questions about billing and data management for digital health technologies. Rural health care providers recognize the many advantages of using digital health in caring for patients with cardiovascular disease but find that digital health is often complex and incompatible with their needs and the needs of their patients. There may be a disconnect between the potential of digital health and how it works in practice, as evidenced by the cycles of adoption and discontinuance of digital health technologies described by rural health care providers. Future rural digital health interventions in cardiovascular care should take into consideration specific complexities and incompatibilities in the rural context.

Rheumatoid arthritis (RA) is a chronic, inflammatory autoimmune disease. Disease-modifying antirheumatic drugs (DMARDs) are the cornerstone of management and methotrexate is broadly considered as first-line treatment. Gastrointestinal side effects and variable bioavailability however limit adherence to and effectiveness of oral methotrexate, while parenteral methotrexate remains underutilized. To explore RA patients' perspective and their level of acceptance towards parenteral methotrexate and to investigate the barriers and enablers to its use. A qualitative study was conducted using semi-structured interviews between May and August 2022. Participants were recruited using convenience and purposive sampling strategy. The Theoretical Framework of Acceptability (TFA) was used to guide the development of the interview guide and data analysis (directed content analysis). Twenty-five participants (68% female, 76% with experience using parenteral methotrexate) were interviewed. All seven TFA constructs were found to influence participants' acceptance of parenteral methotrexate. High acceptance was related to the TFA constructs "perceived effectiveness", "intervention coherence", "self-efficacy" and "ethicality". Experience with disease improvement and gastrointestinal tolerance with parenteral methotrexate was valued by the participants, and understanding these benefits was linked with high acceptability (perceived effectiveness). Participants reported a high level of confidence in using methotrexate injections and adapting to the injection-taking routine (self-efficacy). The user-friendly design of the methotrexate pre-filled syringe, along with the support from healthcare professionals, served as enablers (intervention coherence and ethicality). Minimal opportunity costs (e.g., no major lifestyle sacrifices) further supported acceptability, though some reported initial injection anxiety (affective attitude). Barriers were frequently identified in the "burden" construct, including travel inconvenience and injection-associated cost. Participants without the experience with methotrexate injections expressed the need for further information, particularly regarding the logistical and safety aspects of parenteral methotrexate (intervention coherence). Our findings highlighted that patients' comprehension of the benefits of using parenteral methotrexate, confidence in self-administration, healthcare professionals' support, and the ease of using injections may help optimize treatment acceptability, underscoring the importance of patient's education from healthcare professionals and the availability of patient-friendly devices.

ABSTRACT This paper reports on the final stage of an Australian Research Council Linkage research project that examined codesign interventions in two Australian public library refurbishments. The article investigates how codesign outputs influenced final library designs and identifies key considerations for integrating codesign into public library development projects. Semi-structured interviews were conducted with council staff and architects involved in finalising the designs for both libraries. A directed content analysis of interview transcripts was used to examine the extent to which codesign outputs were incorporated into final designs and to gather reflections on the codesign process. Findings show that codesign outputs significantly influenced both final designs, in one case accounting for an estimated 80–90% of the final design, and in the other, 70–75%. The codesign process provided valuable community engagement, generated diverse ideas, and helped secure funding support. However, challenges included recruiting diverse participants and managing expectations. The paper presents nineteen practical recommendations for planning codesign interventions in public library settings, which cover areas such as workshop configuration, participant recruitment, professional involvement, and budget considerations. These recommendations will form part of a codesign toolkit for public library staff who seek to engage communities in designing physical library spaces.

Background and objectiveSince 2005, health policymakers in Iran have focused on the rural family physician plan to minimize unnecessary specialist referrals and enhance both efficiency and equitable access to services. In September 2021, the urban family physician plan was launched, engaging various organizations, including insurance companies. A trustee was appointed to manage the implementation of the Iranian health insurance program. This study examines how Iran Health Insurance prioritized the urban family physician program on its agenda by applying Kingdon’s agenda-setting model.Materials and methodsThis descriptive qualitative study gathered data through semi-structured interviews with 13 stakeholders in Iran’s urban family physician program, including planners, policymakers, and implementers. Purposive sampling, followed by snowball sampling, was used until data saturation was reached. Directed content analysis was applied, guided by Kingdon’s multiple streams framework.ResultsThree themes emerged: problem, policy, and political streams. The problem stream for Iran’s family physician plan included structural challenges (such as incomplete implementation, physician shortages, fragmented health data systems, poor stakeholder coordination), social-cultural barriers (including low public awareness, resistance to change), and economic issues (such as high treatment costs, inadequate insurance coverage). The policy stream proposed solutions such as electronic systems, standardized protocols, new technologies, expanded education, and improved physician working conditions. Strong government and parliamentary backing were identified as critical to addressing these challenges, emphasizing the need for sustained commitment and holistic strategies.Discussion and conclusionThe WHO, Iranian Parliament, Ministry of Health, and health insurers can serve as policy entrepreneurs to advance the family physician program within Iran’s health insurance system. The WHO can leverage global health data to emphasize Iran’s healthcare challenges, while the Ministry of Health and insurers can pinpoint issues via national research. The Parliament can facilitate public voices to gather input from citizens and experts.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12889-025-23359-y.

Complex care curricula (or "interprofessional student hotspotting") are experiential, longitudinal programs based on complex care practice models where health professions students engage patients with complex health and social needs through personalized, hands-on interventions. Prior studies report mixed impacts of complex care curricula and practice models on hospital readmissions and health care costs, but evaluation of patient-driven goals and outcomes has been sparse. The objective of this study was to characterize the goals of individuals with complex health and social needs that engage with complex care curricula and the associated interventions and barriers reported by interprofessional student teams. Capstone projects of 30 student teams spanning a 5-year period (2015-2020) were analyzed via directed content analysis to identify patient goals, team interventions, and barriers. Thematic analysis revealed that the most common patient goals and team interventions focused on enhancing self-efficacy in managing health (72% and 59%, respectively) and health care system navigation (50% and 69%). Identified barriers fell into 3 major categories: barriers encountered with the health system (28%), related to the individual (66%), and arising in teamwork (50%). Over the course of each curricular cycle, students graduated with an appreciation of the importance of collaborative care for complex patients. The longitudinal impact of this analysis emphasizes patients as key stakeholders in the development of complex care curricula. By deepening our understanding of patient goals, intervention trends, and barriers-we allow for enhanced programming that prepares health professionals for practice, optimizes collaboration on interprofessional health teams, and ensures better outcomes for patients.

Places of end-of-life care and death in health policies of four countries (EOLinPLACE Project).

Purpose People with disability often face barriers accessing healthcare, leading to unmet needs. Since 2020, the Victorian Disability Liaison Officer (DLO) Program has supported individuals in navigating public healthcare. This study explores how DLOs enable people with disability in a Melbourne healthcare network. Methods Using a mixed-methods approach, the study analysed DLO Program data through descriptive statistics and directed content analysis. It examined referral pathways, prioritisation, and intervention themes. Results The study highlights the complexity of DLO interventions. Over 12 months, 602 referrals received DLO support, with 38% receiving multiple interventions and 11% receiving three or more. Interventions were grouped into 14 themes, reflecting the diverse strategies used to overcome healthcare access barriers. Conclusion Specialist knowledge held by the DLO workforce, spanning the intersection of disability and health, is beneficial in delivering diverse and innovative interventions and fostering effective healthcare experiences. Future research will focus on the lived experience of DLO consumers to pinpoint key interventions enabling equitable healthcare access. These findings, alongside the current study, may provide evidence of the DLO Program’s effectiveness at removing barriers to healthcare.

Nursing executives' response to COVID-19 in Spain. An ethnographic study.

From blueprint to practice: Implementation strategies for behavioral health programs in community pharmacy.

IntroductionAssessment in physiotherapy education is essential to ensuring graduates meet professional standards, demonstrate competence and are prepared to provide high-quality, patient-centered care. Assessment approaches (principles guiding assessment design, sequence and implementation) and methods (techniques used to evaluate performance) should be constructively aligned with curriculum content and learning outcomes, and assess the breadth of competencies required for practice. While individual studies describe assessment approaches and methods in physiotherapy education, there is no comprehensive synthesis or strategic analysis of their strengths, weaknesses, opportunities and threats.ObjectivesTo 1) identify and characterize assessment approaches and methods used in physiotherapy education; 2) analyze the strengths, weaknesses, opportunities and threats of assessment approaches and methods used in physiotherapy education.MethodsThis scoping review will follow Joanna Briggs Institute guidance and report according to Preferred Reporting Items for Systematic review and Meta-analysis extensions for Protocols and Scoping Reviews. The protocol is registered with Open Science Framework. Searches will be performed in Medline, CINAHL, EMBASE, ProQuest Education Research Index, Scopus, PsycINFO, and relevant grey literature from inception until July 23, 2025. Eligible studies will report primary research on assessment approaches or methods in the academic curriculum of university-based clinical physiotherapy education programs. Studies focusing only on clinical education, reviews, opinion pieces will be excluded. Two reviewers will independently screen studies and extract data using a standardized tool. A narrative synthesis will characterize assessment approaches and methods, categorizing approaches by guiding principles and methods by type. Methods will be mapped to Miller’s pyramid of clinical competence. A directed content analysis will identify the strengths, weaknesses, opportunities and threats influencing assessments in physiotherapy education.ConclusionThis review will provide a comprehensive synthesis and strategic analysis of assessments in physiotherapy education. Findings will inform evidence-based assessment practices that support optimal student learning, experiences and readiness for contemporary practice.

BackgroundSimulation modalities have been increasingly used within programmatic assessment systems, yet educators typically have not collected and appraised validity evidence to justify such uses. Kane’s validity framework offers a contemporary approach to conducting validation studies of assessment practices. Under the framework, educators collect and appraise validity evidence according to four inferences: the scoring of performance, the generalization of scores to other assessment contexts, the extrapolation of assessment performance to real-world contexts, and the implications or consequences of assessment decisions for learners, educators, programs, patients, and society. We developed a simulation-based echocardiography competence assessment tool (ECAT) and collected validity evidence to evaluate its use as an assessment for learning. We applied Kane’s validity framework to evaluate the utility of the ECAT, with a focus on the implications of the assessment for promoting trainees’ learning.MethodsWe implemented the ECAT in 2017, collecting simulation-based performance data and subsequent interview data. Fourteen cardiology trainees were assessed using the ECAT by four raters, and their performance was video-recorded. After trainees reviewed their performance videos and feedback, we conducted individual interviews with them and the raters who provided feedback. Directed content analysis generated implications and scoring evidence, and quantitative analyses generated scoring and extrapolation evidence. All evidence was critically appraised to form a validity argument about using ECAT as an assessment for learning.ResultsParticipants reported that ECAT scores accurately represented trainees'performance, and that the feedback helped identify learning opportunities. Inter-rater reliability was high at ICC = 0.913 (95% CI 0.81–0.97). Participants’ ECAT scores correlated with their end-of-rotation cardiology exam scores (r = 0.66, p = 0.02) and had positive associations with raters’ judgments of the diagnostic quality of their scans, and with their reported numbers of echocardiograms seen, performed, and interpreted.ConclusionsOur integrated analysis produced a data-informed validity argument supporting the use of the ECAT as a simulation-based assessment for learning. The findings also highlighted multiple areas for further research to optimize the ECAT. Our illustrative example of Kane’s validity framework aims to support simulation educators as they are increasingly called on to justify the use of simulation-based assessments in programmatic and competency-based assessment systems.

Black girls are at elevated sexual risk due to the combined effects of sexual development, adultification, gendered racist stereotyping, and lack of protection. Colorism is a skin-tone stratification system that privileges lighter skinned people of color over their darker skinned counterparts. Although colorism has been conceptualized as a determinant of Black girls' mental, physical, and sexual health, little is known about Black girls' understanding of the influence of colorism on psychological and sexual development. This qualitative study examined the influence of colorism on Black girls' psychological and sexual development. Twenty-five multiethnic Black girls between 9 and 18 participated in semistructured interviews. Directed content analysis utilizing an intersectional approach was conducted to better understand the relationship between colorism and Black girls' health. Our analysis confirmed that Black girls perceive colorism as a significant factor influencing their psychological and sexual development. A conceptual model was developed demonstrating that Black girls perceive skin-tone-related messaging and colorist stereotypes as contributing to an increased risk of violence, internalization of colorist notions, and elevated sexual risk behaviors among Black girls. Current systems, such as families, schools, and media, should seek to address stereotyped messages and mistreatment that harm Black girls' development. Programming surrounding colorism, gendered racism, and discrimination may serve as an opportunity to begin dismantling systems rooted in Eurocentric preferences that encourage the oppression and mistreatment of Black girls based on skin tone. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Background: African American (AA)/Black and Latinx communities have limited access to evidence-based fall prevention programs such as Tai Chi Prime (TCP). Community-led interventions that incorporate peer support are cost-effective and sustainable. Using the Treatment Fidelity Framework (TFF) and a mixed-methods research approach, we evaluated the training and support given to trainees during the TCP leader training pathway process and their subsequent fidelity in delivering six culturally tailored community courses. Methods: Trainees completed feedback forms after each TCP leader training pathway course. Using a fidelity checklist, a TCP master trainer rated six community TCP classes led by race- and language-concordant leaders. Trainees were invited to participate in virtual one-on-one semi-structured interviews to share their perspectives on the appropriateness and relevance of the TCP leader training pathway and their experience leading community TCP classes. Quantitative data was analyzed using descriptive statistics on Microsoft Excel. Three study team members coded qualitative data using directed content analysis approach. Results: Twenty-five candidates enrolled in the TCP leader training. Forty-eight percent identified as AA/Black while 52% identified as Latinx. Eleven trainees (six AA/Black and five Latinx) completed the entire TCP leader training pathway to become certified TCP leaders. Trainees rated the training process as highly satisfactory and appropriate. Leaders from both communities received high fidelity scores for community course delivery. Conclusions: Findings contribute to the existing literature, particularly regarding how to effectively disseminate and evaluate a culturally tailored TCP leader training and certification process for culturally diverse communities while maintaining fidelity to the curriculum.

The purpose of this study was to explore the experiences of informal caregivers receiving nurse telephone support for an older person discharged from hospital and how the nursing support influenced their experiences of caring. A descriptive qualitative study. Purposive sampling was used to recruit participants who cared for older adults from two states in Australia between April 2022 and March 2023 for one-on-one interviews 6 months (n = 28) and 12 months (n = 24) after patient discharge from hospital. Inductive directional content analysis was used to analyse the qualitative data. Three themes were identified: (1) Caregiving elicited a complex mix of emotions; (2) nursing support improved caregivers' preparedness to care over time and (3) caregivers welcomed emotional and practical support as they took on new responsibilities. They reflected that nurse telephone support offered emotional and practical support, helping caregivers feel more confident and less stressed in the caregiving role. The study highlighted the value of proactive nurse-led programs to support informal caregivers after patient discharge from hospital, improving their experience. Providing ongoing support after discharge via telephone communication can play a critical role in caregiver wellbeing and facilitate the sustainability of their caregiving responsibilities in the home. Study design and conduct are reported in line with the consolidated criteria for reporting qualitative studies (COREQ) guidelines. The research team includes a consumer investigator (H.L.) who has provided feedback and input at all stages of the research, including grant application, project design, data analysis and manuscript review. Australian New Zealand Clinical Trials Registry identifier (ANZCTR): 12620000060943.

Between hospital and home: Respiratory rehabilitation challenges and needs among caregivers of children with post-infectious bronchiolitis obliterans.

BackgroundBehavioral and implementation science frameworks should be employed in the design of interventions to change behavior, including those delivered in organizational settings, to enhance their effectiveness, replicability, and transparency. However, this is often not done well in health services research. This deficiency also impacts interventions to address unprofessional behaviors (UBs) among healthcare staff. UBs include rudeness and bullying, which harm patient safety and staff wellbeing. This study builds on an earlier realist review of these UB interventions to retroactively identify their active components.MethodsA systematic search was updated to July 2024 using MEDLINE, Embase, CINAHL, and Google Scholar. Intervention descriptions were extracted from study reports and independently coded using directed content analysis against the May 2024 version of the behavior change technique (BCT) Ontology, which contained 284 BCTs.ResultsThe search identified 262 titles and abstracts, yielding five new reports. Combined with 42 papers from the prior review, 47 reports of 44 interventions were included. Interventions were categorized as single-session (n = 15), multisession (n = 12), combined session (n = 6), professional accountability (n = 7), and structured culture change (n = 4). Complex interventions used more BCTs: session-based interventions focused on awareness-raising and roleplay, professional accountability on consequences, and structured culture change on goal-oriented techniques. Few interventions reported negative outcomes, limiting the understanding of which BCTs drive effectiveness.ConclusionsThe BCT ontology is broadly applicable to organizational behavior change in healthcare. Complex interventions employ consequence-based and goal-oriented BCTs, but the effectiveness of specific BCTs remains unclear due to poor evaluations. Future interventions should use the BCT Ontology to improve intervention reporting and effectiveness.

User-focused monitoring (UFM) is a method for service evaluation led by service users, aimed at enhancing quality and service user involvement. Our study examines the experienced outcomes following the completion of five UFM projects within Swedish mental health service programs. Specifically, we focus on the barriers and facilitators to integrating user-led evaluations into service program development. Through interviews with user monitors, managers, staff, and service users involved in these evaluation projects, we conducted a directed content analysis focused on preconditions, processes, and outcomes. Our findings indicate that UFM projects contribute to specific development measures and improved relationships within service programs but also to broader cultural change. However, a lack of trust among service users in actual change poses a significant obstacle to their involvement. Additionally, the absence of feedback regarding the implementation of change measures by service programs to service user groups risks reinforcing this lack of trust. To enhance the integration of evaluation results into quality development, early engagement with staff groups and clear implementation plans are recommended.

This study examines how the framing of organizational gender-equity policies shapes support among Generation Z employees. Drawing on performativity (Butler, 1990) and intersectionality (Crenshaw, 1991), we conceptualize framing as mediating how Gen Z employees perceive equity initiatives. Using a mixed-methods design, we combine survey data from 4,861 Gen Z respondents in 30 countries with directed content analysis of four HR policy documents (coded for equity vs enforcement, identity recognition, and youth engagement). Results reveal a gender gap: Gen Z women strongly endorse inclusive equity measures, consistent with evidence that women show stronger support for equality policies, whereas Gen Z men are more skeptical of policies framed as exclusive or punitive – mirroring polls finding many Gen Z men say equality efforts have gone too far. These findings suggest that performative policy framing activates social identities differently by gender and that intersectional policy language affects reception. Practically, we recommend framing equity initiatives in terms of shared fairness and collective benefit, using transparent rationale and inclusive identity language. Gen Zers expect fair pay, inclusive policies, and transparency, so HR communications should emphasize fairness and allyship to enhance legitimacy and support among this cohort.

Changes in Oral Health, Oral Behaviours, and Oral Healthcare Utilisation Among Indian Migrants Living in the Netherlands.

Teacher educators are charged with the responsibility of training teachers who will be required to make numerous daily decisions. One effective method to equip teacher candidates to manage the multitude of teaching demands is through the implementation of reflective practice. This study aimed to investigate the placement experiences of The Ohio State University SBAE student teachers by examining their psychological needs and motivation. A directed content analysis approach was used to analyze guided reflective journals to capture both triumphs (needs-satisfying experiences) and tribulations (needs-frustrating experiences). Reflective journal entries were bound by thirteen SBAE student teachers over fifteen weeks in the spring of 2023. Tenets from Self-Determination Theory were used as a lens to guide the theoretical framework for this study. Findings were categorized into needs-satisfying and needs-frustrating themes. Findings highlight student teachers discuss their psychological needs of autonomy, competency, and relatedness through the lens of self-determination theory. We recommend teacher educators provide opportunities for student teachers to reflect on their psychological needs to increase self-regulation and internalization. Further, we recommend that research integrate motivational theories to explore how teacher preparation programs can support the complexities of learning to teach.