Major Barrier For Implementation Research Articles

A multi-component intervention to reduce bias during family planning visits: qualitative insights on implementation from Burkina Faso, Pakistan and Tanzania

Beyond Bias was an intervention introduced in Burkina Faso, Pakistan and Tanzania, with the aim of reducing health worker bias toward young, unmarried and nulliparous women seeking family planning services. This study used qualitative methods – based on interviews with health workers who participated in the intervention, managers at health facilities that participated in the intervention, and policy and program stakeholders at the national level – to understand implementation experiences with the intervention. The results offer insights for organizations or countries seeking to implement Beyond Bias or similar programs, and point to some other key implementation challenges for multi-component interventions in lower-resource settings. The intervention, developed using a human-centered design approach, was seen as key for successful implementation but there were logistical challenges. The digital intervention was disruptive and distracting to many. In addition, the non-financial rewards intervention was perceived as complex, and some participants expressed feeling discouraged when they did not receive a reward. Beyond Bias did not sufficiently attend to the “outer setting,” and this was perceived as a major implementation barrier as it limited individuals’ capacity to fully achieve the desired behavior change; for example, space constraints meant that some health facilities could not ensure private services for all clients. There were scalability concerns related to cost, and there is uncertainty whether diversity of contexts (within and across countries) might constrain implementation of Beyond Bias at scale.

Implementation of a pharmacist skill development "work-with" program.

Pharmacists' clinical competency is necessary to ensure patient safety and medication optimization. There are many barriers to the implementation of competency assessments and scant literature on their implementation. We aimed to determine if a competency assessment program for hospital pharmacists is feasible, acceptable, and effective. Clinical competency assessments of hospital pharmacists were conducted. During the assessments, pharmacists presented a patient case or completed patient care activities while a leadership team member evaluated them using a competency rubric and provided feedback. A postevaluation electronic survey adapted from validated tools regarding perceptions of program feasibility and acceptability was emailed to the pharmacists following each competency assessment and to evaluators at study conclusion. Feasibility was also measured through reviewing rubrics for completion within the 1.5- to 2-hour assessment timeframe. Effectiveness was captured by comparing results to expected competency levels based on experience. In total, 20 assessments were completed. Fifty percent of assessments required longer than the allotted timeframe. Most participants surveyed found the competency assessments implementable, possible, doable, and easy to use. The majority also approved of the implemented assessments and found them appealing, likable, and welcomed and commented that they aided in professional development. For 50% of the competencies assessed, most participants aligned with competency expectations based on years of experience. The implementation of these competency assessments was found to be feasible and acceptable to hospital pharmacists. The rubric used was found to be moderately effective. Major implementation barriers were related to time constraints and criteria for success. Future work will be done to enhance the program's effectiveness.

Challenges in Utilizing Telehealth for Chronic Pain.

Purpose of ReviewChronic pain in the USA has presented with higher prevalence rates among women, older adults, those unemployed, living in poverty, living in rural environments, and adults with public health insurance. The COVID-19 pandemic has heavily played into the biopsychosocial model of pain. Consequently, greater impacts have affected patients with mood disorders, opioid abuse, and chronic pain. Concurrently, telemedicine has become a popular vehicle during the COVID-19 pandemic in continuing to provide quality patient care. The purpose of this article is to review the benefits and challenges related to the delivery of telemedicine for patients with chronic pain.Recent FindingsThe benefits of telemedicine have been examined from patient psychosocial and convenience factors as well in relation to medical practice efficiency. Within chronic pain management, one of telemedicine’s most effective utilization is seen via post-injection follow-up and assessment of further necessary interventions. Challenges also exist in this framework, from lack of physical examination and convenient close therapeutic monitoring and drug screening, to technological and resource cost capabilities of older and disadvantaged chronic pain patients, to barriers in establishing patient-provider rapport. During the COVID-19 pandemic, telehealth services were covered at rates comparable to in-person visits. Health insurance coverage and payment were major barriers for implementation of telemedicine prior to the pandemic. It is difficult to predict ongoing coverage and payment of telehealth services, although the benefits in terms of access and patient satisfaction have clearly been demonstrated.SummaryWhile telemedicine has proven to be a very useful tool with a wealth of advantages, the delivery of virtual healthcare for chronic pain poses a set of challenges that will need to be met to ensure the quality and standard of care continue to be upheld.

Monitoring for COVID-19 by universal testing in a homeless shelter in Germany: a prospective feasibility cohort study

BackgroundLiving conditions in homeless shelters facilitate the transmission of COVID-19. Social determinants and pre-existing health conditions place homeless people at increased risk of severe disease. Described outbreaks in homeless shelters resulted in high proportions of infected residents and staff members. In addition to other infection prevention strategies, regular shelter-wide (universal) testing for COVID-19 may be valuable, depending on the level of community transmission and when resources permit.MethodsThis was a prospective feasibility cohort study to evaluate universal testing for COVID-19 at a homeless shelter with 106 beds in Berlin, Germany. Co-researchers were recruited from the shelter staff. A PCR analysis of saliva or self-collected nasal/oral swab was performed weekly over a period of 3 weeks in July 2020. Acceptability and implementation barriers were analyzed by process evaluation using mixed methods including evaluation sheets, focus group discussion and a structured questionnaire.ResultsNinety-three out of 124 (75%) residents were approached to participate in the study. Fifty-one out of the 93 residents (54.8%) gave written informed consent; thus 41.1% (51 out of 124) of all residents were included in the study. Among these, high retention rates (88.9–93.6%) of a weekly respiratory specimen were reached, but repeated collection attempts, as well as assistance were required. Around 48 person-hours were necessary for the sample collection including the preparation of materials. A self-collected nasal/oral swab was considered easier and more hygienic to collect than a saliva specimen. No resident was tested positive by RT-PCR. Language barriers were the main reason for non-participation. Flexibility of sample collection schedules, the use of video and audio materials, and concise written information were the main recommendations of the co-researchers for future implementation.ConclusionsVoluntary universal testing for COVID-19 is feasible in homeless shelters. Universal testing of high-risk facilities will require flexible approaches, considering the level of the community transmission, the available resources, and the local recommendations. Lack of human resources and laboratory capacity may be a major barrier for implementation of universal testing, requiring adapted approaches compared to standard individual testing. Assisted self-collection of specimens and barrier free communication may facilitate implementation in homeless shelters. Program planning must consider homeless people’s needs and life situation, and guarantee confidentiality and autonomy.

Implementing a digital mental health intervention for individuals with psychosis - a multi-country qualitative study

BackgroundImplementation of psychosocial interventions in mental health services has the potential to improve the treatment of psychosis spectrum disorders (PSD) in low- and middle-income countries (LMICs) where care is predominantly focused on pharmacotherapy. The first step is to understand the views of key stakeholders. We conducted a multi-language qualitative study to explore the contextual barriers and facilitators to implementation of a cost-effective, digital psychosocial intervention, called DIALOG+, for treating PSD. DIALOG+ builds on existing clinician-patient relationships without requiring development of new services, making it well-fitting for healthcare systems with scarce resources.MethodsThirty-two focus groups were conducted with 174 participants (patients, clinicians, policymakers and carers), who were familiarized with DIALOG+ through a presentation. The Southeast European LMICs included in this research were: Bosnia and Herzegovina, Kosovo, (Kosovo is referred throughout the text by United Nations resolution) North Macedonia, Montenegro and Serbia. Framework analysis was used to analyse the participants’ accounts.ResultsSix major themes were identified. Three themes (Intervention characteristics; Carers’ involvement; Patient and organisational benefits) were interpreted as perceived implementation facilitators. The theme Attitudes and perceived preparedness of potential adopters comprised of subthemes that were interpreted as both perceived implementation facilitators and barriers. Two other themes (Frequency of intervention delivery; Suggested changes to the intervention) were more broadly related to the intervention’s implementation. Participants were exceedingly supportive of the implementation of a digital psychosocial intervention such as DIALOG+. Attractive intervention characteristics, efficient use of scarce resources for its implementation and potential to improve mental health services were seen as the main implementation facilitators. The major implementation barrier identified was psychiatrists’ time constrains.ConclusionsThis study provided important insights regarding implementation of digital psychosocial interventions for people with PSD in low-resource settings by including perspectives from four stakeholder groups in five LMICs in Southeast Europe – a population and region rarely explored in the literature. The perceived limited availability of psychiatrists could be potentially resolved by increased inclusion of other mental health professionals in service delivery for PSD. These findings will be used to inform the implementation strategy of DIALOG+ across the participating countries. The study also offers insights into multi-country qualitative research.

Blending new and old in sustainability transitions: Technological alignment between fossil fuels and biofuels in Norwegian coastal shipping

Facing increasing pressure to decarbonize, innovation within the shipping sector has turned to low-and zero carbon solutions. In this paper we investigate how the development and implementation of biodiesel and liquefied biogas (LBG) in Norwegian coastal shipping has been influenced by the technological alignment with fossil fuels. We understand this influence to emanate from the (mis)match of biofuels with the structure of coastal shipping (e.g. infrastructure, knowledge, institutions, actors) which has been shaped by fossil fuels. This way we contribute to the development of Technological Innovation Systems (TIS) framework by discussing the effect of sectoral cross-technology externalities on the functionality of a TIS. Our core data consists of semi-structured interviews, supported by a firm survey with Norwegian shipowners.Our results show that the technological alignment provides the biodiesel and LBG TISs with several benefits, such as access to established markets and infrastructure, which suggests that Norway to some extent has good conditions for maritime biofuel markets to form. However, two major barriers for implementation of biofuels are fuel availability and cost. Considering the competition with battery-electric and hydrogen solutions, the positive externalities of the interchangeability between fossil and biofuels are insufficient to make biodiesel and LBG competitive contenders for coastal shipping. In order to upscale implementation of biofuels in the Norwegian coastal shipping sector, which is needed to reach national and international emission targets, there is a need for strengthened policy interventions. To establish market formation, subsidies for biofuels and feed-in targets would be crucial policy instruments.

Analyzing Industry 4.0 Implementation Barriers in Indian SMEs

Production in small and medium enterprises (SMEs) makes a substantial contribution to the Gross Domestic Product directly and indirectly in developing economies including India. In the present time, applying Industry 4.0 to the SMEs will build a smart manufacturing system that will prove to be economically feasible as well as socially sustainable. The purpose of this study is to identify and prioritize major barriers of implementing Industry 4.0 in Indian SMEs. A questionnaire with 12 barriers which were identified based on the literature survey and expert discussion was made to be filled by industry experts of production, information technology, business and members of the top management in SMEs. Further, Multi-Criteria Decision Making (MCDM) methods like TOPSIS, VIKOR and PROMETHEE are used to find the rank for each barrier. The study reveals that the major implementation barriers of Industry4.0 in Indian SMEs are fear of unemployment, lack of IT training, poor IT infrastructure, etc. The ranking for each barrier will not only help to assess risks in manufacturing, supply chain or business initiative, but also to help the managers in devising risk mitigation plans. This study may be used by firms working under the manufacturing sector.

Where To From Here? Identifying and Prioritizing Future Directions for Addressing Drug-Resistant Infection in Australia

Background: The Australian Government released a national strategy for antimicrobial resistance in 2015 that calls for a collaborative effort to change practices that have contributed to the development of drug-resistant infection and for the implementation of new initiatives to reduce antibiotic use. Although many achievements have been made in antimicrobial stewardship (AMS), particularly in the acute-care hospital setting, progress more broadly has been slow, and novel solutions are now required to improve clinical practice and community awareness. A facilitated workshop was undertaken at the 2019 National Australian Antimicrobial Resistance Forum to explore the complexity of AMS implementation in Australia and to prioritize future action. Methods: Participants engaged in rotating rounds of discussion using a world café format. The participants sat face-to-face at tables of 7 or fewer. At each table were 2 facilitators: one was a note taker and the other was the discussion leader. Each of the 6 facilitator pairs had a topic for discussion related to implementing antimicrobial stewardship in different contexts, with a focus on experience with strategies that have worked, major implementation barriers, and prioritizing the next steps. The topics for discussion included (1) engaging with hospital staff; (2) implementation in resource-poor settings; (3) implementation in primary care and aged care; (4) engaging and empowering the public; (5) linking data with implementation strategies; and (6) leadership. The facilitators moved between tables at 15-minute intervals to encourage evolving rounds of conversation. Once all tables had discussed all of the themes, the discussion concluded and notes were summarized. A qualitative analysis using an interpretive description approach was conducted using the discussion summaries. The documents were independently openly coded by 2 researchers to identify elements relating to the implementation of antimicrobial stewardship. An iterative approach was used to identify themes and reach a consensus on overarching emergent themes from the workshop. Results: In total, 39 experts (ie, pharmacists, infectious disease physicians, infection prevention nurses, researchers, journalists and consumers) participated in the facilitated discussions. Strategies were discussed relating to engaging with clinicians, consumers, and politicians; adapting to funding, governance, and accreditation limitations; and models for outreach of antimicrobial services. Other themes included the role of clinical champions and mentors as leaders and improving use of audit and feedback through focusing on monitoring appropriateness rather than usage. Conclusions: Recommendations from the workshop will be used to prioritize novel ideas to improve the implementation of AMS initiatives across Australia.Funding: NoneDisclosures: None

The Effect of Metal Impurities on the All-Vanadium Redox Flow Battery Performance

Vanadium redox flow batteries (VRFB) are a rapidly emerging technology for grid scale energy storage and the integration of the renewable energy generation. However, the cost of the electrolyte is a major barrier for implementation of VRFBs [1, 2]. The quality of the electrolyte has a significant impact on the cell performance and cost. The presence of impurities even with low concentrations in the vanadium electrolyte solution can alter the stability of the electrolyte and influence cell performance, energy density, operating temperature range, electrochemical kinetics and production costs [1-4]. Because a universal standard for the electrolyte specifications has not been defined in the market, a high purity electrolyte is always favored by researchers and customers to avoid potential detrimental impacts of impurities on the system performance. High purity greatly contributes to the high cost of electrolyte for VRFBs. Thus, understanding the impact of the impurities present in electrolyte on the performance of VRFBs is vital for commercialization of VRFBs [5]. This paper aims to conduct a systematic study on the effect of iron, aluminum and manganese ions (Mn2+, Fe2+ and Al3+) on the performance of VRFBs.A three-electrode system was utilized to conduct cyclic voltammetry (CV) experiments. Carbon paper (thermally treated at temperature of 500o C for 1 h in an air atmosphere), a platinum wire, and a saturated calomel electrode (SCE), were used as the working, counter and reference electrodes, respectively. The battery performance was evaluated in a flow cell using a ‘zero-gap’ cell design with an electrode area of 5 cm2. The electrolytic solution (1 M VOSO4 solution in 3 M H2SO4) was circulated through the cell. Thermally treated carbon papers were used as cathode and anode electrodes. For charge-discharge experiments, constant current density (10, 20, 30, 40 and 60 mAcm−2) was applied with 1.65 and 0.8 V as upper and lower voltage limits. The effects of each impurity were studied at five different concentrations (0.02, 0.04, 0.06, 0.08 & 0.1 M) through CV and charge-discharge experiments.The CV results shown in Figure 1 indicate that side reactions of gas evolution from water electrolysis will increase as the concentrations of the metal impurities increase. Comparison of the effect of three transition metal ions (Mn2+, Fe2+ and Al3+) showed that the highest peak separation was obtained in the presence of Fe2+. The peak separations for Mn2+and Al3+ were almost the same. Figure 2 shows the battery performance obtained in the zero-gap cell for a range of current densities versus cycle number, for a pure electrolyte and in the presence of aluminum and iron. The coulombic efficiency improved as the current density increased. Generally, the presence of impurities affected the coulombic efficiency and could result in side reactions and capacity fading, which will have a negative effect on the battery performance. The voltage and energy efficiencies obtained for a range of current densities are shown in Figures 2 (b) and (c), respectively. Similar to the coulombic efficiency results, the highest voltage efficiency was observed with the pure electrolyte. Based on the cyclic voltammetry results, the kinetics of the vanadium reaction falls, and the peak separation increased with increasing concentration of the contaminant metal ions Al3+ and Fe2+. Thus, the voltage efficiency decreased in the presence of these metal ions in the electrolyte. The energy efficiencies have the same trend and illustrates that the contaminant metal ions are competitive with vanadium ions for adsorption on the electrode surface and thus affect the vanadium redox reaction kinetics [6]. The side reactions caused by the metal ions have a negative influence on the performance of VRFBs.[1] A. Parasuraman, T.M. Lim, Ch, Menictas, M. Skyllas-Kazacos, A review of electrolyte additives and impurities in vanadium redox flow batteries, Electrochimica Acta, 27-40, 2013.[2] Cao, L., Skyllas-Kazacos, M., Menictas, Ch., Noack, A review of electrolyte additives and impurities in vanadium redox flow batteries, Energy Chemistry, pp.1269-1291, 2018.[3] A.K. Singh., N. Yasri., K. Karan, E.P. L. Roberts, Electrocatalytic Activity of Functionalized Carbon Paper Electrodes, ACS Appl. Energy Mater. 2019, 2324−2336.[4] John, J. St., Imergy uses recycled vanadium to cut materials costs for flow batteries, Greentech media, 2014.[5] J.H. Park, J.J. Park, H.J Lee, B.S. Min, J.H. Yang, Influence of Metal Impurities or Additives in the Electrolyte of a Vanadium Redox Flow Battery, The Electrochemical Society, page 1263-1268, 2018.[6] Ding, M., Liu, T., Zhang, Y., Cai, Z., Yang, Y., Yuan, Y., Effect of Fe(III) on positive electrolyte for vanadium redox flow battery, R. SOC. open sci. 181309, 2019. Figure 1

Part I: A Quantitative Study of Social Risk Screening Acceptability in Patients and Caregivers

IntroductionDespite recent growth in healthcare delivery-based social risk screening, little is known about patient perspectives on these activities. This study evaluates patient and caregiver acceptability of social risk screening.MethodsThis was a cross-sectional survey of 969 adult patients and adult caregivers of pediatric patients recruited from 6 primary care clinics and 4 emergency departments across 9 states. Survey items included the Center for Medicare and Medicaid Innovation Accountable Health Communities’ social risk screening tool and questions about appropriateness of screening and comfort with including social risk data in electronic health records. Logistic regressions evaluated covariate associations with acceptability measures. Data collection occurred from July 2018 to February 2019; data analyses were conducted in February–March 2019.ResultsScreening was reported as appropriate by 79% of participants; 65% reported comfort including social risks in electronic health records. In adjusted models, higher perceived screening appropriateness was associated with previous exposure to healthcare-based social risk screening (AOR=1.82, 95% CI=1.16, 2.88), trust in clinicians (AOR=1.55, 95% CI=1.00, 2.40), and recruitment from a primary care setting (AOR=1.70, 95% CI=1.23, 2.38). Lower appropriateness was associated with previous experience of healthcare discrimination (AOR=0.66, 95% CI=0.45, 0.95). Higher comfort with electronic health record documentation was associated with previously receiving assistance with social risks in a healthcare setting (AOR=1.47, 95% CI=1.04, 2.07).ConclusionsA strong majority of adult patients and caregivers of pediatric patients reported that social risk screening was appropriate. Most also felt comfortable including social risk data in electronic health records. Although multiple factors influenced acceptability, the effects were moderate to small. These findings suggest that lack of patient acceptability is unlikely to be a major implementation barrier.

Treatment as prevention and other interventions to reduce transmission of multidrug-resistant tuberculosis.

Drug-resistant tuberculosis (DR-TB) represents a major programmatic challenge at the national and global levels. Only ∼30% of patients with multidrug-resistant TB (MDR-TB) were diagnosed, and ∼25% were initiated on treatment for MDR-TB in 2016. Increasing evidence now points towards primary transmission of DR-TB, rather than inadequate treatment, as the main driver of the DR-TB epidemic. The cornerstone of DR-TB transmission prevention should be earlier diagnosis and prompt initiation of effective treatment for all patients with DR-TB. Despite the extensive scale-up of Xpert® MTB/RIF testing, major implementation barriers continue to limit its impact. Although there is longstanding evidence in support of the rapid impact of treatment on patient infectiousness, delays in the initiation of effective DR-TB treatment persist, resulting in ongoing transmission. However, it is also imperative to address the burden of latent drug-resistant tuberculous infection because it is estimated that many DR-TB patients will become infectious before seeking care and encounter various diagnostic delays before treatment. Addressing latent DR-TB primarily consists of identifying, treating and following the contacts of patients with MDR-TB, typically through household contact evaluation. Adjunctive measures, such as improved ventilation and use of germicidal ultraviolet technology can further reduce TB transmission in high-risk congregate settings. Although many gaps remain in our biological understanding of TB transmission, implementation barriers to early diagnosis and rapid initiation of effective DR-TB treatment can and must be overcome if we are to impact DR-TB incidence in the short and long term.

Business models and innovativeness of potential renewable energy projects in Africa

Abstract This study provides an overview of potential renewable energy (RE) projects for Africa. Pan African University master students were asked by their lecturer to characterize African projects they had in minds in uniform tables. Items of the project investment plan include project synopsis, the sponsors, market analysis and strategy, project scope, regulation and environmental information, project costs, financial projections, business model, and project innovativeness. Students' RE projects are assessed with emphasis put on employed business models and project innovativeness. Criticalities for the implementation of these projects are discussed in African contexts providing outlook for future investment opportunities in the African continent. The work provides insights from the local students' perspective for the various stakeholders interested in RE project investments in Africa. Useful suggestions formulated directly by young Africans are presented which may contribute to improved risks management when these or other potential RE projects will be deployed. Inputs from local people on how they understand the process of implementing RE projects in Africa might be interesting for investors seeking information about suitable ways for RE project deployment. Students characterize local contexts and identify numerous barriers for deployment of RE systems in Africa. Overall, this study explains the potential lying in renewable energy harvesting in Africa, seeks to emphasize major barriers for implementation of RE projects as well as investigates investment opportunities to implement economically feasible RE projects for cleaner and climate friendly energy future of this continent.

Obstetric early warning score in Scandinavia. A survey of midwives' use of systematic monitoring in parturients

Objectivesystematic monitoring has recently been implemented widely in non-obstetric departments. In the UK, Early Warning Score (EWS) systems specifically designed for the obstetric population (OEWS) are used. No information on the use of OEWS in Scandinavia has been reported. Consequently, we wanted to investigate the use of vital signs and attitude towards systematic monitoring of parturients in Denmark, Norway and Sweden. Designelectronic questionnaires sent to heads of midwifery. The heads of midwifery referred two clinically active midwives. All in-hospital obstetric departments in Scandinavia were invited to participate. Findingsheads of midwifery from 76 departments (68%), and 125 clinical midwives (82%) responded. Ten per cent of midwives reported use of OEWS. Reported implementation barriers to OEWS included lack of evidence and suspected impact on the parturient due to frequent interruptions.fifty-four per cent of clinical midwives reported a systolic blood pressure threshold of 90–139mmHg, while 33% reported a threshold of>160mmHg. Ninety-three per cent stated a low threshold for maternal heart rate<60 bpm whereas 10% reported an upper threshold heart rate ≥ 150 bpm. Forty-seven per cent reported call for assistance thresholds for maternal heart rate at 60–110 bpm. Key conclusionsOEWS is not implemented in Scandinavian obstetric departments and reported thresholds of vital signs varied considerably. Major barriers for implementation in Scandinavia include midwives’ concern of interruptions for the parturient and increased workload, and unclear benefit from use of OEWS. Local departments should provide midwives with unambiguous thresholds for vital signs in parturients either through local guidelines or via OEWS.

Implementation of Global NCD Monitoring Framework in Punjab, Haryana and Chandigarh–A Feasibility study

Background: In India, a national NCD monitoring framework was developed (June 2013) in consonance with the World Health Organization (WHO) global NCD monitoring framework with 10 targets and 21 indicators. A feasibility study was undertaken in Punjab, Haryana, and Chandigarh with few objectives. Objectives: To review the existing monitoring framework, identify the possible data sources, and collect the secondary data for NCDs. Methods: In-depth interview was conducted with the three state program officers (SPOs), and Health Management Information System (HMIS) reports (2010) were reviewed. Data from non-health sectors were collected and possible data sources were identified. Results: It was observed that SPOs were not clear of the data for indicators and targets. Food and drug licensing authority, schools, colleges, and offices may be possible sources of additional data. Current HMIS was inadequate. Multiple issues such as scarcity of data, excess dependency on hospital-based data, lack of manpower, inter-sectoral coordination, and periodic STEP wise approach to surveillance (STEPS) surveys are the major barriers for implementation. Conclusion: We concluded that with the existing resources, it was not feasible to implement the NCD monitoring framework. Recommendations: National surveys should incorporate NCD indicators, and periodic STEPS survey at state level are necessary for indicator generation.

The CRISP colorectal cancer risk prediction tool: an exploratory study using simulated consultations in Australian primary care

BackgroundIn Australia, screening for colorectal cancer (CRC) with colonoscopy is meant to be reserved for people at increased risk, however, currently there is a mismatch between individuals’ risk of CRC and the type of CRC screening they receive.This paper describes the development and optimisation of a Colorectal cancer RISk Prediction tool (‘CRISP’) for use in primary care. The aim of the CRISP tool is to increase risk-appropriate CRC screening.MethodsCRISP development was informed by previous experience with developing risk tools for use in primary care and a systematic review of the evidence. A CRISP prototype was used in simulated consultations by general practitioners (GPs) with actors as patients. GPs were interviewed to explore their experience of using CRISP, and practice nurses (PNs) and practice managers (PMs) were interviewed after a demonstration of CRISP. Transcribed interviews and video footage of the ‘consultations’ were qualitatively analyzed. Themes arising from the data were mapped onto Normalization Process Theory (NPT).ResultsFourteen GPs, nine PNs and six PMs were recruited from 12 clinics. Results were described using the four constructs of NPT: 1) Coherence: Clinicians understood the rationale behind CRISP, particularly since they were familiar with using risk tools for other conditions; 2) Cognitive participation: GPs welcomed the opportunity CRISP provided to discuss healthy and unhealthy behaviors with their patients, but many GPs challenged the screening recommendation generated by CRISP; 3) Collective Action: CRISP disrupted clinician-patient flow if the GP was less comfortable with computers. GP consultation time was a major implementation barrier and overall consensus was that PNs have more capacity and time to use CRISP effectively; 4) Reflexive monitoring: Limited systematic monitoring of new interventions is a potential barrier to the sustainable embedding of CRISP.ConclusionsCRISP has the potential to improve risk-appropriate CRC screening in primary care but was considered more likely to be successfully implemented as a nurse-led intervention.

Green roofs in temperate climate cities in Europe – An analysis of key decision factors

This paper aims to identify and assess the main decision factors that are relevant for the diffusion of green roof technology in cities of temperate climate in Europe. A mixed design method was applied to identify relevant factors and to structure these along a Strengths, Weaknesses, Opportunities and Threats framework. The factors were subsequently assessed by a sample of green roof experts, using an Analytical Hierarchy Process. The results indicate that prospects for green roofs are in general rather bright, and that dissemination potential is substantial. Green roofs are particularly likely to benefit from climate change and respective counter-strategies, as they are seen as an adaptation and mitigation measure. However, current barriers to adoption need to be carefully considered. Especially the dilemmatic incentive structures, in that building owners bear most of the risks and potential disadvantages, while the public collectively benefits from green roof advantages, could be a major implementation barrier. Without supportive policies, green roofs are thus unlikely to move from niche to regime level in the near future.

Promotion of active transportation among state departments of transportation in the U.S

Abstract Objectives This research aimed to assess the level of support for active transportation among state departments of transportation (DOTs) in the U.S. Methods We conducted an inventory plans adopted by 51 state DOTs and a survey of state DOT pedestrian and bicycle coordinators in the U.S. in 2010 (n=39, 72% response rate). Results Overall, the plans were not very encouraging of planning and design elements that would encourage walking and bicycling. Only two items (Establish pedestrian and bicycle facilities requirements and standards and Safer intersections for pedestrians and bicyclists) were encouraged or required by at least half of the states. States were more supportive of including bicycle and pedestrian facilities (e.g. trails, sidewalks, and bike lanes) and less supportive of policies related to land use and urban design and reallocating road space (e.g. road diets or narrower streets). The overall levels of support were positively correlated to levels of urbanization. According to the state coordinators, support for bicycle and pedestrian projects and policies increased over time, but support is stronger among top management than highway engineering staff. Funding was identified as the major implementation barrier, particularly in more rural states. Conclusions Change within state DOTs to incorporate bicycle and pedestrian modes is a slow process, influenced by both management and engineering staff. Education at several levels and through different mechanisms could play an important role in changing DOT culture, though funding for projects is also a major barrier. Effective advocacy groups may also play a positive role.

A qualitative examination of major barriers in implementation of reverse logistics within the South Australian construction sector

Despite extensive research on the benefits of reverse logistics (RL), it has yet to become commonplace in the construction industry. Furthermore, the uptake and number of studies on RL remains very limited within the Australian context and particularly related to the construction industry. This paper is aimed at filling that knowledge gap by employing an exploratory approach to examine the critical barriers faced by South Australian construction organizations in implementing RL practices. Semi-structured interviews and a ranking approach facilitated the treatment of qualitative data through quantitative coding using cloud-based applications. The research identified 12 barriers to RL implementation, four of them very significant according to the responses of the interviewees: the regulatory environment, additional costs involved, lack of recognition in the construction supply chain, and extra effort required. The study also explored their inter-relationships through the Co-occurrence Index. The study proposes some remedial measures for RL implementation in South Australia based on the barriers identified.

Facilitators and barriers to implementation of a pragmatic clinical trial in Aboriginal health services.

To identify facilitators and barriers to clinical trial implementation in Aboriginal health services. Indepth interview study with thematic analysis. Six Aboriginal community-controlled health services and one government-run service involved in the Kanyini Guidelines Adherence with the Polypill (KGAP) study, a pragmatic randomised controlled trial that aimed to improve adherence to indicated drug treatments for people at high risk of cardiovascular disease. 32 health care providers and 21 Aboriginal and Torres Strait Islander patients. A fundamental enabler was that participants considered the research to be governed and endorsed by the local health service. That the research was perceived to address a health priority for communities was also highly motivating for both providers and patients. Enlisting the support of Aboriginal and Torres Strait Islander staff champions who were visible to the community as the main source of information about the trial was particularly important. The major implementation barrier for staff was balancing their service delivery roles with adherence to often highly demanding trial-related procedures. This was partially alleviated by the research team's provision of onsite support and attempts to make trial processes more streamlined. Although more intensive support was highly desired, there were usually insufficient resources to provide this. Despite strong community and health service support, major investments in time and resources are needed to ensure successful implementation and minimal disruption to already overstretched, routine services. Trial budgets will necessarily be inflated as a result. Funding agencies need to consider these additional resource demands when supporting trials of a similar nature.

Choosing conflict on the road to sustainable mobility: A risky strategy for breaking path dependency in urban policy making

Previous studies have identified implementation problems connected to sustainable mobility. These difficulties raise the question of which strategies can be successfully pursued to break path dependencies in urban policy making. This article is focused on corporate mobility management as one specific example of sustainable mobility initiatives, and analyses the formation and implementation of a travel policy for employees at the city administration of Örebro, Sweden. The analysis reveals how controversies can evolve into major implementation barriers for sustainable mobility initiatives. The analysis centres on the playing out of power relations between politicians and groups of officers in the development of interventions to break path dependencies. The strategy pursued in Örebro turned out to be very challenging within the municipality, since it required significant transformation of the officials’ personal travel behaviour, and so led to open conflicts within the city administration. The case demonstrates that radical and confrontational attempts to break path dependencies may result in the same watering down as less controversial, more consensual strategies. When handling controversial sustainable mobility measures there may be more benefit in deliberative strategies of raising awareness, creating new consciousness or institutionalising desired discursive shifts.