Mixed-methods Implementation Study Research Articles

Improving Patient-Centered Care for Young People in General Practice With a Codesigned Screening App: Mixed Methods Study.

BackgroundDespite experiencing a high prevalence and co-occurrence of mental health disorders and health-compromising behaviors, young people tend not to seek professional help for these concerns. However, they do regularly attend primary care, making primary care providers ideally situated to identify and discuss mental health and lifestyle issues as part of young people’s routine health care.ObjectiveThe aim was to investigate whether using a codesigned health and lifestyle-screening app, Check Up GP, in general practice influenced young people’s assessment of the quality of their care (measures of patient-centered care and youth friendliness), and their disclosure of sensitive issues. In addition, this study aimed to explore young people’s acceptance and experience of using a screening app during regular health care.MethodsThis was a mixed methods implementation study of Check Up GP with young people aged 14 to 25 years attending a general practice clinic in urban Melbourne, Australia. A 1-month treatment-as-usual group was compared to a 2-month intervention group in which young people and their general practitioners (GPs) used Check Up GP. Young people in both groups completed an exit survey immediately after their consultation about disclosure, patient-centered and youth-friendly care, and judgment. In addition, participants in the intervention group were surveyed about app acceptability and usability and their willingness to use it again. Semistructured interviews with participants in the intervention group expanded on themes covered in the survey.ResultsThe exit survey was completed by 30 young people in the treatment-as-usual group and 85 young people in the intervention group. Young people using Check Up GP reported greater disclosure of health issues (P<.001), and rated their GP higher in patient-centered care: communication and partnership (P=.01), personal relationship (P=.01), health promotion (P=.03), and interest in effect on life (P<.001). No differences were found on core indicators of youth-friendly care: trust, level of comfort, expectations met, and time to ask questions. In all, 86% (73/85) of young people felt the app was a “good idea” and only 1% (1/85) thought it a “bad idea.” Thematic analysis of qualitative interviews with 14 participants found that Check Up GP created scope to address unmet health needs and increased sense of preparedness, with use moderated by honesty, motivation, app content and functionality, and app administration.ConclusionsIntegrating a health and lifestyle-screening app into face-to-face care can enrich young people’s experience of seeing their GP, create scope to identify and address unmet health needs, and increase patient-centered care. Further research is needed to investigate the effect of using a health and lifestyle-screening app in a diverse range of clinic types and settings, and with a diverse range of GPs and youth.

Linked symptom monitoring and depression treatment programmes for specialist cancer services: protocol for a mixed-methods implementation study

IntroductionThere is growing awareness that cancer services need to address patients’ well-being as well as treating their cancer. We developed systematic approaches to (1) monitoring patients’ symptoms including depression using...

Developing implementation strategies for firearm safety promotion in paediatric primary care for suicide prevention in two large US health systems: a study protocol for a mixed-methods implementation study

IntroductionThe promotion of safe firearm practices, or firearms means restriction, is a promising but infrequently used suicide prevention strategy in the USA. Safety Check is an evidence-based practice for improving...

Adoption of a Portal for the Primary Care Management of Pediatric Asthma: A Mixed-Methods Implementation Study.

BackgroundPatient portals may improve communication between families of children with asthma and their primary care providers and improve outcomes. However, the feasibility of using portals to collect patient-reported outcomes from families and the barriers and facilitators of portal implementation across diverse pediatric primary care settings have not been established.ObjectiveWe evaluated the feasibility of using a patient portal for pediatric asthma in primary care, its impact on management, and barriers and facilitators of implementation success.MethodsWe conducted a mixed-methods implementation study in 20 practices (11 states). Using the portal, parents of children with asthma aged 6-12 years completed monthly surveys to communicate treatment concerns, treatment goals, symptom control, medication use, and side effects. We used logistic regression to evaluate the association of portal use with child characteristics and changes to asthma management. Ten clinician focus groups and 22 semistructured parent interviews explored barriers and facilitators of use in the context of an evidence-based implementation framework.ResultsWe invited 9133 families to enroll and 237 (2.59%) used the portal (range by practice, 0.6%-13.6%). Children of parents or guardians who used the portal were significantly more likely than nonusers to be aged 6-9 years (vs 10-12, P=.02), have mild or moderate/severe persistent asthma (P=.009 and P=.04), have a prescription of a controller medication (P<.001), and have private insurance (P=.002). Portal users with uncontrolled asthma had significantly more medication changes and primary care asthma visits after using the portal relative to the year earlier (increases of 14% and 16%, respectively). Qualitative results revealed the importance of practice organization (coordinated workflows) as well as family (asthma severity) and innovation (facilitated communication and ease of use) characteristics for implementation success.ConclusionsAlthough use was associated with higher treatment engagement, our results suggest that achieving widespread portal adoption is unlikely in the short term. Implementation efforts should include workflow redesign and prioritize enrollment of symptomatic children.ClinicalTrialClinicaltrials.gov NCT01966068; https://clinicaltrials.gov/ct2/show/NCT01966068 (Archived by WebCite at http://www.webcitation.org/6i9iSQkm3)

Implementation of an Interprofessional Team Review of Adverse Events in Obstetrics Using a Standardized Computer Tool: A Mixed Methods Study

As part of a larger study, an interprofessional team piloted a computer tool called Standardized Clinical Outcome Review (SCOR) to review adverse obstetric events that occurred at a tertiary care hospital over a 12-month period. We sought to understand whether the SCOR tool offered a feasible, acceptable, and appropriate strategy for improving patient safety through improved review of incidents. We designed a mixed methods implementation study. Following completion of the 12-month pilot period, team members completed a questionnaire and participated in a focus group. Quantitative data analysis was performed using descriptive statistics, and qualitative data were analyzed using grounded theory to generate themes. The SCOR tool was easy to implement with an interprofessional team. Despite technical challenges with the software, the tool was quicker and more efficient than traditional case review methods. The content was appropriate for an obstetric unit and provided objective identification of factors contributing to adverse events. Team members were positive about the use of the tool in their institution and in wider contexts and believed that it was a valuable tool for raising awareness and addressing patient safety at their unit. SCOR was an acceptable and appropriate tool for the interprofessional team review of adverse outcomes, and its use represents a significant advance in the quality assurance process for formal peer review of incidents.

Peer-led healthy lifestyle program in supportive housing: study protocol for a randomized controlled trial

BackgroundThe risk for obesity is twice as high in people with serious mental illness (SMI) compared to the general population. Racial and ethnic minority status contribute additional health risks. The aim of this study is to describe the protocol of a Hybrid Trial Type 1 design that will test the effectiveness and examine the implementation of a peer-led healthy lifestyle intervention in supportive housing agencies serving diverse clients with serious mental illness who are overweight or obese.MethodsThe Hybrid Trial Type 1 design will combine a randomized effectiveness trial with a mixed-methods implementation study. The effectiveness trial will test the health impacts of a peer-led healthy lifestyle intervention versus usual care in supportive housing agencies. The healthy lifestyle intervention is derived from the Group Lifestyle Balanced Program, lasts 12 months, and will be delivered by trained peer specialists. Repeated assessments will be conducted at baseline and at 6, 12, and 18 months post randomization. A mixed-methods (e.g., structured interviews, focus groups, surveys) implementation study will be conducted to examine multi-level implementation factors and processes that can inform the use of the healthy lifestyle intervention in routine practice, using data from agency directors, program managers, staff, and peer specialists before, during, and after the implementation of the effectiveness trial.DiscussionThis paper describes the use of a hybrid research design that blends effectiveness trial methodologies and implementation science rarely used when studying the physical health of people with SMI and can serve as a model for integrating implementation science and health disparities research. Rigorously testing effectiveness and exploring the implementation process are both necessary steps to establish the evidence for large-scale delivery of peer-led healthy lifestyle intervention to improve the physical health of racial/ethnic minorities with SMI.Trial registrationwww.clinicaltrials.gov; NCT02175641, registered 24 June 2014

Evidence summaries (decision boxes) to prepare clinicians for shared decision-making with patients: a mixed methods implementation study.

BackgroundDecision boxes (Dboxes) provide clinicians with research evidence about management options for medical questions that have no single best answer. Dboxes fulfil a need for rapid clinical training tools to prepare clinicians for clinician-patient communication and shared decision-making. We studied the barriers and facilitators to using the Dbox information in clinical practice.MethodsWe used a mixed methods study with sequential explanatory design. We recruited family physicians, residents, and nurses from six primary health-care clinics. Participants received eight Dboxes covering various questions by email (one per week). For each Dbox, they completed a web questionnaire to rate clinical relevance and cognitive impact and to assess the determinants of their intention to use what they learned from the Dbox to explain to their patients the advantages and disadvantages of the options, based on the theory of planned behaviour (TPB). Following the 8-week delivery period, we conducted focus groups with clinicians and interviews with clinic administrators to explore contextual factors influencing the use of the Dbox information.ResultsOne hundred clinicians completed the web surveys. In 54% of the 496 questionnaires completed, they reported that their practice would be improved after having read the Dboxes, and in 40%, they stated that they would use this information for their patients. Of those who would use the information for their patients, 89% expected it would benefit their patients, especially in that it would allow the patient to make a decision more in keeping with his/her personal circumstances, values, and preferences. They intended to use the Dboxes in practice (mean 5.6 ± 1.2, scale 1–7, with 7 being “high”), and their intention was significantly related to social norm, perceived behavioural control, and attitude according to the TPB (P < 0.0001). In focus groups, clinicians mentioned that co-interventions such as patient decision aids and training in shared decision-making would facilitate the use of the Dbox information. Some participants would have liked a clear “bottom line” statement for each Dbox and access to printed Dboxes in consultation rooms.ConclusionsDboxes are valued by clinicians. Tailoring of Dboxes to their needs would facilitate their implementation in practice.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-014-0144-6) contains supplementary material, which is available to authorized users.

Expanding contraceptive options for PMTCT clients: a mixed methods implementation study in Cape Town, South Africa.

BackgroundClients of prevention of mother-to-child transmission (PMTCT) services in South Africa who use contraception following childbirth rely primarily on short-acting methods like condoms, pills, and injectables, even when they desire no future pregnancies. Evidence is needed on strategies for expanding contraceptive options for postpartum PMTCT clients to include long-acting and permanent methods.MethodsWe examined the process of expanding contraceptive options in five health centers in Cape Town providing services to HIV-positive women. Maternal/child health service providers received training and coaching to strengthen contraceptive counseling for postpartum women, including PMTCT clients. Training and supplies were introduced to strengthen intrauterine device (IUD) services, and referral mechanisms for female sterilization were reinforced. We conducted interviews with separate samples of postpartum PMTCT clients (265 pre-intervention and 266 post-intervention) to assess knowledge and behaviors regarding postpartum contraception. The process of implementing the intervention was evaluated through systematic documentation and interpretation using an intervention tracking tool. In-depth interviews with providers who participated in study-sponsored training were conducted to assess their attitudes toward and experiences with promoting voluntary contraceptive services to HIV-positive clients.ResultsFollowing the intervention, 6% of interviewed PMTCT clients had the desired knowledge about the IUD and 23% had the desired knowledge about female sterilization. At both pre- and post-intervention, 7% of clients were sterilized and IUD use was negligible; by comparison, 75% of clients used injectables. Intervention tracking and in-depth interviews with providers revealed intervention shortcomings and health system constraints explaining the failure to produce intended effects.ConclusionsThe intervention failed to improve PMTCT clients’ knowledge about the IUD and sterilization or to increase use of those methods. To address the family planning needs of postpartum PMTCT clients in a way that is consistent with their fertility desires, services must expand the range of contraceptive options to include long-acting and permanent methods. In turn, to ensure consistent access to high quality family planning services that are effectively linked to HIV services, attention must also be focused on resolving underlying health system constraints weakening health service delivery more generally.

“Psychosomatic consultation in the workplace” – a new model of care at the interface of company-supported mental health care and consultation-liaison psychosomatics: design of a mixed methods implementation study

BackgroundMental health issues are gaining in importance in society and the economic system. At the same time, the accessibility and stigmatisation of the mental health care system in Germany can obstruct help-seeking behavior and delay early psychotherapeutic interventions. Therefore, new models of care are being established at the interface of company-supported health promotion and conventional health insurance sponsored outpatient care for people developing mental illnesses. Two large industrial companies, in cooperation with two psychosomatic clinics, have recently established a model of “psychosomatic consultation in the workplace“. This new model of care offers the opportunity for a first psychotherapeutic door to door consultation with occupational medicine within the industrial workplace. The main empirical goals of this study are:1) Describing the differences between patients who use this new diagnostic and therapeutic offer within the industrial workplace vs. patients who visit a conventional regional outpatient clinic, especially in regard to symptom duration and severity, work ability, and demographic characteristics, and2) A first evaluation of how patients may benefit more from this new model of care compared to those first seen by standard outpatient care.In the qualitative part of the study, occupational physicians, psychosomatic therapists, involved personnel and select employees of the involved companies will be asked to comment on their experiences with this new approach.Methods/DesignThe implementation study will take place in Ulm and in Stuttgart, with each site looking at one regional conventional psychosomatic outpatient clinic and one psychosomatic consultation offer within the workplace. 70 consecutive patients in each setting will be recruited (overall n = 280). For the cross-sectional study and pre-post comparison we will use established and validated survey instruments (PHQ, SF-12, WAI, MBI, IS) as well as standardized questions about health care use. For data analysis, we will use uni- and multivariate analytical methods. Qualitative data analysis (expert interviews) will be carried out using Mayring’s content analysis method.DiscussionThe results of this study have the potential to provide evidence-based knowledge about an innovative model of psychotherapeutic outpatient care and to further promote tailored solutions for early psychotherapeutic interventions within the worksite.Trial RegistrationDRKS00003184