Potential Implementation Strategies Research Articles

Can we nudge to reduce the perioperative low value care? Decision making factors influencing safe practice implementation.

Highlight sources of low-value care (LVC) during the perioperative period help understanding the decision making behind its persistence, the barriers for change, and the potential implementation strategies to reduce it. The behavioural economics science spread of use through aligned strategies or nudge units offer an opportunity to improve success in the LVC reduction. LVC, such as unneeded surgeries, or preanaesthesia tests for low-risk surgeries in low-risk patients, is a relevant source of waste and preventable harm, most especially in the perioperative period. Despite the international focus on it, initial efforts to reduce it in the last decade have not clearly shown a sustainable improvement. Understanding the shared decision-making process and the barriers to be expected when tackling LVC is the first step to build the change. Applying a structured strategy based on the behavioural science principles may be the path to increasing high value care in an effective an efficient way. It is time to foster nudge units at different healthcare system levels.

S6-2 Barriers and facilitators perceived by stakeholders regarding the implementation of physical activity interventions for people aged over 50

Abstract Aim Although there are many proven effective physical activity (PA) interventions for middle-aged and older adults (MAOA), implementation in a real world setting is often lacking. Intermediary organizations (further referred to as ‘stakeholders’) often determine the final exposure of the intervention to the target population and therefore have a crucial role in the implementation process. This study provides insight in stakeholders’ perceptions of barriers and facilitators (i.e. implementation determinants) regarding implementation of PA interventions among MAOA. Method A semi-structured interview guide was developed based on the Consolidated Framework for Implementation Research (CFIR), including five domains of implementation determinants, i.e.: interventions characteristics, outer setting (e.g., the target population’s needs and policies), inner setting (e.g., organizational goals ), individuals’ characteristics (e.g., stakeholders’ self-efficacy) and the implementation process. Using snowball sampling (starting with the regional health counselor) stakeholders were recruited to participate in the interviews. Thematic analyses, guided by a CFIR-based codebook, was applied. Results We completed 25 interviews, involving representatives of regional health counselors (n = 5), municipalities (n = 3), sportservice organizations (n = 5), welfare organizations (n = 3), and several individual organizations. Analyses showed that in all CFIR domains relevant implementation determinants were identified. Stakeholders mentioned being able to play a relevant role in the implementation of PA intervention. Collaboration between organizations is essential to successfully perform all steps needed to implement interventions. Focusing on a broader perspective than increasing PA behavior, such as stimulating positive health seemed an important facilitator when implementing PA intervention. An often mentioned barrier was that most policy plans currently focus on youth, consequently resulting in a lack of means to implement interventions for MAOA. Conclusion Gaining insight in the perception of stakeholders’ most relevant implementation determinants is a crucial step in the development of an effective implementation plan. In a next phase of our study, a collaboration meeting between stakeholders will be organized in which determinants will be ranked. The ranking of these determinants will be discussed with the symposium audience as well. Matching the implementation determinants, potential implementation strategies will be discussed.

New Education Policy 2020: Evolution, Key Milestones, and Prominent Features

The National Education Policy (NEP) 2020 marks a significant shift in the Indian education system, aiming to transform it to meet the evolving needs of the 21st century. This study explores the NEP 2020, tracing its roots from previous educational policies, and highlights its provisions, with a specific focus on School Education, including the establishment of Cluster Schools. Additionally, it examines the Standard Setting and Accreditation of schools (SSSA) as a key aspect of the NEP 2020, discussing its implications and provisions. The study begins by analysing the historical context of the NEP 2020, comparing it with previous educational policies to identify the evolution of key principles and ideologies. It identifies the NEP 2020 as a comprehensive and transformative policy framework designed to address the multidimensional challenges faced by the Indian education system. One of the significant provisions of the NEP 2020 in the area of School Education is the establishment of Cluster Schools. These schools aim to promote collaborative learning, resource sharing, and increased efficiency by clustering multiple schools under a common administrative and academic framework. The study explores the concept of Cluster Schools, delves into their benefits, challenges, and potential implementation strategies, and provides relevant state examples that have successfully implemented this model. Furthermore, the study investigates the Standard Setting and Accreditation of schools (SSSA) as a vital component of the NEP 2020. SSSA is envisioned to ensure quality education by setting standards, evaluating schools, and promoting continuous improvement. The research examines the provisions and guidelines related to SSSA, discussing the impact on school infrastructure, curriculum development, teacher training, and assessment practices.

Comparison of methods to engage diverse stakeholder populations in prioritizing PrEP implementation strategies for testing in resource-limited settings: a cross-sectional study

BackgroundThere is a lack of consensus about how to prioritize potential implementation strategies for HIV pre-exposure prophylaxis (PrEP) delivery. We compared several prioritization methods for their agreement and pragmatism in practice in a resource-limited setting.MethodsWe engaged diverse stakeholders with clinical PrEP delivery and PrEP decision-making experience across 55 facilities in Kenya to prioritize 16 PrEP delivery strategies. We compared four strategy prioritization methods: (1) “past experience surveys” with experienced practitioners reflecting on implementation experience (N = 182); (2 and 3) “pre- and post-small-group ranking” surveys before and after group discussion (N = 44 and 40); (4) “go-zone” quadrant plots of perceived effectiveness vs feasibility. Kendall’s correlation analysis was used to compare strategy prioritization using the four methods. Additionally, participants were requested to group strategies into three bundles with up to four strategies/bundle by phone and online survey.ResultsThe strategy ranking correlation was strongest between the pre- and post-small-group rankings (Tau: 0.648; p < 0.001). There was moderate correlation between go-zone plots and post-small-group rankings (Tau: 0.363; p = 0.079) and between past-experience surveys and post-small-group rankings (Tau: 0.385; p = 0.062). For strategy bundling, participants primarily chose bundles of strategies in the order in which they were listed, reflecting option ordering bias. Neither the phone nor online approach was effective in selecting strategy bundles. Participants agreed that the strategy ranking activities conducted during the workshop were useful in prioritizing a final set of strategies.ConclusionsBoth experienced and inexperienced stakeholder participants’ strategy rankings tended to prioritize strategies perceived as feasible. Small group discussions focused on feasibility and effectiveness revealed moderately different priorities than individual rankings. The strategy bundling approach, though less time- and resource-intensive, was not effective. Future research should further compare the relative effectiveness and pragmatism of methodologies to prioritize implementation strategies.

Supporting the helpers: what do peer deliverers of HIV interventions need to sustain their implementation efforts?

Peer-led HIV interventions are an increasingly common and low-cost strategy to address shortages of professionally trained health workers for implementing evidence-based HIV prevention and treatment interventions to populations who experience health disparities. There is a need to understand the experiences and unmet needs of this essential workforce responsible for implementing and delivering HIV interventions to ensure their implementation efforts are sustainable. This commentary provides a brief overview of barriers to peer deliverers' sustained engagement in the HIV workforce and potential implementation strategies to promote the sustainment of peer deliverers' implementation efforts.

Implementation Strategies for Sustainable Vehicle Fleet Management

Abstract Research purpose. Against the backdrop of climate change, pressure is growing in the transport sector to reduce CO2 emissions. Numerous companies are therefore setting specific targets to curb the CO2 emissions of their own vehicle fleets. As a rule, this requires the replacement of combustion vehicles by vehicles with alternative drives. In addition to the selection of suitable technologies, economic aspects play a prominent role in this transformation process. Based on a practical case study, potential implementation strategies for achieving a specific CO2 target are to be examined for a parcel service provider. The focus here is on a fleet of diesel combustion vehicles from the small van class with a permissible total weight of fewer than 3.5 tons, which are to be replaced by vehicles with electric drive (BEV) in order to achieve a specific CO2-savings target. The research objective can be easily extended if one considers, on the one hand, that climate protection cannot be limited to individual countries but has to take place on a global level and, on the other hand, that sustainable strategic planning of vehicle fleets also concerns other vehicle segments, such as company cars for individual transport or trucks with higher permissible gross weights. Design / Methodology / Approach. In the first step, framework conditions and criteria are defined that are needed for an evaluation of the implementation strategies. In the second step, a practical case study is constructed. In the third step, different scenarios and strategies for the conversion of the vehicle fleet are designed in order to achieve the set CO2-emission targets. In the last step, the economic and ecological effects of the different strategies and scenarios are measured and analysed with the help of the calculation tool "DIPO-tool", which was developed at the Ludwigshafen University of Business and Society LUBS for research and teaching purposes. To evaluate sustainability, in addition to the established metrics for Tank-to-Wheel (TtW) and Well-to-Wheel (WtW), a holistic life cycle approach is implemented that takes into account emissions during vehicle production. Findings. Against the backdrop of expected further technological development and numerous parameters with a considerable leverage effect on economic and ecological evaluation criteria, it seems advisable from the point of view of sustainability to use alternative drives as soon as possible. From the point of view of economic efficiency, a more differentiated picture emerges depending on the framework conditions, e.g., subsidies. Originality / Value / Practical implications. The originality of the approach lies in the application of a practical case study and the attempt to reduce the complexity of the decision problem by using an Excel-based calculation tool. The value of the study lies in the realisation that, due to the complexity, a simple optimisation approach does not seem viable but rather the evaluation and analysis of different scenarios. The practical impact can be described in the sense that the used DIPO-tool can provide effective support for sustainable implementation strategies for vehicle fleets.

Developing a Tailored eHealth Self-Management Intervention for Patients With Chronic Kidney Disease in China: Intervention Mapping Approach.

Chronic kidney disease (CKD) is a major public health concern. Adequate self-management skills are vital to reduce CKD burden, optimize patient health outcomes, and control health care expenditures. Using eHealth to support CKD self-management has the potential to promote healthy behaviors and improve health outcomes of patients with CKD. However, knowledge of the implementation of such interventions in general, and in China specifically, is still limited. This study aims to develop a tailored eHealth self-management intervention for patients with CKD in China based on the Dutch Medical Dashboard (MD) eHealth self-management intervention. We used an intervention mapping approach. In phase 1, a systematic review and 2 qualitative studies were conducted to examine the needs, beliefs, and perceptions of patients with CKD and health care professionals regarding CKD self-management and eHealth interventions. Afterward, key factors gathered from the aforementioned studies were categorized following the 5 domains of the Consolidated Framework for Implementation Research (CFIR). In phase 2, we specified program outcomes, performance objectives, determinants, theory-based methods, and practical strategies. Knowledge obtained from previous results was combined to complement core components of the MD self-management intervention and adapt them for Chinese patients with CKD. Additionally, the CFIR-Expert Recommendations for Implementing Change Matching Tool was pragmatically used to generate a list of potential implementation strategies to address the key factors influencing the implementation of eHealth CKD self-management interventions, and implementation strategies were discussed and finalized with the intervention monitoring group. An overview of the CFIR domains showed the essential factors influencing the implementation of eHealth CKD self-management interventions in Chinese settings, including "knowledge and beliefs" in the domain "individual characteristics," "quality and advantage of eHealth intervention" in the domain "intervention characteristics," "compatibility" in the domain "inner setting," and "cultural context" in the domain "outer setting." To ensure the effectiveness of the Dutch MD-based self-management intervention, we did not change the core self-management intervention components of MD that underlie its effectiveness, such as self-monitoring. We identified surface-level cultural adaptations involving customizing intervention content, messages, and approaches to the observable cultural characteristics of the local population to enhance the intervention's appeal, receptivity, and feasibility, such as providing video or voice call options to support interactions with health care professionals. Furthermore, the adapted modules such as Knowledge Center and My Self-Monitoring were developed in a mobile health app. Our study resulted in the delivery of a culturally tailored, standardized eHealth self-management intervention for patients with CKD in China that has the potential to optimize patients' self-management skills and improve health status and quality of life. Moreover, our study's research approach and results can inform future research on the tailoring and translation of evidence-based, eHealth self-management interventions to various contexts. ClinicalTrials.gov NCT04212923; https://classic.clinicaltrials.gov/ct2/show/NCT04212923.

Implementation of a women’s reproductive behavioral health telemedicine program: a qualitative study of barriers and facilitators in obstetric and pediatric clinics

BackgroundPerinatal Mood and Anxiety Disorders and Substance Use Disorders are common and result in significant morbidities and mortality. Despite evidence-based treatment availability, multiple barriers exist to care delivery. Because telemedicine offers opportunities to overcome these barriers, the objective of this study was to characterize barriers and facilitators to implementing a mental health and substance use disorder telemedicine program in community obstetric and pediatric clinics.MethodsInterviews and site surveys were completed with practices engaged in a Women’s Reproductive Behavioral Health Telemedicine program (N = 6 sites; 18 participants) at the Medical University of South Carolina and telemedicine providers involved in care delivery (N = 4). Using a structured interview guide based on implementation science principles, we assessed program implementation experiences and perceived barriers and facilitators to implementation. A template analysis approach was used to analyze qualitative data within and across groups.ResultsThe primary program facilitator was service demand driven by the lack of available maternal mental health and substance use disorder services. Strong commitment to the importance of addressing these health concerns provided a foundation for successful program implementation yet practical challenges such as staffing, space, and technology support were notable barriers. Services were supported by establishing good teamwork within the clinic and with the telemedicine team.ConclusionCapitalizing on clinics’ commitment to care for women’s needs and a high demand for mental health and substance use disorder services while also addressing resource and technology needs will facilitate telemedicine program success. Study results may have implications for potential marketing, onboarding and monitoring implementation strategies to support clinics engaging in telemedicine programs.

Applying the Behaviour Change Wheel to support deprescribing in long-term care: Qualitative interviews with stakeholder participants

BackgroundImplementation and behavioural science are increasingly being used to support development and translation of evidence-based interventions into practice. We used the Behaviour Change Wheel (BCW) approach in two stakeholder forums to identify target behaviours and supporting actions to inform the development of a framework to support deprescribing in long-term care homes. During our planning for these forums, we found many applications of the BCW approach used in healthcare. However, we found no accounts of stakeholders' experiences when the BCW approach was used with large groups of people who were mostly unfamiliar with behavioural science. ObjectiveThe goal of this research was to gain insight into the use of the BCW approach in the context of developing a framework to support deprescribing in long-term care. MethodsThis descriptive qualitative study employed one-on-one semi-structured interviews with Ontario long-term care stakeholders who had participated in one or both of two in-person forums that we hosted. Interviews were transcribed verbatim and an inductive content-analysis approach was used to code data and determine themes. ResultsFifteen interviews were conducted. Four themes were identified. First, the BCW was new and made sense, but people found it hard to identify target behaviours before planning solutions. Second, participants varied in their opinions as to whether the ‘right’ people were participating. Third, participants found that the forum activities, worksheets and facilitators helped people use the approach. Fourth, stakeholder perspectives about potential implementation challenges and strategies to maximize success were identified. ConclusionsOverall, participants were positive about the use of the BCW approach, however, its usefulness could be optimized by enhancing explanations, facilitation and logistics to ensure an initial focus on targeting behaviours. Making stakeholder perspectives transparent and ensuring mechanisms are present to ensure all views are sought and considered are also important to optimizing participant experience.

Identifying barriers and enablers to rigorous conduct and reporting of preclinical laboratory studies.

Use of rigorous study design methods and transparent reporting in publications are 2 key strategies proposed to improve the reproducibility of preclinical research. Despite promotion of these practices by funders and journals, assessments suggest uptake is low in preclinical research. Thirty preclinical scientists were interviewed to better understand barriers and enablers to rigorous design and reporting. The interview guide was informed by the Theoretical Domains Framework, which is a framework used to understand determinants of current and desired behavior. Four global themes were identified; 2 reflecting enablers and 2 reflecting barriers. We found that basic scientists are highly motivated to apply the methods of rigorous design and reporting and perceive a number of benefits to their adoption (e.g., improved quality and reliability). However, there was varied awareness of the guidelines and in implementation of these practices. Researchers also noted that these guidelines can result in disadvantages, such as increased sample sizes, expenses, time, and can require several personnel to operationalize. Most researchers expressed additional resources such as personnel and education/training would better enable the application of some methods. Using existing guidance (Behaviour Change Wheel (BCW); Expert Recommendations for Implementing Change (ERIC) project implementation strategies), we mapped and coded our interview findings to identify potential interventions, policies, and implementation strategies to improve routine use of the guidelines by preclinical scientists. These findings will help inform specific strategies that may guide the development of programs and resources to improve experimental design and transparent reporting in preclinical research.

Emergency medical services: the next linking asset for public health approaches to palliative care?

Emergency medical services (EMS) are a unique workforce providing 24/7 emergency care across high-income countries (HICs) and low- and middle-income countries (LMICs). Although traditionally perceived as first responders to traumatic and medical emergencies, EMS scope of practice has evolved to respond to the changing needs of communities, including a growing demand for community-based palliative care. Public health provides a useful framework to conceptualise palliative and end-of-life care in community-based settings. However, countries lack public policy frameworks recognising the role EMS can play in initiating palliative approaches in the community, facilitating goals of care at end of life and transporting patients to preferred care settings. This article aims to explore the potential role of EMS in a public health palliative care approach in a critical discussion essay format by (1) discussing the utility of EMS within a public health palliative care approach, (2) identifying the current barriers preventing public health approaches to EMS palliative care provision and (3) outlining a way forward through priorities for future research, policy, education and practice. EMS facilitate equitable access, early provision, expert care and efficacious integration of community-based palliative care. However, numerous structural, cultural and practice barriers exist, appearing ubiquitous across both HICs and LMICs. A Public Health Palliative Care approach to EMS Framework highlights the opportunity for EMS to work as a linking asset to build capacity and capability to support palliative care in place; connect patients to health and community supports; integrate alternative pathways by engaging multidisciplinary teams of care; and reduce avoidable hospital admissions by facilitating home-based deaths. This article articulates a public health approach to EMS palliative and end-of-life care provision and offers a preliminary framework to illustrate the components of a potential implementation and policy strategy.

Surgeon Perspectives on Determinants of Same-Day Mastectomy: A Roadmap for Implementing Change.

Same-day discharge after mastectomy without immediate reconstruction (MwoR) has been shown to be safe, with improved patient satisfaction when compared with patients discharged 1 or more days after surgery. Nevertheless, only 16% of patients undergoing MwoR in Michigan are discharged on the day of surgery, with significant variation between facilities (3-88%). Our objective was to explore determinants of same-day discharge and offer strategies for broader implementation of this practice. We conducted semi-structured interviews with surgeons performing MwoR across the state of Michigan. Recruitment utilized purposeful and snowball sampling methods. The Tailored Implementation in Chronic Disease (TICD) framework was used to inform the creation of the interview guide. Interviews were transcribed and then analyzed using directed content analysis guided by the TICD framework. Salient determinants were organized into patient, provider, and system-level factors. Participants (n = 26) included general surgeons, breast surgeons, and surgical oncologists. Most surgeons (n = 18, 69%) reported that they discharged fewer than 60% of patients the same day after MwoR. The most common barriers included patient knowledge at the patient level; awareness of evidence, surgeon dogma, and peer influence at the provider level; and team processes and operating room logistics at the system level. We identified surgeon-defined determinants of same-day discharge after MwoR. For the identified barriers, potential implementation strategies could include incorporation of preoperative drain teachings for patients, utilizing consensus statements and opinion leaders to disseminate evidence supporting same-day mastectomies, and conducting workshops with relevant stakeholders to establish consistent facility practice patterns among surgical teams.

Implementation Plan for a High-Frequency, Low-Touch Care Model at Specialized Type 1 Diabetes Clinics: Model Development.

Individuals with type 1 diabetes (T1D) are more likely to achieve optimal glycemic management when they have frequent visits with their health care team. There is a potential benefit of frequent, telemedicine interventions as an effective strategy to lower hemoglobin A1c (HbA1c). The objective is this study was to understand the provider- and system-level factors affecting the successful implementation of a virtual care intervention in type 1 diabetes (T1D) clinics. Semistructured interviews were conducted with managers and certified diabetes educators (CDEs) at diabetes clinics across Southern Ontario before the COVID-19 pandemic. Deductive analysis was carried out using the Theoretical Domains Framework, followed by mapping to behavior change techniques to inform potential implementation strategies for high-frequency virtual care for T1D. There was considerable intention to deliver high-frequency virtual care to patients with T1D. Participants believed that this model of care could lead to improved patient outcomes and engagement but would likely increase the workload of CDEs. Some felt there were insufficient resources at their site to enable them to participate in the program. Member checking conducted during the pandemic revealed that clinics and staff had already developed strategies to overcome resource barriers to the adoption of virtual care during the pandemic. Existing enablers for high-frequency virtual care for T1D can be leveraged, and barriers can be overcome with targeted clinical incentives and support.

Engaging Latino sexual minority men in PrEP and behavioral health care: multilevel barriers, facilitators, and potential implementation strategies.

Latino sexual minority men (LSMM) are affected by HIV and behavioral health disparities. Evidence-based HIV-prevention and behavioral health (BH) services are not sufficiently scaled up to LSMM. The current study identified multilevel barriers and facilitators to LSMM's use of HIV-prevention and BH services. LSMM (N = 290) in South Florida, a US HIV epicenter, completed a battery of measures potentially associated with pre-exposure prophylaxis (PrEP) and BH treatment use. Stochastic search variable selection (SSVS) followed by multiple linear regression analyses identified variables associated with engagement in PrEP and BH treatment. Multilevel determinants of PrEP and BH treatment engagement were identified, with most identified determinants being at the relational level (e.g., stigma, discrimination based on income and immigration status, personal recommendation for treatment). Individual (e.g., knowledge, self-efficacy) and structural (e.g., financial stress) determinants were also identified. Accordingly, modifiable leverage points to enhance the reach of PrEP and BH treatment to LSMM include educating and enhancing the perceived relevance of services, de-stigmatizing and normalizing via peer examples, bolstering self-efficacy, and building trust.

Communication partner training with familiar partners of people with aphasia: A systematic review and synthesis of barriers and facilitators to implementation.

Factors influencing the implementation of communication partner training (CPT) with familiar partners of people with aphasia (PWA) have previously been documented using disparate approaches. To date there has been no synthesis of these factors using a common theoretical framework. Investigating CPT implementation factors using a common theoretical framework may further our understanding of universal barriers and guide future development of tailored, theoretically informed implementation strategies. (1) To determine the perceived and/or observed barriers and facilitators to implementing CPT with familiar partners of adults with aphasia; (2) to map extracted barriers and facilitators to a common theoretical framework; (3) to synthesize extracted barriers and facilitators; and (4) to identify potential implementation strategies to address the most frequently identified barriers and facilitators. A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Four electronic databases (MEDLINE, EMBASE, CINAHL, Web of Science) were systematically searched in April 2021. Empirical qualitative and/or quantitative research studies reporting barriers/facilitators to speech-language therapists (SLTs) implementing CPT with familiar partners of adults with aphasia were included. The search was limited to English or French articles with no date limit applied. Methodological quality of included studies was assessed using the Mixed-Methods Appraisal Tool (MMAT). A framework and content analysis was then conducted to extract and synthesize the implementation factors in alignment with the Theoretical Domains Framework (TDF), followed by a theoretically informed mapping exercise to identify potential implementation strategies. The database searches yielded 2115 studies. Following screening, 17 studies were included in the review. Overall, the included studies had good methodological quality. Extracted implementation factors were classified as barriers, facilitators or mixed (i.e., both) and aligned with 13 of the 14 TDF domains, plus two additional domains: 'carer perspectives on the CPT intervention' and 'patient/carer characteristics'. Synthesized data revealed eight key theoretical domains: Environmental context and resources; Social influences; Beliefs about consequences; Skills; Memory, attention and decision-making; Knowledge; Beliefs about capabilities; and Reinforcement. Within each domain, the research team identified common categories and developed illustrative examples of theoretically informed implementation strategies. This systematic review and theory-informed synthesis of previously reported CPT implementation factors enabled the identification of key barriers to SLTs delivering this best practice. This led to proposed implementation strategies that should be validated, refined and evaluated in future research involving stakeholders who have contextual understanding of implementing CPT. What is already known on the subject CPT of familiar partners of PWA is an effective intervention that is inconsistently used in clinical settings. Factors influencing CPT implementation have previously been identified, but using disparate approaches and frameworks. A synthesis of these factors articulated around a common framework is currently not available. What this paper adds to existing knowledge This paper provides a theory-informed synthesis of previously reported barriers and facilitators to SLTs implementing CPT with familiar partners of PWA. It highlights key factors influencing the uptake of this best practice and includes suggestion of implementation strategies to address them. What are the potential or actual clinical implications of this work? The key influencing factors and proposed implementation strategies reported in this paper may support stakeholders in the future design of tailored and theoretically informed implementation strategies aiming to improve the delivery of familiar CPT in their setting.

Pediatricians’ Disclosure and Documentation of Sickle Cell Trait Found on Newborn Screening: Barriers and Possible Implementation Strategies

Introduction All states in the US require hemoglobinopathy testing as part of the newborn screen (NBS) which incidentally identifies individuals with sickle cell trait (SCT). Each state has its own protocol for disclosure of SCT results to families (i.e., via primary care provider (PCP), public health nurse, direct mailing to family) with no standards for documentation in the electronic health record (EHR). Our past work showed that SCT is documented 53% of the expected rate within our EHR. Though gaps in documentation may not equate to lack of disclosure, such gaps demonstrate a risk for inadequate counseling and loss of data with transitions of care. Further, the majority of individuals with SCT are Black or Hispanic. Failure to disclose SCT may contribute to inequities in healthcare and hamper informed reproductive decision making. Objective To identify barriers and facilitators to PCPs’ documentation and disclosure of SCT. Methods A cross sectional survey of outpatient PCPs at 43 pediatric offices within a pediatric health system in Delaware, Pennsylvania, and Florida was conducted. Using Likert scales, rating scales, and free text response, the survey assessed PCP practices surrounding NBS results, attitudes toward SCT disclosure and documentation, and ranking of implementation strategies from the "Expert Recommendations for Implementing Change” project intended to increase SCT documentation and disclosure. Recruitment and survey administration was via REDCap. Lunch was provided to offices with >75% participation. Free text items were analyzed using qualitative methods. Descriptive statistics were used for other items. The study was approved by the IRB. ResultsParticipants: Seventy-eight PCPs from 43 practices completed surveys (51% recruitment rate). Fourteen offices received lunch incentives. PCPs worked in their offices a mean of 7.1 years (SD 6.8y). Most (76%) identified as female and White (66%), with 17% Asian, 4% Black, and 12% Hispanic. Practice locations varied in percentages of patients insured by Medicaid (3-76%) or who identify as Black (2-91%). NBS Results: Most PCPs had a process for reviewing NBS results with ~1/3 actively seeking results (i.e., log into a separate portal). The majority "always” checked a NBS during infancy but "never/occasionally” checked for an older new patient, before sports participation, or transition to adult medicine. All PCPs endorsed the importance for families and PCPs to know about hemoglobin traits but 14% thought a family may not want to know and 30% thought a family may have trouble understanding results. Nearly half (45%) thought a non-PCP should discuss results. SCT: Almost all participants routinely discuss SCT during infancy. 16% routinely discuss it with adolescents and 56% "rarely/never” discuss SCT before transition to adult medicine. 10% "rarely/never” discuss inheritance patterns, but nearly one third "rarely/never” discuss possible medical complications and reproductive planning options. PCPs had varying confidence levels for several tasks (Table). Barriers: In free text questions, PCPs identified barriers to discussing SCT (during infancy or adolescence) including PCP knowledge/comfort, adequate time, NBS availability, lack of "good” handouts, and family health literacy. Additional barriers included believing adolescents are not interested. Potential Interventions: The highest ranked interventions to help increase the documentation and discussion of SCT included having a designated person to review the NBS, prompts within the EHR and templates for documentation, NBS program providing disclosure, longer appointment slots, educational sessions to increase PCP knowledge/comfort, and educational materials for families. Least helpful rated interventions included chart audits, incentives, leadership/society endorsements, or simulated discussions. Conclusions Despite PCPs recognizing the importance of discussing SCT, they rarely do so outside of infancy and have varying degrees of confidence in doing so. PCPs recognized several system-based (i.e. time, EHR prompts) and personal barriers (i.e. confidence, knowledge) to discussing SCT. They expressed preferences for a range of potential implementation strategies. Real world studies are needed to determine whether strategies designed to address these barriers increase discussion and documentation of SCT across childhood and enhance care equity. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Habitat quality assessment provides indicators for socio-ecological management: a case study of the Chinese Loess Plateau.

The impact of changing land use and land cover (LULC) on regional habitat quality have attracted extensive attention. The Loess Plateau is an ecologically fragile area; LULC changes in this region have complex impacts on habitat quality at multiple spatiotemporal scales. This study developed an integrated assessment method based on multi-source data to assess habitat quality changes in the Loess Plateau during recent years (2000-2015) and in the future (2015-2050) under four typical scenarios. A significant increase in urban land use was observed on the Loess Plateau from 2000 to 2050, which resulted in a continuous decrease in the cropland area. The area of forest and grassland landscapes was also reduced by both urban and cropland expansion, with the most significant loss in the grasslands. A future overall decreasing trend in overall habitat quality is predicted, but the SSP1-2.6 scenario is significantly better than the SSP5-8.5 scenario. Urban expansion contributes a rapidly increasing proportion of habitat quality decline on the Loess Plateau; urban land will become the most significant threat to regional habitat quality by 2030. Policies for socio-ecological protection with clear, high-level objectives can effectively promote habitat quality. It is recommended that national nature reserves be delineated and ecological functions in the study area be continuously monitored. This research provides a potential socio-ecological baseline and implementation strategy for the habitat conservation-oriented management of large and fragile ecological regions.

Formative Evaluation of the Acceptance of HIV Prevention Artificial Intelligence Chatbots By Men Who Have Sex With Men in Malaysia: Focus Group Study.

BackgroundMobile technologies are being increasingly developed to support the practice of medicine, nursing, and public health, including HIV testing and prevention. Chatbots using artificial intelligence (AI) are novel mobile health strategies that can promote HIV testing and prevention among men who have sex with men (MSM) in Malaysia, a hard-to-reach population at elevated risk of HIV, yet little is known about the features that are important to this key population.ObjectiveThe aim of this study was to identify the barriers to and facilitators of Malaysian MSM’s acceptance of an AI chatbot designed to assist in HIV testing and prevention in relation to its perceived benefits, limitations, and preferred features among potential users.MethodsWe conducted 5 structured web-based focus group interviews with 31 MSM in Malaysia between July 2021 and September 2021. The interviews were first recorded, transcribed, coded, and thematically analyzed using NVivo (version 9; QSR International). Subsequently, the unified theory of acceptance and use of technology was used to guide data analysis to map emerging themes related to the barriers to and facilitators of chatbot acceptance onto its 4 domains: performance expectancy, effort expectancy, facilitating conditions, and social influence.ResultsMultiple barriers and facilitators influencing MSM’s acceptance of an AI chatbot were identified for each domain. Performance expectancy (ie, the perceived usefulness of the AI chatbot) was influenced by MSM’s concerns about the AI chatbot’s ability to deliver accurate information, its effectiveness in information dissemination and problem-solving, and its ability to provide emotional support and raise health awareness. Convenience, cost, and technical errors influenced the AI chatbot’s effort expectancy (ie, the perceived ease of use). Efficient linkage to health care professionals and HIV self-testing was reported as a facilitating condition of MSM’s receptiveness to using an AI chatbot to access HIV testing. Participants stated that social influence (ie, sociopolitical climate) factors influencing the acceptance of mobile technology that addressed HIV in Malaysia included privacy concerns, pervasive stigma against homosexuality, and the criminalization of same-sex sexual behaviors. Key design strategies that could enhance MSM’s acceptance of an HIV prevention AI chatbot included an anonymous user setting; embedding the chatbot in MSM-friendly web-based platforms; and providing user-guiding questions and options related to HIV testing, prevention, and treatment.ConclusionsThis study provides important insights into key features and potential implementation strategies central to designing an AI chatbot as a culturally sensitive digital health tool to prevent stigmatized health conditions in vulnerable and systematically marginalized populations. Such features not only are crucial to designing effective user-centered and culturally situated mobile health interventions for MSM in Malaysia but also illuminate the importance of incorporating social stigma considerations into health technology implementation strategies.

Current Practices, Willingness and Perceived Ability to Implement an Injury Prevention Exercise Program Among Post-Primary Physical Education Teachers.

Musculoskeletal injuries are common in adolescents, and recently schools have been suggested as an opportune location for injury prevention strategies. This study aimed to identify the current practices and perceptions of post-primary PE teachers in Ireland on injury prevention exercise programs (IPEP), which are key to informing potential implementation strategies. Post-primary PE teachers (n=287) completed an online anonymous survey. Outcome measures included current IPEP practices in PE class, teachers' attitudes toward IPEPs, willingness to implement, and perceived ability to implement an IPEP in PE class. Descriptive statistics were calculated, and Mann-Whitney U tests were used to compare differences between groups. Results indicated that only 1 in 5 PE teachers currently used an IPEP in class. Of these, no teacher used an existing IPEP exactly as intended, while most teachers were willing to implement an IPEP (80.5%). Those who previously received formal IPEP education or were aware of an existing IPEP had significantly higher perceived ability to implement an IPEP in class (p < .001). This study demonstrates that despite a willingness among PE teachers to implement IPEPs in class, few currently do. Thus, post-primary PE class may be an under-utilized setting for adolescent injury prevention and warrants further investigation.

The RE-AIM framework-based evaluation of the implementation of the Maternal and Child Health Handbook program in Angola: a mixed methods study

BackgroundThe World Health Organization recommends the Maternal and Child Health Handbook (MCH-HB) to promote health service utilization from pregnancy to early childhood. Although many countries have adopted it as a national health policy, there is a paucity of research in MCH-HB’s implementation. Thus, this study aimed to evaluate the MCH-HB’s implementation status based on the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance), and identify facilitators of, and barriers to its implementation in Angola to understand effective implementation strategies.MethodsA cross-sectional survey was conducted targeting all health facilities which implemented MCH-HB, subsamples of health workers, and officers responsible for the MCH-HB at the municipality health office. Using the 14 indicators based on the RE-AIM framework, health facilities’ overall implementation statuses were assessed. This categorized health facilities into optimal-implementation and suboptimal-implementation groups. To identify barriers to and facilitators of MCH-HB implementation, semi-structured interviews were conducted among health workers and municipality health officers responsible for MCH-HB. The data were analyzed via content analysis.ResultsA total of 88 health facilities and 216 health workers were surveyed to evaluate the implementation status, and 155 interviews were conducted among health workers to assess the barriers to and facilitators of the implementation. The overall implementation target was achieved in 50 health facilities (56.8%). The target was achieved by more health facilities in urban than rural areas (urban 68.4%, rural 53.6%) and by more health facilities of higher facility types (hospital 83.3%, health center 59.3%, health post 52.7%). Through the interview data’s analysis, facilitators of and barriers to MCH-HB were comprehensively demonstrated. MCH-HB’s content advantage was the most widely recognized facilitator and inadequate training for health workers was the most widely recognized barrier.ConclusionsStrengthening education for health workers, supervision by municipality health officers, and community sensitization were potential implementation strategies. These strategies must be intensified in rural and lower-level health facilities.