Qualitative Research Archives - Page 7 of 10 - Implementation Science at UW

✪ Adapting Evidence-Based Falls Prevention Programs for Remote Delivery — Implementation Insights through the RE-AIM Evaluation Framework to Promote Health Equity

Abstract:

COVID-19 disproportionally impacted the health and well-being of older adults—many of whom live with chronic conditions—due to their higher risk of dying and being hospitalized. It also created several secondary pandemics, including increased falls risk, sedentary behavior, social isolation, and physical inactivity due to limitations in mobility from lock-down policies. With falls as the leading cause of preventable death and hospitalizations, it became vital for in-person evidence-based falls prevention programs (EBFPPs) to pivot to remote delivery. In Spring 2020, many EBFPP administrators began re-designing programs for remote delivery to accommodate physical distancing guidelines necessitated by the pandemic. Transition to remote delivery was essential for older adults and persons with disabilities to access EBFPPs for staying healthy, falls and injury free, out of hospitals, and also keeping them socially engaged. We collaborated with the Administration on Community Living (ACL), the National Council on Aging (NCOA), and the National Falls Prevention Resource Center (NFPRC), for an in-depth implementation evaluation of remotely delivered EBFPPs. We examined the process of adapting and implementing four EBFPPs for remote delivery, best practices for implementing the programs remotely within the RE-AIM evaluation framework. This enhances NFPRC’s ongoing work supporting dissemination, implementation, and sustainability of EBFPPs. We purposively sampled organizations for maximum variation in organization and provider type, geographic location, and reach of underserved older populations (Black, Indigenous, or other People of Color (BIPOC), rural, disabilities).

This qualitative evaluation includes provider-level data from semi-structured interviews (N = 22) with program administrators, staff, and leaders. The interview guide included what, why, and how adaptations were made to EBFPP interventions and implementation strategies using Wiltsey-Stirman (2019) adaptations framework (FRAME), reach, and implementation outcomes (acceptability, feasibility, fidelity, and costs; Proctor et al., 2011), focusing on equity to learn for whom these programs were working and opportunities to address inequities. Findings demonstrate remote EBFPPs made planned and fidelity-consistent adaptations to remote delivery in partnership with researchers and community organizations, focusing on participant safety both in program content and delivery. Supports using and accessing technology were needed for delivery sites and leaders to facilitate engagement, and improved over time. While remote EBFPP delivery has increased access to EBFPPs for some populations from the perspective of program administrator, leaders, and staff (e.g., caregivers, rural-dwellers, persons with physical disabilities), the digital divide remains a barrier in access to and comfort using technology. Remote-delivered EBFPPs were acceptable and feasible to delivery organizations and leaders, were able to be delivered with fidelity using adaptations from program developers, but were more resource intensive and costly to implement compared to in-person. This work has important implications beyond the pandemic. Remote delivery has expanded access to groups traditionally underserved by in-person programming, particularly disability communities. This work will help answer important questions about reach, accessibility, feasibility, and cost of program delivery for older adults and people with disabilities at risk for falls, those living with chronic conditions, and communities most vulnerable to disparities in access to health care, health promotion programming, and health outcomes. It will also provide critical information to funders about elements required to adapt EBFPPs proven effective in in-person settings for remote delivery with fidelity to achieve comparable outcomes.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Implementing point-of-care medical information systems into trauma and general surgeon practice in a middle-income country: a qualitative study utilizing the Consolidated Framework for Implementation Research

Abstract:

Background

Point-of-care medical information systems (POCMIS) can provide an efficient and effective means of strengthening health systems globally through their encouragement of continued medical education. Using the Consolidated Framework for Implementation Research (CFIR) as a guide, this research provides suggestions for improved implementation of POCMIS in low- and middle-income countries informed by an intervention implemented across public and military hospitals in Lima, Peru.

Methods

Analysis is based on qualitative interviews conducted with 12 Peruvian surgeons across eight public hospitals and one military hospital who received an intervention that provided free access to UpToDate and introduced Google Translate. The post-intervention interviews were transcribed, translated, and analyzed for themes overlapping with CFIR constructs to expose barriers to implementation and suggestions for improved implementation of future interventions.

Results

Barriers included a lack of seniority buy-in and engaged leadership, an overabundance of personal preferences for multiple POCMIS, and a culture of assumption that inhibited open communication regarding access to and use of POCMIS. Suggestions for improved implementation focused on the adaptation of the intervention. Namely, surgeons discussed regionally-specific adaptations as well as adaptations specific to their surgical specialty including visual, rather than written, representation of the information available via POCMIS.

Conclusions

Results indicate necessary adaptations for implementing interventions including POCMIS in LMICs, mimicking much of the implementation science literature on intervention adaptation. In addition to explicit suggestions provided by surgeons, we also suggest actionable steps to adapt to barriers identified in our data. Rapid assessment procedures (RAP) are one established methodological technique useful for assessing organization culture prior to implementation, allowing for necessary cultural adaptations. Dynamic adaption process (DAP) is another useful and established method that breaks implementation into four phases allowing for adaptations based on the initial assessment of the intervention site.

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Acute and intensive care nurses’ perspectives on suicide prevention with medically hospitalized patients: Exploring barriers, facilitators, interests, and training opportunities

✪ Integration of a Digital Health Intervention Into Immunization Clinic Workflows in Kenya: Qualitative, Realist Evaluation of Technology Usability

Abstract:

Background

In an effort to increase vaccination coverage in low-resource settings, digital tools have been introduced to better track immunization records, improve data management practices, and provide improved access to vaccination coverage data for decision-making. Despite the potential of these electronic systems to improve the provision of health services, few digital health interventions have been institutionalized at scale in low- and middle-income countries.

Objective

In this paper, we aimed to describe how health care workers in Kenya had integrated an electronic immunization registry into their immunization clinic workflows and to use these findings to inform the development of a refined program theory on the registry’s usability.

Methods

Informed by realist methodology, we developed a program theory to explain usability of the electronic immunization registry. We designed a qualitative study based on our theory to describe the barriers and facilitators influencing data entry and use. Qualitative data were collected through semistructured interviews with users and workflow observations of immunization clinic sessions. Our findings were summarized by context-mechanism-outcome relationships formed after analyzing our key themes across interviews and workflow observations. Using these relationships, we were able to identify common rules for future implementers.

Results

Across the 12 facilities included in our study, 19 health care workers were interviewed, and 58 workflow sessions were observed. The common rules developed from our qualitative findings are as follows: rule 1—ensure that the users complete training to build familiarity with the system, understand the value of the system and data, and know where to find support; rule 2—confirm that the system captures all data needed for users to provide routine health care services and is easy to navigate; rule 3—identify work-arounds for poor network, system performance, and too few staff or resources; and rule 4—make users aware of expected changes to their workflow, and how these changes might differ over time and by facility size or number of patients. Upon study completion, we revised the program theory to reflect the importance of the goals and workflows of electronic immunization registries aligning with reality.

Conclusions

We created a deeper understanding of the underlying mechanisms for usability of the registry. We found that the electronic immunization registry had high acceptability among users; however, there were numerous barriers to using the system, even under ideal conditions, causing a misalignment between the system and the reality of the users’ workflows and their environment. Human-centered design and human-factors methods can assist during pilot stages to better align systems with users’ needs and again after scale-up to ensure that interventions are suitable for all user settings."

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Managers’ and providers’ perspectives on barriers and facilitators for the implementation of differentiated service delivery models for HIV treatment in Mozambique: a qualitative study

Abstract:

Introduction

In 2018, Mozambique's Ministry of Health launched a guideline for a nationwide implementation of eight differentiated service delivery models to optimize HIV service delivery and achieve universal coverage of HIV care and treatment. The models were (1) Fast-track, (2) Three-month Antiretrovirals Dispensing, (3) Community Antiretroviral Therapy Groups, (4) Adherence Clubs, (5) Family-approach, and three one-stop shop models for (6) Tuberculosis, (7) Maternal and Child Health, and (8) Adolescent-friendly Health Services. This study identified drivers of implementation success and failure across these differentiated service delivery models.

Methods

Twenty in-depth individual interviews were conducted with managers and providers from the Ministry of Health and implementing partners from all levels of the health system between July and September 2021. National-level participants were based in the capital city of Maputo, and participants at provincial, district and health facility levels were from Sofala province, a purposively selected setting. The Consolidated Framework for Implementation Research (CFIR) guided data collection and thematic analysis. Deductively selected constructs were assessed while allowing for additional themes to emerge inductively.

Results

The CFIR constructs of Relative Advantage, Complexity, Patient Needs and Resources, and Reflecting and Evaluating were identified as drivers of implementation, whereas Available Resources and Access to Knowledge and Information were identified as barriers. Fast-track and Three-month Antiretrovirals Dispensing models were deemed easier to implement and more effective in reducing workload. Adherence Clubs and Community Antiretroviral Therapy Groups were believed to be less preferred by clients in urban settings. COVID-19 (an inductive theme) improved acceptance and uptake of individual differentiated service delivery models that reduced client visits, but it temporarily interrupted the implementation of group models.

Conclusions

This study described important determinants to be addressed or leveraged for the successful implementation of differentiated service delivery models in Mozambique. The models were considered advantageous overall for the health system and clients when compared with the standard of care. However, successful implementation requires resources and ongoing training for frontline providers. COVID-19 expedited individual models by loosening the inclusion criteria; this experience can be leveraged to optimize the design and implementation of differentiated service delivery models in Mozambique and other countries.

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✪ Improving the Usability of Written Exposure Therapy for Therapists in the Department of Veterans Affairs Telemental Health: Formative Study Using Qualitative and User-Centered Design Methods

Abstract:

Background

User modifications are common in evidence-based psychosocial interventions (EBPIs) for mental health disorders. Often, EBPIs fit poorly into clinical workflows, require extensive resources, or pose considerable burden to patients and therapists. Implementation science is increasingly researching ways to improve the usability of EBPIs before implementation. A user-centered design can be used to support implementation methods to prioritize user needs and solutions to improve EBPI usability.

Objective

Trauma-focused EBPIs are a first-line treatment for patients with posttraumatic stress disorder (PTSD) in the Department of Veterans Affairs. Written exposure therapy (WET) is a brief, trauma-focused EBPI wherein patients handwrite about trauma associated with their PTSD. Initially developed for in-person delivery, WET is increasingly being delivered remotely, and outcomes appear to be equivalent to in-person delivery. However, there are logistical issues in delivering WET via video. In this evaluation, we explored usability issues related to WET telehealth delivery via videoconferencing software and designed a solution for therapist-facing challenges to systematize WET telehealth delivery.

Methods

In the Discover phase, both groups had challenges delivering WET and other PTSD therapies via telehealth because of technology issues with videoconferencing software, environmental distractions, and workflow disruptions. Narrative transfer (ie, patients sending handwritten trauma accounts to therapists) was the first target for design solution development as it was deemed most critical to WET delivery. In the Design and Build phase, we identified design constraints and brainstormed solution ideas. This led to the development of 3 solution workflows that were presented to a subgroup of therapist users through cognitive walkthroughs. Meetings with this subgroup allowed workflow refinement to improve narrative transfers. Finally, to facilitate using these workflows, we developed PDF manuals that are being refined in subsequent phases of the implementation project (not mentioned in this paper).

Results

Conclusion

The Discover, Design and Build, and Test framework can be a useful tool for understanding user needs in complex EBPI interventions and designing solutions to user-identified usability issues. Building on this work, an iterative evaluation of the 3 solution workflows and accompanying manuals with therapists and patients is underway as part of a nationwide WET implementation in telehealth settings.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Barriers and Facilitators to Father’s Engagement in a Depression and Alcohol Use Intervention in Kenya: Father, Family, and Community Factors

Abstract:

In Kenya, there is a treatment gap for depression and alcohol use that is especially large for fathers, which has consequences for families. While treatments exist, there are challenges to implementation. This study aimed to understand barriers and facilitators to implementing a treatment for fathers’ depression and alcohol use in Eldoret, Kenya. Guided by the Consolidated Framework for Implementation Research and the Integrated Sustainability Framework, we conducted 18 key informant interviews and 7 focus group discussions (31 total participants) with stakeholders in Eldoret (hospital leaders, policy makers, mental health providers, community leaders, fathers, lay providers, and patients previously engaged in treatment). Interviews were analyzed using the framework method; themes were matrixed by framework domains. Participants identified barriers and facilitators, and opportunities for implementation, in the following domains: innovation, outer setting, inner setting, individual, sustainability, and characteristics of systems. Barriers included a lack of resources, stigma, masculine norms, cost of services, and alcohol dependence. Facilitators included community buy-in, family support, providers with lived experience, government support, and relevant treatment content. Findings will inform implementation strategy development for an intervention for fathers with depression and alcohol use, and family problems with local relevance and scalable potential.

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✪ Identifying research practices toward achieving health equity principles within the Cancer Prevention and Control Research Network

Abstract:

Purpose

Although there is national recognition for health equity-oriented research, there is limited guidance for researchers to engage partnerships that promote health equity in cancer research. The Cancer Prevention and Control Research Network’s (CPCRN) Health Equity Work Group developed a toolkit to guide researchers in equitable collaborations.

Methods

The CPCRN’s Health Equity Work Group collectively outlined health and racial equity principles guiding research collaborations with partners that include communities, community-based organizations, implementing partners in the clinical setting including providers and health care organizations, and policy makers. Using a network-wide survey to crowdsource information around ongoing practices, we leveraged and integrated the network’s experience and collaborations.

Results

Data from the survey formed the preliminary basis for the toolkit, with a focus on sharing fiscal resources with partners, training and capacity building, collaborative decision-making, community-driven research agenda setting, and sustainability. The final toolkit provides reflection considerations for researchers and collated exemplary resources, supported by the contemporary research.

Conclusions

The toolkit provides a guide to researchers at all experience levels wanting to engage in equitable research collaborations. Future efforts are underway to evaluate whether and how researchers within and outside CPCRN are able to incorporate these principles in research collaborations.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Implementation of a Psychosocial Support Intervention for Adolescents on Antiretroviral Treatment: Challenges and Experiences from Ehlanzeni District, South Africa

Abstract:

Adolescents living with HIV (ALHIV) need support from family, peers and health workers to remain on antiretroviral therapy and achieve and sustain viral suppression. This paper qualitatively explores the implementation of a psychosocial support intervention (PSS) in five primary health care facilities in the Ehlanzeni district, South Africa. Data were collected through key informant interviews and focus group discussions with ALHIV on ART. Data analysis employed inductive thematic analysis. Informed consent was obtained prior to all data collection. The PSS intervention facilitated full disclosure of HIV status to adolescents, supported treatment adherence through health education, peer support, health care provider- and client relations, and quick access to health service delivery. However, COVID-19 restrictions and regulations challenged the implementation of the intervention. The PSS intervention showed promise to support adolescent’s adherence and retention in care. We recommend innovative approaches to account for systemic disruptions, as evidenced by the COVID-19 pandemic.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Development of a Field Guide for Assessing Readiness to Implement Evidence-Based Cancer Screening Interventions in Primary Care Clinics

Abstract:

Evidence-based interventions, including provider assessment and feedback, provider reminders, patient reminders, and reduction of structural barriers, improve colorectal cancer screening rates. Assessing primary care clinics’ readiness to implement these interventions can help clinics use strengths, identify barriers, and plan for success. However, clinics may lack tools to assess readiness and use findings to plan for successful implementation. To address this need, we developed the Field Guide for Assessing Readiness to Implement Evidence-Based Cancer Screening Interventions (Field Guide) for the Centers for Disease Control and Prevention’s (CDC’s) Colorectal Cancer Control Program (CRCCP).

We conducted a literature review of evidence and existing tools to measure implementation readiness, reviewed readiness tools from selected CRCCP award recipients (n = 35), and conducted semi-structured interviews with key informants (n = 8). We sought feedback from CDC staff and recipients to inform the final document. The Field Guide, which is publicly available online, outlines 4 assessment phases: 1) convene team members and determine assessment activities, 2) design and administer the readiness assessment, 3) evaluate assessment data, and 4) develop an implementation plan. Assessment activities and tools are included to facilitate completion of each phase. The Field Guide integrates implementation science and practical experience into a relevant tool to bolster clinic capacity for implementation, increase potential for intervention sustainability, and improve colorectal cancer screening rates, with a focus on patients served in safety net clinic settings. Although this tool was developed for use in primary care clinics for cancer screening, the Field Guide may have broader application for clinics and their partners for other chronic diseases.

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