Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 16th
and 17th July 2020
O1. Implementation study of an inter-professional support programme for patients with
type 2 diabetes in a Swiss primary care setting
Noura Bawab1,2,3, Joanna C. Moullin4, Olivier Bugnon1,2,3, α, Clémence Perraudin1,
α
1Community Pharmacy, Centre for Primary Care and Public Health (Unisanté), University
of Lausanne, Rue du Bugnon 44, 1011 Lausanne, Switzerland; 2School of Pharmaceutical
Sciences, University of Geneva, Rue Michel-Servet 1, 1211 Geneva 4, Switzerland; 3Institute
of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University
of Lausanne, Rue Michel-Servet 1, 1211 Geneva 4, Switzerland; 4Faculty of Health Sciences,
Curtin University, Bentley WA 6102, Australia
Correspondence: Noura Bawab (Noura.bawab@unisante.ch)
α equal co-senior authors
Background:
The Swiss federal government promoted the evaluation of an inter-professional patient
support model, including regular motivational interviews (patient-pharmacist), medication
adherence and patient-reported outcomes monitoring and interactions with physicians.
The aim of this 15-month study was to evaluate the implementation process of a programme
tailored to patients with type 2 diabetes, taking at least one oral antidiabetic treatment.
Materials and methods:
This is a prospective, multi-centric, observational, cohort study using a hybrid implementation-effectiveness
design and the Framework for the Implementation of Services in Pharmacy (FISpH) [1].
Outcomes were assessed at each stage of the implementation process using both quantitative
and qualitative methods. A set of implementation measures reported on the process
(number of pharmacies going through the stages), outcomes (e.g. reach, fidelity) and
impact (influencing factors and implementation strategies).
Results:
Describes the indicators of progress along the implementation process.
Two-hundred-twelve patients were included to benefit from the support programme in
27 pharmacies. The mean inclusion rate per pharmacy was 8 patients (SD 6, range: 1-29).
We observed a step-by-step implementation process: 1) internal organisation: teaching
and coaching of the pharmacy team, identification of eligible patients, 2) preparation
of inter-professional collaboration: information and local networking with physicians;
and 3) relationship building with patients. Main influencing factors were pharmacists’
skills in motivational interviewing, support from pharmacy owners, pre-existing local
inter-professional networks and profitability of the programme.
Conclusions:
This evaluation provided evidence regarding the implementation capacity and acceptability
of the programme by pharmacy teams, patients with diabetes and physicians: a promising
start for inter-professional chronic care services.
Acknowledgements
We are very grateful to the stakeholders (FOPH, pharmaSuisse, santésuisse, curafutura)
for funding the study. We would like to sincerely thank all the pharmacies, patients
and physicians for their participation, as well as Aurélien Georges for helping with
the facilitation of the focus groups.
Trial Registration:
Not applicable
Consent to publish
Not applicable.
Reference
1. Moullin JC, Sabater-Hernandez D, Benrimoj SI. Model for the evaluation of implementation
programs and professional pharmacy services. Res Social Adm Pharm. 2016;12(3):515-22.
Fig. 1 (abstract O1).
Indicators of progress of the implementation process
P2. Building capacity from within - upskilling healthcare professionals to lead an
evidence-based implementation approach
April Morrow1,2, Priscilla Chan1, Emily Hogden1 & Natalie Taylor1,2
1Cancer Research Division, Cancer Council NSW, Woolloomooloo, NSW, Australia; 2 Faculty
of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
Correspondence: April Morrow (April.morrow@nswcc.org.au)
Background:
Translating evidence into complex health systems is an ongoing challenge. Hospital-based
implementation trials are often led by external researchers who, despite expertise
in implementation science, lack the necessary understanding of the inner workings
of the healthcare system. Partnerships with behavioural scientists to upskill healthcare
professionals to lead evidence-based implementation approaches may be more sustainable
for effective translation. However, limited guidance exists on the implementation
training and support needs of healthcare professionals, and few training programs
have been described or evaluated to date.
Method:
The Hide and Seek Project (HaSP) is a cluster randomised controlled trial testing
two implementation approaches for improving hereditary cancer referral at eight Australian
hospitals. Nine healthcare professionals were recruited from hospitals as ‘Implementation
Leads’ and trained via a one-day workshop. Ongoing support is provided by the researchers
via teleconferencing prior to key study activities. Implementation Leads participated
in semi-structured interviews to explore their perceptions of the training program.
Interview transcripts were analysed using inductive thematic analysis. Training contents
will be presented.
Results:
Nine Implementation Leads from various professional backgrounds completed the workshop,
all of whom participated in post-training interviews. Four key themes were identified:
(1) workshop feedback, (2) knowledge and skills, (3) implementation barriers and facilitators,
and (4) building health system capacity for implementation. The workshop was positively
received, and participants felt well-supported by the research team. A number of areas
for improvement were identified.
Conclusion:
Whilst maximising the potential for HaSP trial success, this training has the potential
for a prolonged impact within the health system, with healthcare professionals having
gained knowledge and skills they felt were transferrable to other clinical contexts.
Insights from the evaluation will guide future efforts to deliver training on a larger
scale across a range of healthcare contexts.
Trial Registration: ACTRN12618001072202
Consent to publish
All participants consented for publication
O3. How can strategies to address mental ill-health in doctors and medical students
be optimised? The interplay of intervention and implementation identified in the ‘Care
Under Pressure’ realist review
Mark Pearson1, Daniele Carrieri2,3, Karen Mattick2, Chrysanthi Papoutsi4, Simon Briscoe5,
Geoff Wong4, Mark Jackson2
1Wolfson Palliative Care Research Centre, Hull York Medical School, Faculty of Health
Sciences, University of Hull, Hull, HU6 7RX, UK; 2College of Medicine and Health,
University of Exeter, Exeter, EX1 2LU, UK; 3Wellcome Centre for Cultures and Environments
of Health, University of Exeter, Exeter, EX1 2LU, UK; 4Nuffield Department of Primary
Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK; 5Exeter HS&DR Evidence
Synthesis Centre, Institute of Health Research, College of Medicine and Health, University
of Exeter, Exeter, EX1 2LU, UK
Correspondence: Mark Pearson (mark.pearson@hyms.ac.uk)
Background:
The impact of the work environment on the mental health of doctors is internationally
recognised. However, research syntheses on interventions that provide support, advice
and/or treatment to sick doctors have not fully taken account of intervention complexity
and heterogeneity, the multiple dimensions of the issue, nor the challenges of implementing
strategies to address mental ill-health in doctors. We: 1) conducted a realist review
of interventions to improve doctors’ and medical students’ mental ill-health, engaging
throughout with a diverse group of stakeholders; 2) developed recommendations to support
tailoring, implementation, monitoring and evaluation of these strategies.
Method:
Realist review, conducted and reported consistent with RAMESES standards. Research
and policy sources identified through bibliographic database searches, purposive searches,
and stakeholder engagement. Extracted data analysed using a realist lens to identify
explanatory context-mechanism-outcome configurations (CMOcs) of mental ill-health
in doctors and medical students.
Results:
179 sources were included, 45% of which were from the USA and 74% of which were published
in 2009 or later. The synthesis produced 19 CMOcs (processes, relationality, balance,
and implementation) explaining how mental ill-health develops in the workplace and
how strategies can be implemented to reduce mental ill-health. Trust was identified
as highly important in explaining the interplay between implementation strategy, intervention
development, and the broader workplace context.
Conclusion:
Interventions to improve doctors’ and medical students’ mental ill-health should take
account of the complexity of the issue and its implementation by operating at multiple
levels and engaging diverse stakeholders. Refining existing complex interventions,
informed by the CMOcs in this review, is likely to be more efficient and ultimately
more effective than developing new interventions. This review has demonstrated the
importance of Realist review in critically synthesising diverse evidence about complex
health service issues so that implementable multi-level strategies can be developed.
Acknowledgements
This project is funded by the by the National Institute for Health Research (NIHR)
HS&DR (project number 16/53/12) and supported by the NIHR Collaboration for Leadership
in Applied Health Research and Care South West Peninsula. The views expressed are
those of the author(s) and not necessarily those of the NHS, the NIHR or the Department
of Health and Social Care.
Systematic review registration: PROSPERO CRD42017069870
O4. Identifying embedded, low-value nutrition care practices for de-implementation
- a nominal group technique approach
Alita Rushton1, Kai Elmas1, Dr Jack Bell1,2
1Department of Nutrition & Dietetics, The Prince Charles Hospital, Brisbane, Queensland,
Australia; 2School of Human Movement & Nutrition Sciences, The University of Queensland,
Brisbane, Queensland, Australia
Correspondence: Jack Bell (jack.bell@health.qld.gov.au)
Background:
Traditional malnutrition models of care apply individualised, dietitian administered
nutrition care. Shifting to systematised and/or interdisciplinary alternatives is
an important step towards improved service efficiencies, effectiveness, and patient
reported experience measures. This study consequently applied a nominal group technique
approach with experts in field to identify and prioritise low-value nutrition care
practices for de-implementation.
Method:
Workshops using the nominal group technique were undertaken at eight hospitals across
Queensland, Australia administered by a single experienced clinician/implementation
expert. Purposively sampled dietitians and nutrition assistants were asked the question
“What highly individualised malnutrition care activities do you think we could replace
with systematised, interdisciplinary malnutrition care?”. Each participant was provided
opportunity to individually list and present responses, discuss them as a group, and
then vote for the highest priorities; each participant was allowed five votes.
Results:
Nine workshops were conducted across eight sites. Dietitians (51) and assistants (12)
identified 101 dietetics actions to replace with systematised, interdisciplinary alternatives.
These were spread across screening (n=5), assessment (n=31), diagnosis (n=2), intervention
(n=45), and monitoring and evaluation (n=18) domains of the nutrition care process.
Actions that received the highest number of nominal group technique votes were: comprehensive
dietitian assessments for low risk referrals (n=50); dietetics follow-up reviews where
unlikely to add substantial benefit (n=32); individualised inpatient educations by
dietitian where specialised education or counselling were considered low-value (n=28);
individualised food and fluid support for patients who do not require specialised
dietitian care (n=22); and assistants undertaking malnutrition screening (n=19).
Conclusion:
Findings highlight the nominal group technique as a useful approach to prioritising
embedded, low-value clinical care activities for de-implementation. The individual
and group elements of the framework supported establishment of consensus amongst practicing
clinicians and policy makers. These findings are currently supporting practice and
policy value-based healthcare reform across Queensland hospitals.
Acknowledgements
This program has received funding support from Allied Health Professions Office, Queensland,
and the Australian Government Medical Research Futures Fund
O5. Bridging the Implementation Gap: Using implementation research to understand how
six countries implemented evidence-based interventions to reduce amenable under-5
mortality
Agnes Binagwaho1, Miriam F Frisch1, Jovial Thomas Ntawukuriryayo1, Dieudonné Nkurunziza1,
Kelechi Udoh1, Amy VanderZanden1, Laura Drown1, Lisa R Hirschhorn2
1University of Global Health Equity, Kigali, Rwanda; 2Department of Medical Social
Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
Correspondence: Agnes Binagwaho (abinagwaho@ughe.org)
Background:
Despite health-system evidence-based interventions (EBIs) known to reduce amenable
under-5 childhood mortality (U5M), countries struggle to effectively bridge the implementation
gap. We applied implementation research (IR) to understand how six countries (Rwanda,
Senegal, Ethiopia, Bangladesh, Nepal, Peru) implemented EBIs to contribute to successfully
dropping U5M.
Method:
We developed an IR framework building on the Exploration, Preparation, Implementation,
Sustainment Framework and Consolidated Framework for Implementation Research to include
adaptation (EPIAS) and capture contextual factors at the global, national, health
system, and individual levels.[1,2] We used mixed methodology to analyze EBI implementation
and successes and challenges.
Results:
These countries took a five-step implementation approach, reflecting EPIAS, to implement
the EBIs, recognizing contextual factors needing to be addressed or influencing implementation
strategies.
Exploration: Understand and research the problem and possible solutions; identify
multisectoral stakeholders; identify possible implementation strategies.
Preparation: for implementation: Choose EBIs or implementation strategies that fit
national contexts, priorities, and identified gaps; identify contextual factors to
be addressed or influencing strategies; develop evidence-based guidelines for implementation;
plan for monitoring and evaluation.
Initiate implementation: Disseminate national protocols; train personnel and stakeholders;
implement interventions and accountability frameworks; monitor implementation; follow
research and new guidelines to identify new EBIs or strategies.
Adaptation: Use monitoring data and stakeholder engagement to determine gaps in fidelity,
reach, acceptability, and effectiveness; make evidence-based adaptations; continue
monitoring to assess impact; identify new resources needed.
Sustainment: Ensure longer-term funding; cultivate a culture of evaluation and implementation
of needed changes; integrate training and capacity-building.
These countries’ success in U5M reduction also included broader initiatives to reduce
disease burden (ex. sanitation) and improve child and family resilience (ex. economic
development, female empowerment).
Conclusion:
These findings provide lessons for other countries to better adapt and implement health-system
delivered EBIs to accelerate U5M reduction and achieve equity.
P6. Protocol for participatory, theory-informed design of an implementation research
programme for health system strengthening to improve the delivery of maternal, surgical
and primary care in sub-Saharan Africa (ASSET)
Seward N1*, Araya R2, Hanlon C2,3,4, Harding R5, Hinrichs-Krapels S6,7, Lund C2,6,
Mayston R2, Murdoch J8, Thornicroft G1,2, Gao W5, Radhakrishnan M1, Sevdalis N1
1Centre for Implementation Science, Health Service and Population Research Department,
Institute of Psychiatry, Psychology & Neuroscience, King’s College London, UK; 2Centre
for Global Mental Health, Health Service and Population Research Department, Institute
of Psychiatry, Psychology & Neuroscience, KCL, UK; 3Department of Psychiatry, WHO
Collaborating Centre for Mental Health Research and Capacity-Building, School of Medicine,
College of Health Sciences, Addis Ababa University, Ethiopia; 4Centre for Innovative
Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health
Sciences, Addis Ababa University, Ethiopia; 5Cicely Saunders Institute Of Palliative
Care, Policy & Rehabilitation, KCL, UK; 6King’s Global Health Institute, KCL, UK;
7The Policy Institute, KCL, UK; 8School of Health Sciences, University of East Anglia,
UK
Correspondence: Seward N (nadine.seward@kcl.ac.uk)
Background:
Achieving Universal Health Coverage that includes the availability and delivery of
high-quality evidence-based care has been identified as a priority for health system
strengthening (HSS) in Low- and Middle-Income Countries (LMICs) [1]. ASSET is an implementation
research programme for HSS working on three care platforms across four sub-Saharan
African countries; Ethiopia, Sierra Leone, South Africa, and Zimbabwe.
The overall aim of the implementation science theme within ASSET is to advance our
understanding of how to design and evaluate HSS interventions across different health
systems and contexts to: (1) understand what implementation strategies work, for whom
and how, and (2) improve implementation science methodologies applied to such HSS
interventions.
Methods:
Using a mixed-method approach we will use implementation determinant and evaluation
frameworks as part of ‘effectiveness-implementation hybrid trial’ designs to evaluate
ASSET programme interventions. The pre-implementation phase will collect information
on contextual barriers and/or enablers that influence selection of different HSS interventions.
The implementation and evaluation phase will evaluate: (1) effectiveness of implementation
strategies (based on standardised implementation outcomes assessment), (2) influence
of context on the effectiveness of implementation strategies in delivering the interventions,
and (3) influence of context on the mechanisms introduced by the interventions to
produce improvement.
To facilitate comparisons between countries/platforms, we will adapt the ‘matrixed
multiple case study’ approach [2]. This methodology organises, analyses and presents
common and heterogeneous findings across implementation sites, in order to seek generalizable
knowledge regarding what and how local factors influence implementation.
Results: This is a protocol to design and evaluate HSS interventions, so as such no
results are applicable.
Conclusions:
This research programme will create a compilation of implementation strategies used
in LMIC contexts and compare the associated barriers and the effectiveness on implementation
outcomes. Given this is one of the first large scale programmes to design and evaluate
HSS interventions across multiple study sites, we hope to use this opportunity to
address key methodological challenges associated with such programmes.
References
1. Kruk M, Gage A, Arenault C. High quality health systems n the Sustainable Development
Goal era: time for a revolution. Lancet Global Health. 2018; 6(11). 10.1016/s2214-109x(18)30386-3
2. Kim, B, Sullivan J, Ritchie M. Comparing variations in implementation process and
influences across multiple sites: what works, for whom, and how? Psychiatry Research.
2019; 283. 10.1016/j.psychres.2019.112520
O7. Delivering NICE Joint Pain Advice in the workplace
Mike Hurley1, Sally Irwin2, Jo Erwin3, Fay Sibley2, Amber Gibney2, Andrea Carter2
1St George's University of London and Kingston University, Centre for Health and Social
Care Research, London, United Kingdom; 2Musculoskeletal Programme, Health Innovation
Network, London, United Kingdom; 3Bone & Joint Research Office, Royal Cornwall Hospitals
NHS Trust, Truro, United Kingdom
Correspondence: Mike Hurley (michael.hurley@sgul.kingston.ac.uk)
Background:
NICE recommend people with knee, hip and/or back pain receive self-management and
lifestyle advice, emphasising the importance of physical activity and maintaining
healthy weight. Unfortunately, delivering NICE advice to the millions of people requiring
help is prevented by limitations in time, facilities and expertise. Moreover, using
healthcare facilities and professionals medicalises a problem most people see as a
natural part of living and ageing. Joint Pain Advice (JPA) can deliver NICE advice
in a variety of health and community settings, using a range healthcare and non-healthcare
professionals [1,2]. Here we extend JPA delivery into workplace settings using local
health champions.
Method:
In workplaces, 2-3 people were trained to deliver JPA. This involved an initial assessment
of participant’s pain (using VAS), musculoskeletal health and function (MSK-HQ), activity
level (number of days/week active for >30mins). Participants were taught simple self-management
strategies, encouraged to adopt healthier lifestyle using motivational interviewing,
goal-setting action/coping planning and personalised care plans constructed. Participants
were reviewed 3 times over 6-months, baseline outcomes reassessed, progress highlighted,
health messages reinforced and plans and care plans revised if necessary. Results
presented as mean change (95% CI)
Results:
Twelve large public organisations or small/medium private enterprises delivered JPA
to 417 people. Participants attendance was 75%, suggesting they found JPA acceptable,
valued advice tailored to their individual needs and experienced tangible benefits.
Overall the MSK-HQ improved by 8 points (CI 6.6 to 9.2), pain 1 (-1.33 to -0.88),
activity for >30mins by 1.5 (1.1 to 1.8), self-reported physical function by 1.5 (1.1
to 1.8).
Conclusion:
Delivering NICE advice for management of chronic joint pain through JPA in workplace
settings using local health champions is practicable, beneficial and valued. This
can avoid medicalising the problem and “prevent turning people into patients”. JPA
could benefit small medium or large employers across the UK.
Acknowledgements
This work was funded by the Department of Work and Pensions Work and Health Unit Challenge
Fund
References
1. Hurley M V., Semple A, Sibley F, Walker A. Evaluation of a health trainer–led service
for people with knee, hip and back pain. Perspect Public Health. 2019;139(6):308–15.
2. Health Innovation Network. Joint Pain Advice – A Model of Care for Chronic Joint
Pain [Internet]. [cited 2020 Jun 26]. Available from: https://healthinnovationnetwork.com/projects/joint-pain-advisor-exploring-a-new-model-of-care-for-chronic-joint-pain/
P8. Increasing access to rehabilitation for knee and hip osteoarthritis – extending
ESCAPE-pain delivery to community venues
M. Hurley1, 2, M. Connelly2, H. Sheldon2, A. Gibney2, R. Hallett3, A. Carter2
1St George’s University of London and Kingston University, Faculty of Health, Social
Care and Education, London, United Kingdom; 2Health Innovation Network, Musculoskeletal
Programme, London, United Kingdom; 3Faculty of Health, Social Care and Education,
St George’s University of London and Kingston University, 6th Floor, Hunter Wing,
Faculty of Health, Social Care and Education, London, United Kingdom
Correspondence: M. Hurley (michael.hurley@sgul.kingston.ac.uk)
Background:
ESCAPE-pain is a rehabilitation programme for knee and/or hip osteoarthritis [1,2].
It is usually delivered in physiotherapy departments, but NHS constraints limits access
to the programme. Delivering ESCAPE-pain in community venues could increase accessibility
and provide on-going support (3). This study extended delivery of ESCAPE-pain into
community venues and evaluated its effectiveness and participant’s experiences.
Method:
We trained 369 exercise professionals to deliver ESCAPE-pain in 41 community centres.
Pain, function and quality of life (using Knee or Hip Osteoarthritis Outcome Score,
K/HOOS) and self-reported activity levels (minutes/week) were measured before and
after the programme. Semi-structured interviews estimated people’s experiences of
the programme.
Results:
386 participants were recruited, mean age 70 years. Before the programme only 24%
of participants were “active”, i.e. doing >30 mins activity/week, after participating
almost 78% were “active” doing >30 mins/week. Participants reported improvements in
pain (10 K/HOOS points; p<0.0001), function (9pts; p<0.0001), QoL (10pts; p<0.0001).
These improvements enabled people to walk better, farther, without aids and reduced
their social isolation. Better understanding of their problems, ability to self-manage
their problems and exercise self-efficacy (the confidence to use exercise to control
pain and its impact), made people much more optimistic and they described “the world
was a brighter place”. Concomitant with these improvements overall healthcare utilisation
reduced. Because they enjoyed the programme most participants were planning to continue
exercising to try to maintain these benefits, had joined classes and taken up activities
(swimming, golf, walking, yoga).
Conclusion:
ESCAPE-pain can be safely delivered by exercise professionals as a community-based
rehabilitation programme, it retains its effectiveness and nurtures habitual exercise
in participants. As a community-based programme will enable many more people to access
the programme and benefit. As a result of this study ESCAPE-pain is now being in many
more community venues across the UK [3].
Acknowledgements
This work was supported by grants from Sport England, Versus Arthritis and the Health
Innovation Network (South London's Academic Health Science Network).
References
1. ESCAPE. Enabling Self-management and Coping with Arthritic Pain using Exercise
[Internet]. [cited 2020 Jun 20]. Available from: https://escape-pain.org/
2. Hurley M V, Walsh NE, Mitchell H, Nicholas J, Patel A. Long-term outcomes and costs
of an integrated rehabilitation program for chronic knee pain: A pragmatic, cluster
randomized, controlled trial. Arthitis Care Res. 2012;64(2):238–47.
3. Hurley MV, Carter A. ESCAPE-into the community - A community-based rehabilitation
programme for elderly people with chronic joint pain. Perspect Public https://escape-pain.org/Health.
2016;136(2)
O9. Contextual equipoise: a novel concept to inform ethical implications for implementation
research using randomised controlled trials in low- and middle-income countries
Seward N1, Hanlon C2,3,4, Colbourn T5&, Murdoch J 6&, Prince M7, Venkatapuram S7,
Sevdalis N1
1Centre for Implementation Science, Department of Health Services and Population Research,
Institute of Psychiatry, Psychology & Neuroscience, Kings College, UK; 2Centre for
Global Mental Health, Department of Health Services and Population Research, Institute
of Psychiatry, Psychology & Neuroscience, King’s College London, UK; 3Department of
Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-Building,
School of Medicine, College of Health Sciences, Addis Ababa University, Ethiopia;
4Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa),
College of Health Sciences, Addis Ababa University, Ethiopia; 5 UCL Institute for
Global Health, University College London, UK; 6 School of Health Sciences, University
of East Anglia, UK; 7Kings Global Health Institute, Kings College London, UK
Correspondence: Seward N (nadine.seward@kcl.ac.uk)
&Equal contributors
Background:
The call for universal health coverage within low-and middle-income countries, requires
the implementation and scale-up of interventions that are known to be effective.1
Achieving universal health coverage requires robust implementation research (IR) that
evaluates the influence of context on the effectiveness of interventions to deliver
evidence-based care [1]. However, where IR uses a randomised controlled trial (RCT)
to test the effectiveness of interventions to deliver care that is known to be effective,
clinical equipoise may no longer be relevant [2].
IR is fundamentally about evaluating the influence of context on the effectiveness
of interventions to deliver evidence-based care [3]. However, the process of conceptualising
whether there is sufficient evidence about context to generalise findings from previous
research to a new setting is rarely reported, leaving uncertainty as to whether an
RCT is justified. This raises important ethical concerns surrounding participants
in the control arm of an RCT being exposed to unnecessary harms associated with denying
individuals access to care that is known or can be expected to be effective, in the
local context [2].
Proposed methods to address ethical concerns:
To address this ethical concern, we propose a complementary approach to clinical equipoise
for IR, known as “contextual equipoise.” We further propose that IR that uses an RCT
needs to clearly articulate the grounds for contextual equipoise. However, the process
of understanding contextual equipoise raises ontological and epistemological challenges
for assessing the certainty of evidence. We discuss these challenges and argue that
a guiding principle should be uncertainty amongst key stakeholders, as to the influence
of context on the delivery evidence-based care.
Results:
This abstract proposes a complementary approach to clinical equipoise for IR, so it
is in preliminary stages.
Conclusions:
To guide researchers, we describe how theory-driven methods can be applied to help
understand if contextual equipoise is justified. We hope our approach helps researchers
to better understand and ensure the ethical principle of beneficence is upheld in
the real-world contexts of IR in low-resource settings.
Acknowledgements
We would like to thank Shalini Ahuja and Leila Younes for reviewing the manuscript
and providing insight as to the salience of this topic for implementation researchers
in Global Health.
References
1. Peterson HB, Haidar J, Fixsen D, Ramaswamy R, Weiner BJ, Leatherman S. Implementing
Innovations in Global Women's, Children's, and Adolescents’ Health: Realizing the
Potential for Implementation Science. Obstetrics & Gynecology. 2018;131(3):423-30.
2. World Health Organization. Ethics in implementation researcy. Facilitator’s guide.
Geneva: World Health Organization; 2019. https://apps.who.int/iris/bitstream/handle/10665/325608/9789241515375-eng.pdf?ua=1
(accessed Dec 2019).
3. Peters DH, Adam T, Alonge O, Agyepong I, Tran N. Implementation research: what
it is and how to do it. BMJ : British Medical Journal. 2013;347:f6753.
P10. Implementation of e-mental health interventions for informal caregivers of adults
with chronic diseases: a systematic review
Chelsea Coumoundouros1, Erika Mårtensson1,2, Giulia Ferraris3, Louise von Essen1,
Robbert Sanderman3,4, Joanne Woodford1
1Clinical Psychology in Healthcare, Department of Women’s and Children’s Health, Uppsala
University, Uppsala, Sweden; 2Centre for Gender Research, Uppsala University, Uppsala,
Sweden; 3Department of Health Psychology, University Medical Center Groningen, University
of Groningen, Groningen, the Netherlands; 4Department of Psychology, Health and Technology,
University of Twente, Enschede, the Netherlands
Correspondence: Chelsea Coumoundouros (chelsea.coumoundouros@kbh.uu.se)
Background:
Many informal caregivers experience mental health difficulties. E-mental health interventions
offer effective and accessible mental health support; however, these interventions
are often not implemented. To explore implementation of e-mental health interventions
for informal caregivers, a systematic review was conducted to (1) examine implementation
barriers and facilitators, and (2) identify implementation and intervention features
associated with intervention effectiveness.
Method:
Multiple electronic databases were searched for studies published since 2007 reporting
on the implementation and/or effectiveness of e-mental health interventions for informal
caregivers of adults with chronic diseases. A thematic synthesis of data related to
implementation will be used to identify implementation barriers and facilitators.
A qualitative comparative analysis, using data from pragmatic randomized controlled
trials, will be used to determine combinations of conditions related to an intervention’s
implementation or program features, sufficient for intervention effectiveness.
Results:
Electronic database searches yielded 9248 unique records to undergo title/abstract
screening. The literature screening process is currently underway to identify full-texts
eligible for inclusion in the analysis. Preliminary findings will be presented. Implementation
barriers and facilitators identified in the thematic synthesis will be presented.
These barriers and facilitators will be linked to initial results from the qualitative
comparative analysis, as barriers and facilitators may relate to conditions important
for intervention effectiveness. Practical applications of these findings will be discussed.
If a qualitative comparative analysis cannot be completed prior to the conference,
pragmatic trials reporting on intervention effectiveness will be descriptively summarized
and analysis plans discussed.
Conclusions:
This review will identify key factors to consider during implementation of e-mental
health interventions for informal caregivers and present potential solutions to overcome
implementation barriers. These findings can be used to inform intervention design
and implementation strategies to facilitate the implementation of e-mental health
services for informal caregivers.
Acknowledgements
This work was supported by the European Union’s Horizon 2020 research and innovation
program under the Marie-Sklodowska Curie grant agreement No 814072.
P11. The importance of stakeholder engagement in the development and implementation
of novel interventions in lower-resourced settings: Experiences from the Healthy Pregnancy,
Healthy Baby (HPHB) Study
Slemming W1, Drysdale R2, Makusha T3 & Richter L2
1Division of Community Paediatrics, Department of Paediatrics and Child Health, Faculty
of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; 2DSI-NRF
Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg,
South Africa; 3Human Sciences Research Council, Durban, South Africa
Correspondence: Slemming W (Wiedaad.Slemming@wits.ac.za)
Background:
The 2015 South African Department of Health and the 2016 World Health Organization’s
antenatal care guidelines include the recommendation of a routine pregnancy ultrasound
before 24 weeks.
The HPHB study in Soweto, South Africa, uses scientific evidence on the value of early
ultrasounds as a basis for designing an intervention that capitalises on the socio-emotional
responses of prospective parents to images of their foetus’s development, the sound
of their heartbeat and images that they can share with family and friends. The intervention
is embedded in routine health services at Chris Hani Baragwanath Hospital (CHBH) and
is being tested through a randomised controlled trial with evaluation of benefits
for parents and children at 6 weeks and 6 months’ follow-up. This ongoing study employed
multilevel stakeholder engagement strategies during early conceptualisation and development,
as well as throughout implementation of the trial.
Method:
Stakeholder engagement included meetings and presentations with health policy and
management at national and provincial levels; management, clinicians and clerical
staff at the referring hospital; district and ward health service staff, non-governmental
organizations , academics and researchers.
Results:
Formative research conducted with pregnant women attending antenatal clinic at CHBH
was key to the intervention development and design. Close collaborations were established
with the clinical services at CHBH to ensure efficient and effective recruitment practices
and clinical oversight of the trial procedures. Ongoing consultation with a key stakeholder
network comprising policy makers, programme implementers, academics, researchers and
representatives of multilateral and public benefit organisations, inform intervention
procedures and strategies to address challenges that arise during trial implementation.
Implementation is monitored and informed through ongoing reflection from staff and
formal and informal feedback received from participants.
Conclusion:
Meaningful and effective stakeholder engagement is necessary for the development and
translation of promising interventions that can be integrated into routine health
services, especially in lower-resourced settings.
Acknowledgements
The authors would like to thank Chris Hani Baragwanath Hospital and the MRC-Wits Developmental
Pathways for Health Research Unit (DPHRU) for facilitating the study
Trial Registration: The trial is registered through the Pan African Clinical Trials
Registry (PACTR201808107241133).
O12. An emergency response to the covid-19 pandemic: the Cyprus situation
Pallari Elena (elena.pallari@outlook.com)
University College London, MRC Clinical Trials and Methodology Unit, 90 High Holborn,
London WC1V 6LJ, England
Background:
The translation of scientific findings in healthcare is notoriously slow, except for
a few ground-breaking innovations, healthcare interventions and recently the global
response to the public health emergency posed by the novel coronavirus (covid-19).
Materials and methods:
In this study, I evaluated the government plans of the Republic of Cyprus in response
to the covid-19 outbreak. I applied the Promoting Action on Research Implementation
in Health Services (PARiHS) framework to guide our assessment, using the data provided
by the Department of Medical and Public Health Services of the Ministry of Health,
the Press and Information Office and publicly available data to assess the healthcare
capacity to the pandemic response.
Results:
The initiative of the government of the Republic of Cyprus has been responsive and
reactive but not proactive, following the robust and vigorous prototype set by the
Chinese government. As soon as the first two covid-19-positive cases were diagnosed
on the island, the appropriate services were activated, and a thorough contact-tracing
lead to the collection of 195 samples (Figure 1). This was the turning point for the
government to initiate immediate measures to slow the spread within the community.
Conclusions:
As the hub of covid-19 shifted from China to Italy, with Europe becoming the epicentre
of the disease, so did the evidence and sharing of best practices in dealing with
the pandemic. The PARiHS framework was a useful model to map the spontaneous practice-based
implementation plans of the Cypriot government to protect the health of an island
with a population of under a million residents.
Keywords:
covid-19, Cyprus, healthcare capacity, PARiHS framework
Acknowledgements
The author would like to thank Dr Christina Yiannaki, Permanent Secretary at the Department
of Medical and Public Health Services of the Ministry of Health.
Fig. 2 (abstract O12).
The analysis of the evidence, facilitation and context of the response to the covid-19
in Cyprus using the Promoting Action on Research Implementation in Health Services
(PARiHS) framework
P13. A systematic review of barriers and enablers to the uptake of new medicines
Kristina Medlinskiene1,2, Justine Tomlinson1,2, Iuri Marques1, Susan Richardson3,
Katherine Striling2, and Duncan Petty1
1Medicine Optimisation Research Group, School of Pharmacy and Medical Sciences, University
of Bradford, Bradford, United Kingdom, BD7 1DP, UK; 2Medicine Management and Pharmacy
Services, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom, LS1 3EX, UK;
3Department of Management, Huddersfield Business School, University of Huddersfield,
Huddersfield, HD1 3DH, UK
Correspondence: Kristina Medlinskiene (k.medlinskiene1@bradford.ac.uk)
Background:
Implementation of innovations in healthcare, including new medicines, in the United
Kingdom is often lacking behind other countries [1]. The slow uptake of new medicines
can delay improvements in patient care and healthcare efficiency. This systematic
review aimed to identify factors affecting the uptake of new medicines into practice
within healthcare organisations.
Method:
The systematic review followed the developed protocol registered with PROSPERO database
(CRD42018108536).
Results:
The search yielded 35,806 unique titles. Screening of titles and abstracts resulted
in 151 papers for full-text review, which further excluded 113 papers. Eleven studies
were identified after screening references and citations of included studies. A total
of 49 studies were included in the review. The majority of the studies (n=47) were
quantitative. Most of the studies (n=36) used secondary data from various databases,
e.g. insurance databases. The methodological quality of studies ranged from 45% to
81% with a mean score of 67%. The review findings were grouped into five thematic
areas: patient, prescriber, drug, organisational, and external environment factors
(Figure 1). Of the five thematic areas coded, organisational, external environment,
prescriber and patient factors were the most frequently discussed in the reviewed
studies.
Conclusions:
The systematic review highlighted various factors affecting the uptake of new medicines.
However, factors related to behaviour change were scarcely studied in the reviewed
studies. Our further research builds on and explores the review findings using a qualitative
approach to identify factors that may not be present in the secondary data, for instance
factors related to behaviour change.
Acknowledgements
This research work was supported by funding from Leeds Teaching Hospitals NHS Trust
and Pharmacy Research UK.
Reference
1. Office for Life Sciences and Welcome Trust. Accelerated Access Review: Final Report
[Internet]. 2016 [cited 10th March 2019]. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/565072/AAR_final.pdf
Fig. 3 (abstract P13).
Summary of identified factors in reviewed studies affecting the uptake of new medicines
P14. Relevant involvement and how it can improve implementation for novel digital
mental health interventions
Humma Andleeb1, Aislinn Bergin2, 3, Dan Robotham1, Sue Brown2, 3, Jennifer Martin2,
3
1 The McPin Foundation, 7-14 Great Dover Street, London, SE1 4YR, United Kingdom;
2 NIHR MindTech MedTech Co-operative, Institute of Mental Health, School of Medicine,
University of Nottingham, Nottingham, United Kingdom;
3 NIHR Nottingham Biomedical Research Centre, Mental Health and Technology Theme,
University of Nottingham, Nottingham, United Kingdom
Correspondence: Humma Andleeb (hummaandleeb@mcpin.org)
Background:
gameChange is the NIHR 2017 Mental Health Challenge Award winning project, exploring
whether a virtual reality therapy (VRT) can reduce social avoidance for people who
experience psychosis, led by Oxford University. The project includes a year-long randomised
controlled trial of the gameChange intervention across five NHS trusts. Of 432 participants
recruited, half will receive their usual treatment and half will receive six sessions
of VRT through a headset guided by a virtual coach. The project also includes a focus
on the implementation and adoption of the VRT within the NHS, with involvement a key
priority. This poster reports on the implementation strand, led by MindTech in partnership
with The McPin Foundation, a mental health research charity.
Method:
Barriers and facilitators were identified and, along with the expertise of the project’s
Lived Experience Advisory Panel, iteratively informed meetings, workshops and visits
involving stakeholders (including staff and service users) in all participating trial
sites. The condition, technology, organisation and adopters as well as wider system
and value proposition were considered so as to facilitate implementation [1].
Results:
The research and design of the VRT was shaped through experiential and professional
expertise of the condition and the organisation; through geographical and organisational
knowledge accounting for appropriate recruitment and site variability. It also enabled
reflection of research practice through prioritisation of data collection methods
and analysis, strengthening relevance to real-life practice.
Conclusion:
The involvement of potential users from early in development can support not just
the intervention’s design but also its delivery and implementation. This enables even
new and untried digital health interventions to be designed, developed and delivered
in more contextually relevant ways. Consequently, these DHIs can be adopted more confidently
into healthcare services.
Thus, we conclude that relevance in practice can come from involvement in research.
Trial Registration: ISRCTN17308399
Reference
Greenhalgh T, Wherton J, Papoutsi C, Lynch J, Hughes G, Hinder S, Fahy N, Procter
R, Shaw S. Beyond adoption: a new framework for theorizing and evaluating nonadoption,
abandonment, and challenges to the scale-up, spread, and sustainability of health
and care technologies. Journal of medical Internet research. 2017;19(11):e367.
P15. Factors influencing implementation of two psychoeducational programmes for severe
hypoglycaemia in type 1 diabetes: analysis of the qualitative arm of the eeffectiveness-implementation
hybrid type 2 trial
Tayana Soukup1, Louise Hull1, Ioannis Bakolis1, Andy Healey1, Dulmini Kariyawasam2,
Augustin Brooks3, Simon Heller4, Stephanie Amiel5, Nick Sevdalis1, People with Diabetes
Group1
1Centre for Implementation Science, Health Service and Population Research Department,
King’s College London, United Kingdom; 2Diabetes Department, Guy’s and St Thomas’
NHS Foundation Trust, London, United Kingdom3 Diabetes Department, Royal Bournemouth
and Christchurch Hospitals NHS Foundation Trust, Dorset, United Kingdom; 4Diabetes
Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom;
5Diabetes Department, King’s College Hospital NHS Foundation Trust, London, United
Kingdom
Correspondence: Tayana Soukup (Tayana.soukup@kcl.ac.uk)
Background:
To facilitate scale-up of two psychoeducational programmes for people with type 1
diabetes and problematic hypoglycaemia, we have set out to build our understanding
of facilitators and barriers to their implementation post-trial.
Method:
This was an effectiveness-implementation hybrid type 2 trial (NCT02940873) taking
place between 2016 and 2021 across five hospitals in the UK and USA. It tested two
psychoeducational programmes for managing hypoglycaemia in diabetes.
Qualitative interviews were conducted with 50% of the programme participants (N=41),
all healthcare professionals involved in intervention delivery (N=28), and people
who declined to take part in the programmes (N=4).
NVivo 12 was used to analyse the interviews and interpret the responses inductively
and deductively using a thematic approach. Ethical approval was received and all research
participants provided written consent.
Results:
Four themes were identified from the interviews as important to consider for scale-up
of the two psychoeducational programmes:
Stakeholder buy-in, incl. both, healthcare professionals and patients, to ensure that
sufficient number of patients who would benefit the most from the programmes are identified
effectively, given that this is a niche patient group (10% of population with type
1 diabetes),
Adequate funding to ensure that hospitals in the UK are able to deliver the programmes,
and adequate insurance cover is available for the patients in the USA to receive the
programme,
Fidelity and quality assurance to ensure that the programmes are delivered as originally
intended providing most benefit to patients;
Adaptations necessary to increase reach so that more patients have access to the programmes,
including flexible mode of delivery, location of the courses, timing of the sessions,
and the intensity of the content.
Conclusion:
Tension was identified between (1) needing to ensure the fidelity and quality assurance
of the programmes post-trial, and (2) adaptations needed to increase reach.
O16. The role of stakeholder-engaged effectiveness-implementation hybrid designs in
health care research: methodological challenges and opportunities through the lens
of a case hybrid study
Tayana Soukup1, Louise Hull1, Ioannis Bakolis1, Andy Healey1, Dulmini Kariyawasam2,
Augustin Brooks3, Simon Heller4, Stephanie Amiel5, Nick Sevdalis1, People with Diabetes
Group1
1Centre for Implementation Science, Health Service and Population Research Department,
King’s College London, United Kingdom; 2Diabetes Department, Guy’s and St Thomas’
NHS Foundation Trust, London, United Kingdom; 3Diabetes Department, Royal Bournemouth
and Christchurch Hospitals NHS Foundation Trust, Dorset, United Kingdom; 4Diabetes
Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom;
5Diabetes Department, King’s College Hospital NHS Foundation Trust, London, United
Kingdom
Correspondence: Tayana Soukup (Tayana.soukup@kcl.ac.uk)
Background:
Through the lens of an effectiveness-implementation hybrid type 2 study (NCT02940873)
we describe how such multidimensional methodology can help form stakeholder-centred
interventions, care and practice. We also reflect on methodological challenges and
opportunities with stakeholder-engaged hybrids in the effort to help advance the emerging
field of these designs in health care research.
Method:
The case study tested two psychoeducational programmes in diabetes. It consisted of
effectiveness testing accompanied by the implementation assessments while shaped by
the stakeholder inputs - these have been parallel yet mutually interacting formative
processes.
The key intervention stakeholders for the hybrid were identified through the stakeholder
snowballing technique. The engagement with the identified stakeholders was structured
based on the principles reported in the literature, i.e., clear goals for engagement
and regular communication channels for continuous partnership building. In total 17
study meetings were conducted with overall 28 intervention stakeholders, including,
individuals with lived experience (n=6), and healthcare professionals (n=22).
Results:
The stakeholder input has enabled relevant, feasible, and appropriate implementation
outcomes, validated surveys, interview questions, participant groups, and measurement
time-points to be identified. We also identified key challenges and opportunities
of working within such complex research landscape, thus contributing to the scientific
understanding of stakeholder-engaged hybrid methods for evaluating and implementing
complex interventions within health care. These were as follows: (1) data richness,
(2) wide range of participant groups, and (3) pre- and post-intervention assessments.
Conclusion:
Stakeholder-led methodology and engagement is critical to ensuring relevance and feasibility
of the study design across different hospital settings and countries helping overcome
challenges. Such design involves systematic study planning and organisation based
on the principles for stakeholder engagement reported in the literature, and a thoughtful
assessment of outcomes utilising mixed methods across multi-participant groups and
sources.
P17. Using ‘Theory-of-Change’ methodology to design a scale-up strategy: Lessons from
the national implementation of a pragmatic Quality Improvement skills curriculum for
urologists
Zuhur Balayah1, Zarnie Khadjesari2, Aoife Keohane1, Wilson To3, James SA Green3, Nick
Sevdalis1
1Center for Implementation Science, Health Service & Population Research Department,
Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King’s College London,
London, UK; 2School of Health Sciences, University of East Anglia, Norwich, UK; 3Department
of Urology, Bart’s NHS Trust, Whipps Cross Hospital, London, UK
Correspondence: Zuhur Balayah (zuhur.balayah@kcl.ac.uk)
Background:
Engaging stakeholders in some form of ‘co-producing’ a scale-up strategy is often
included as a requirement of scale-up efforts. We report an application of stakeholder-driven
Theory-of-Change (ToC) methodology to design UK-wide scale-up strategy of an evidenced
quality improvement skills training programme for urologists. We narrate the ToC development
process; and map the ToC elements onto the Consolidated Framework for Implementation
Research (CFIR).
Method:
ToC methodology included: (i) multidisciplinary stakeholder input (i.e. urologist
consultants/trainees, patients, nurses, managers, medical education/improvement science
experts) and (ii) iterative-cycles of defining a consensual scale-up plan. Phase 1:
national needs assessment and reviews of QI education in surgery (2016-2018) informed
draft ToC; Phase 2: draft ToC was reviewed in a multidisciplinary workshop (N=10);
Phase 3: revised ToC was refined in semi-structured stakeholder interviews (N=6) and
in a final workshop (N=10). Phase 4: refined ToC received a final round of stakeholder
interviews (N=4). Data was analysed using the Framework Method.
Results:
The ToC (Figure 1) specifies assumptions, inputs and activities needed to achieve
scale-up, and their enablers. ToC components mapped well onto the CFIR domains: i)
identification of underlying assumptions elucidate intervention characteristics; ii)
implementation strategies listed under activities and associated outcomes link with
characteristics of individuals and process domains; iii) consensually generated enablers
(facilitators/barriers) indicate key features of inner and outer settings.
Conclusion:
ToC methodology facilitated effective engagement of stakeholders and identification
of a nationally implementable scale-up strategy; and allowed mapping of CFIR elements,
for subsequent scale-up. We conclude these are complementary approaches for scale-up
design.
Consent to publish
Not applicable
Fig. 1 (abstract P17).
Consolidated Logic Model of implementation plan for education in Quality Improvement
(QI) programme for urology residents in the UK, informed by evidence review and key
stakeholders’ input (including 3rd sector national representatives from the British
Association of Urological Surgeons, BAUS; the British Association of Urological Nurses,
BAUN; and The Urology Foundation). Concepts and strategies identified through the
application of the Theory-of-Change (ToC) were arranged in a Logic Model. The ToC
can be used as an ‘implementation blueprint’ to activate engagement from national
bodies to support implementation activities. Abbreviations: BJUI = British Journal
of Urology International; CQC = Care Quality Commission; GIRFT = Getting It Right
First Time; IJUN = International Journal Urological Nursing; ISCP = Intercollegiate
Surgical Curriculum Programme; JCU = Journal of Clinical Urology; JME = Journal of
Medical Education; JSE = Journal of Surgical Education; NHSE = National Service Health
England; NHSI = National Health Service Improvement; SAC = Specialist Advisory Committee
O18. Combining implementation research with implementation practice to translate evidence-based
interventions into routine care within complex adaptive systems: The Systems-informed
Participatory Action Implementation Research (SPAIR) approach
Hossai Gul1, Dr Janet Long1, Dr Stephani Best1,2, Prof. Frances Rapport1, Prof. Jeffrey
Braithwaite1
1Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia;
2Murdoch Children’s Research Institute, Melbourne, VIC, Australia
Correspondence: Hossai Gul (hossai.gul@mq.edu.au )
Background:
There is a clinical implementation gap in patient care between what is applied and
what we know works best. Changing this within a complex system is challenging. Studying
change from outside the system is even harder. This study aimed to develop an anchoring
framework seeking to bring implementation research and implementation practice together
for the benefit of translating new science into quality care at the coalface of change.
Method:
Phase 1: Examination of existing literature to understand how researchers outside
healthcare approached wicked problems such as poverty, domestic violence, AIDS prevention.
Methodological and epistemological aspects of approaches were noted and compared to
implementation science models, frameworks, and theories to assess the methodological
and epistemological grounding.
Phase 2: Development of a new framework for undertaking implementation research in
parallel with implementation practice to understand changes in complex adaptive systems.
Phase 3: Deployed the newly developed framework across 3 projects focused on the design
and implementation of genomic service delivery models.
Results:
The new framework - Systems-informed Participatory Action Implementation Research
(SPAIR) - combines Systems science, Participatory Action Research (PAR), and Implementation
science models, frameworks, and theories (Figure 1). Preliminary results using the
SPAIR approach: 1) flexible to deploy using implementation frameworks, 2) direct,
real-time positive impact on implementation efforts, 3) builds implementation science
skills and capacity within organisations, and 4) directly promotes implementation
science and practice.
Conclusion:
SPAIR can be deployed as the underlying template for leading implementation research
and practice within complex adaptive systems.
Fig. 1 (abstract O18).
SPAIR framework
P19. Understanding the intervention co-design process for perioperative antibiotic
use at tertiary care hospital in Southern part of India: a two phased qualitative
study
Shalini Ahuja1¥, Gregory Godwin2¥, Gabriel Birgand3, Andrew Leather2, Sanjeev Singh4,
Pranav V4, Nathan Peiffer-Smadja3, Esmita Charani3, Alison Holmes3, Nick Sevdalis1,
on behalf of co-investigators of ASPIRES
1Centre for Implementation Science, Health Services and Population Research Department,
King’s College London, UK; 2 Faculty of Life Sciences and Medicine, King’s College
London, UK; 3Faculty of Medicine, Department of Infectious Disease, Imperial College
London, UK; 4AMRITA Hospital, Kerala, India
Correspondence: Shalini Ahuja (shalini.ahuja@kcl.ac.uk)
¥
Joint first authors
Background:
Increased antibiotic consumption, linked to antimicrobial resistance and health care
associated infections, is a major health issue in low- and middle income countries
[1]. Antimicrobial stewardship is a crucial intervention to improve antibiotic usage
throughout the surgical pathway and decrease surgical site infection. The aim of this
study is to understand the co-design process of selecting interventions and implementation
strategies, and to identify barriers and facilitators to the delivery of interventions
targeting infection prevention and control (IPC) and antibiotic use perioperatively.
Method:
A two-phased qualitative study was undertaken. Phase 1: in depth interviews (n=10)
were conducted to understand the context and to identify potential interventions and
strategies. Phase 2: theory of change consultative workshops (n=2) explored barriers
and facilitators in the implementation of the interventions [2]. Data were analysed
using framework thematic analysis and thematic synthesis principles.
Results:
Overburdened health workforce along with cultural and professional hierarchies were
amongst the various factors identified, exacerbated by organisational factors including
lack of resources and ineffective information relay systems. In comparison, existing
antimicrobial stewardship (AMS) programme and department specific IPC protocols within
the hospital were critical facilitators. Potential implementation strategies were
selected: cascade feedback to health workers on infection rates; emphasise AMS and
IPC protocols through additional on the job trainings; ensure communication consistency
amongst IPC and AMS teams.
Conclusion:
Context specific barriers and facilitators can inform implementation practice to reduce
inappropriate antibiotic use. Future intervention design studies can consider three
policy implications strategies which emerged from our analysis and experience: enhancing
consultations during the intervention design, better consideration of implementation
challenges during design, and better recognition of co-ordinating mechanisms between
different departments.
References
1. Charani, E., de Barra, E., Rawson, T. M., Gill, D., Gilchrist, M., Naylor, N. R.,
& Holmes, A. H. (2019). Antibiotic prescribing in general medical and surgical specialties:
a prospective cohort study. Antimicrob Resist Infect Control, 8, 151.
2. Breuer E, Lee L, De Silva M, Lund C. Using theory of change to design and evaluate
public health interventions: a systematic review. Implement Sci. 2016;11:63.
O20. Use of feedback data to reduce surgical site infections and optimise antibiotic
use in surgery: a systematic scoping review
Shalini Ahuja1, Nathan Peiffer-Smadja3, Kimberly Peven2, Michelle White2, Sanjeev
Singh4, Marc Mendelson5, Alison Holmes3, Andrew Leather2, Gabriel Birgand3, and Nick
Sevdalis1, ASPIRES study coinvestigators
1Centre for Implementation Science, Health Services and Population Research Department,
King’s College London, UK; 2Faculty of Life Sciences and Medicine, King’s College
London, UK; 3Faculty of Medicine, Department of Infectious Disease, Imperial College
London, UK; 4AMRITA Hospital, Kerala, India; 5Division of Infectious Diseases & HIV
Medicine at Groote Schuur Hospital, University of Cape Town (UCT), South Africa
Correspondence: Shalini Ahuja (shalini.ahuja@kcl.ac.uk)
Background:
Surgical site infection (SSI) prevention is a major issue, particularly in the era
of antimicrobial resistance. Reducing SSI rates will require, among other priorities,
optimisation of antibiotic usage which may be enhanced by feedback [1]. Within the
area of surgery, it remains unclear how feedback can best be used to reduce SSIs and
improve antibiotic usage. Therefore, this study aims to understand how data from surveillance
and audit are utilised in routine surgical practice.
Method:
A systematic scoping review was conducted. Two electronic health-oriented databases
and the bibliographies of relevant articles were searched. We included studies that
assessed the use of feedback as a strategy either in the prevention and management
of SSI and/or in the use of antibiotics perioperatively. The results of included studies
were synthesised using a narrative synthesis approach underpinning thematic analysis
principles. Implementation strategies were grouped into 73 discrete strategies as
suggested by the ERIC implementation science research group [2]. The quality of the
individual studies was assessed using Integrated Quality Criteria for Systematic Review
of Multiple Study Designs.
Results:
We identified 21 studies: 17 focused on SSI outcomes and 8 described antibiotic usage
in surgery in relation to SSI. These 21 studies described several interventions, mostly
multimodal with feedback as a component. Among studies reporting antibiotic usage
in surgery most (71%,) discussed compliance with surgical antibiotic prophylaxis.
Fifty-five percent of the studies on SSI outcomes reported significant reduction in
infection rates. Feedback was often provided in written format (62%), either individualised
(38%) or in group (48%). In 65% of the studies, between one and five of 73 ERIC implementation
strategies were used while only one study reported using more than 15 implementation
strategies.
Conclusion:
Our study summarises the efficacy of auditing and surveillance outputs by analysing
implementation strategies and highlights the need for feedback to all levels of health
care professionals involved in perioperative care of surgical patients.
References
1. Biccard, B. M., Madiba, T. E., Kluyts, H.-L., Munlemvo, D. M., Madzimbamuto, F.
D., Basenero, A., . . . Zubia, N. Z. (2018). Perioperative patient outcomes in the
African Surgical Outcomes Study: a 7-day prospective observational cohort study. The
Lancet, 391(10130), 1589-1598. doi:10.1016/s0140-6736(18)30001-1
2. Powell, B. J., Waltz, T. J., Chinman, M. J., Damschroder, L. J., Smith, J. L.,
Matthieu, M. M., . . . Kirchner, J. E. (2015). A refined compilation of implementation
strategies: results from the Expert Recommendations for Implementing Change (ERIC)
project. Implement Sci, 10, 21. doi:10.1186/s13012-015-0209-1
O21. Deliberation before implementation: Co-designing and co-producing effective relationships
in youth justice settings
Jackie Dwane, Dr. Sean Redmond, Eoin O’Meara Daly, Caitlin Lewis
Research Evidence into Policy, Programme and Practice (REPPP), School of Law, University
of Limerick, Limerick, Ireland
Correspondence: Jackie Dwane (Jacqueline.dwane@ul.ie)
Background:
There are 105 youth diversion projects across Ireland targeting young people in trouble
with the law. It is estimated that 60 percent of professionals’ time spent in these
projects relates to building professional relationships with young people. This relationship
effort accounts for approximately €8 million taxpayer’s investment each year. The
objective of the relationship is to motivate young people towards pro-social trajectories.
However, the practice is largely uncodified or sufficiently described in terms of
highlighting and incentivising approaches which are informed by the available evidence.
Method:
An Action Research Project (ARP) on behalf of the Department of Justice and Equality
is underway to identify the most potent mechanisms within the best relationships.
The study involves 16 projects. Initially a Systematic Evidence Review of high quality
youth programmes examined underlying relationship ‘mechanisms’. The project then involved
academics and practitioners co-designing new evidence informed guidance on relationship-building
to improve the effectiveness of everyday practice. An implementation study will complement
a realist evaluation of the ARP. The researchers are routinely collecting data through
a series of reflective conversations with practitioners over several months to track
the experiences of each project implementing the new guidance, time stamped to document
key internal and external events. Focused workshops with the wider teams will further
interrogate this experience. The researchers are using the Proctor implementation
outcomes framework [1] to shape their analysis of the data collected from across the
16 projects.
Results:
The implementation study charts the projects’ experience of co-design and transforming
guidance into practice. Projects have responded to phase one of the co-design process
with enthusiasm and we can report initial ‘buy-in’ and motivation is high.
Conclusion:
This presentation will outline the implementation study so far in terms of the methodological
design, interim implementation findings, next steps and our reflections on a complex
co-design process.
Acknowledgements
This study is presented on behalf of Research Evidence into Policy, Programme and
Practice (REPPP). The Action Research Project is funded and supported by the Department
of Justice and Equality. Special thank you goes to the participating Garda Youth Diversion
Projects and the Department of Justice and Equality.
Reference
1. Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes
for implementation research: conceptual distinctions, measurement challenges, and
research agenda. Adm Policy Ment Health. 2011 Mar;38(2):65–76.
O22. Accelerating the implementation of evidence: Core competencies for implementation
practice
Julia E. Moore and Sobia Khan*
The Center for Implementation, Toronto, Ontario, Canada
Correspondence: Sobia Khan (Sobia.Khan@thecenterforimplementation.com)
Background:
While the field of implementation science has advanced in recent years, this has coincided
with a growing divide between the science and practice of implementation. One strategy
to bridge this gap is training implementation practitioners to apply implementation
science to their initiatives in a thoughtful and proactive way. Effective implementation
capacity building should be based on core competencies - the knowledge, skills, attitudes,
and behaviours needed to apply implementation science. There is a growing body of
literature on core competencies for implementation scientists, but the same progress
has not been made for core competencies for implementation practitioners. Building
applied implementation science capacity at the practitioner level can foster better
implementation and overall improved population-level impacts; therefore, understanding
the core competencies for applying implementation science at the front line is paramount.
The goal of this project was to extrapolate and synthesize core competencies for implementation
practitioners.
Method:
We scanned the published and grey literature to identify core competencies for implementation
practice. Six documents outlining (or including components of) core competencies for
implementation practice were retrieved. Two analysts reviewed each document using
a content analysis approach. Competencies relevant to implementation practice were
extracted into an abstraction form and consolidated into a list of common competencies.
The refined list of competencies was then grouped thematically into overarching implementation
“activities” (e.g., understanding the problem, facilitating implementation).
Results:
We identified 37 core competencies which we categorized into 10 implementation activities:
Inspiring Stakeholders and Developing Relationships; Building Implementation Teams;
Understanding the Problem; Using Evidence to Inform all Aspects of KT; Assessing the
Context; Facilitating Implementation; Evaluation; Planning for Sustainability; Brokering
Knowledge; and Disseminating Evidence. Additionally, we identified 5 values or guiding
principles for implementation practice, which emerged from the document review.
Conclusion:
The competencies can be used as a guide to prioritize capacity building efforts.
Acknowledgements
Support and funding from Health Canada for this project.
P23. Pathways to practice change: How to use implementation science theories, models,
and frameworks
Julia E. Moore and Sobia Khan
The Center for Implementation, Toronto, Ontario, Canada
Correspondence: Julia E. Moore (Julia.moore@thecenterforimplementation.com)
Background:
There is recent acknowledgement of a growing divide between implementation science
and practice. Unfortunately, applying implementation science in practice can be challenging
because implementation scientists have not emphasized how models, theories, and frameworks
can be applied. Given that implementation science is an applied science, describing
and understanding its real-world applications is critical in order to implement evidence-based
interventions and achieve outcomes.
Method:
Based on a synthesis of the literature, we developed and administered an approach
to train practitioners to apply implementation science to practice.
Results:
Step 1
. Select a process model. Implementation efforts should first be guided by a process
model that describes the actionable steps required to close the evidence-to-practice
gap.
Step 2
. Select a theory of change. At its core, implementation science is about creating
individual, organizational, and/or systems change. Therefore, implementation efforts
require a theory of change of each level of change (individual, team, organization,
community, system). Theories are typically applied during program development stages
of implementation process models, where barriers and facilitators to change are assessed
and behavior change strategies are selected that are linked to specific change theories.
Step 3
. Select frameworks that align with the objectives of each process model stage. There
are over 150 frameworks used in implementation science; therefore, it can be challenging
to select an appropriate framework. Most implementation efforts require the use of
multiple frameworks, for example a framework to consider individual barriers and facilitators
to change, contextual factors, roles in implementation, and implementation outcomes.
Conclusion:
This approach to practice implementation provides a roadmap for how to understand
and organize the implementation science MTFs in a practical and applied manner. What
makes this approach unique is the way that these distinct elements from implementation
science, which are inherently interconnected, are linked and woven together to build
a practical bridge from research to practice.
P24. From Research to Routine Practice: National Scale Up of a vital signs triage
device into routine maternity care in Sierra Leone
Alexandra Ridout1, Venetia Goodhart2, Sophie Bright2, Sattu Issa3, Betty Sam2, Jane
Sandall1, Andrew Shennan1
1King’s College London, SE1 7EH, United Kingdom; 2Welbodi Partnership, Freetown, Sierra
Leone; 3Ministry of Health and Sanitation, Freetown, Sierra Leone
Correspondence: Alexandra Ridout (Alexandra.ridout@kcl.ac.uk)
Background:
In Sierra Leone (SL) 1 in 17 women die during pregnancy. The majority of deaths are
preventable, detectable by abnormalities in blood pressure and heart rate (vital signs).
The CRADLE vital signs monitor is accurate and affordable, incorporating a traffic-light
early warning system and shock index calculator.
A hybrid effectiveness-implementation RCT demonstrated that the CRADLE device and
training significantly reduced maternal death and eclampsia in SL. Working with the
Ministry of Health and Sanitation (MOHS), funded by DfID, we are implementing a national
scale-up built on locally piloted strategies.
Methods:
The “Theory of Readiness for Change” and “IHI Framework for Going to Full Scale” guided
scale-up of this complex intervention. Support systems and adoption mechanisms were
continuously iterated. We recorded acceptability, fidelity, adoption and reach alongside
policy and practice implications.
Results:
MoHS, WHO and UNICEF provided political and organisational leadership alongside key
stakeholders at the national launch in January2020. To date 402 MoHS and 23 NGO staff
from two districts have been trained. This Test of Scale has refined the implementation
package across a range of healthcare settings. MoHS have built ownership and sustainability
by integrating the programme into SL’s EmONC and Midwifery Schools’ Curricula. The
project has benefitted from local redesign, guided by a national working group. The
training schedule and device distribution plan have been adapted to align with district
health meetings. Whatsapp groups have improved timely data collection and beneficiary
feedback.
Conclusion:
During this Test of Scale we have built a learning system, rolling out 280 CRADLE
devices across 139 healthcare facilities and training 402 MoHS healthcare providers. The
refined full scale is expected to reach 2500 healthcare providers and >750,000 pregnant
women in the first year, strengthening the health system capacity, reducing maternal
mortality and promoting rollout of the CRADLE package in other countries.
Trial Registration: The original CRADLE 3 trial is registered with the ISRCTN registry,
number ISRCTN41244132.
O25. Determinants of keeping the link with Primary Care in a medium-sized city in
Brazil
Carlos Alberto dos Santos Treichel1,2, Ioannis Bakolis2, Rosana Teresa Onocko Campos1
1Department of Collective Health, University of Campinas, Campinas-SP, BR; 2Department
of Biostatistics and Health Informatics & Health Services and Population Research
Department, Centre for Implementation Science, Institute of Psychiatry, Psychology
and Neuroscience, Kings College London, London, UK
Correspondence: Carlos Alberto dos Santos Treichel (treichelcarlos@gmail.com )
Background
This study is part of a research that aims to implement devices to integrate the Mental
Health Care Network (MHCN) in medium-sized city in Brazil. In order to better inform
the implementation process, this study sought to make an evaluative diagnosis about
the functioning of the MHCN based on the potential factors of keeping the link with
Primary Care (PC) after being on a Specialized Mental Health Care Service (SMHCS).
Method
This was a cross-sectional study, conducted with 341 users from SMHCS, between August
and November 2019. Crude and adjusted associations between keeping the link with PC
after being refereed on a SMHCS and a number of socio-demographic and health care
service indicators were explored with the use of Poisson regression models with robust
variance estimators.
Results
There were strong evidence of a positive association between keeping a link with primary
care and have been referred to the current service by the PC (RR: 1.38; 95% CI: 1.06,
1.79); private sector services (RR: 1.66; 95% CI: 1.19, 2.32), being refereed from
Community Health Agents (RR: 1.26; 95% CI: 1.04, 1.53). It was less likely to keep
the link if you were male (RR: 0.82; 95% CI: 0.67, 0.99), employed (RR: 0.78; 95%
CI: 0.60, 1.00), had a diagnosis of psychosis (RR: 0.69; 95% CI: 0.52, 0.91) or substance
abuse (RR: 0.57; 95% CI: 0.41, 0.80) and better social support (RR: 0.73; 95% CI:
0.58, 0.91).
Conclusion
While there is a gap regarding keeping the link with PC among users diagnosed with
psychosis and substance abuse, the action of the PC in the referral of cases and follow-up
through the visit of Community Health Agents proved to be a strategy that should be
encouraged in order to promote the keeping of the link with PC among users of the
MHCN.
Acknowledgements
This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de
Nível Superior - Brasil (CAPES) - Finance Code 001. The research that originated this
study was funded by the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP),
process nº 2018/10366-6.
P26. Evaluation of Project Echo: Palliative care education for nurses in long term
care facilities
Alice Coffey1, Helen Flanagan2, Martina O’Reilly2, Valerie O’Reilly2, Pauline Meskell1,
Maria Bailey1, Eileen Carey1, Jane O’Doherty1, Cathy Payne3, Karen Charnley3
1Department of Nursing and Midwifery, University of Limerick, Limerick, Ireland; 2Milford
Care Centre, Limerick, Ireland; 3All-Ireland Institute of Hospice and Palliative Care,
Dublin, Ireland
Correspondence: Jane O’Doherty (Jane.ODoherty@ul.ie)
Background:
Project ECHO is a pioneering tele-mentoring programme, which was developed in the
School of Medicine at the University of New Mexico. It uses technology and existing
resources to magnify the capacities of the health care workforce, building a bridge
across healthcare settings, and providing healthcare without barriers. The model was
shown to be an effective way of addressing the knowledge gap among healthcare professionals.
The aim of this study was to evaluate the impact of Phase 3 of Project ECHO.
Methods:
A mixed method approach underpinned by the RE-AIM framework (Reach, Effectiveness,
Adoption, Implementation and Maintenance) [1]. Data were collected from participating
sites on resident referral, evaluation of educational sessions and focus groups with
ECHO participants.
Results:
Reach:15 nursing homes were invited to take part and 12 participated. Efficacy: Data
from the ECHO session evaluations and focus groups showed a positive impact on participants,
particularly from the shared learning experiences but areas for future learning were
identified. Adoption: Staff reported knowledge improvement and the translation into
changes in practice. Implementation: Data on resident referral to acute care during
the ECHO project shows that 50% were referred by nursing home staff.
Conclusions:
Recommendations for maintenance of positive outcomes include strategies to improve
staff participation and encourage General Practitioner involvement in the programme.
Acknowledgements
The authors wish to thank the Health Service Executive (HSE) who commissioned this
work for use by All-Ireland Institute of Hospice and Palliative Care (AIIHPC). Thanks
to all nursing home staff, nursing home managers, education providers and specialist
palliative care team members who have taken part in this research.
Reference
Green LW, Glasgow R. Evaluating the Relevance, Generalization, and Applicability Of
Research. Eval Health Prof. 2006; 29:(1), 126-153.
O27. Furthering implementation science in HIV research through coordination of, consultation
with, and collaboration among 65 projects to end the HIV epidemic in the US
Dennis H Li1,2,3,4, Nanette Benbow1,2,3, JD Smith1,2,3,5,6, Juan Villamar1,2, Brennan
Keiser4, Melissa Mongrella4, Thomas Remble2,4,5, Brian Mustanski1,2,3,4,5
1Department of Psychiatry and Behavioral Sciences, Northwestern University, Chicago,
IL, USA; 2Center for Prevention Implementation Methodology, Northwestern University,
Chicago, IL, USA; 3Third Coast Center for AIDS Research, Chicago, IL, USA; 4Institute
for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago,
IL, USA; 5Department of Medical Social Sciences, Northwestern University, Chicago,
IL, USA; 6Department of Preventive Medicine, Northwestern University, Chicago, IL,
USA
Correspondence: Dennis H Li (dennis@northwestern.edu )
Background:
The first year of the USA’s Ending the HIV Epidemic (EHE) strategy funded 65 planning
projects in 46 high-priority jurisdictions to begin studying implementation of evidence-based
HIV interventions in local healthcare and public health systems. To maximize the value
of implementation science (IS) in these projects, we established the Implementation
Science Coordination, Consultation, and Collaboration Initiative (ISC3I) with two
goals: (1) support high-quality IS through expert technical assistance and (2) create
opportunities to develop generalizable knowledge from local knowledge through cross-project
information sharing, measure harmonization, and data synthesis. This presentation
describes the first year of this innovative approach to coordinating HIV implementation
research nationally.
Methods:
To launch ISC3I, we invited project leads, their primary implementation partners,
and federal health agencies to a two-day summit that focused on applying IS concepts
to HIV contexts, facilitated researchers and partners’ co-development of an implementation
research logic model, and fostered cross-project dialogue. We created an online community
of practice (COP) as a clearinghouse for IS resources and ISC3I training and collaboration
activities (e.g., webinars, expert coaching, videoconference discussions). We also
established infrastructure to collect data from the projects, which we are using to
inform coordinated IS measures and constructs to put forth for recommended use across
future EHE-related projects.
Results:
Because most project leads had limited prior IS training or experience, and most projects
are in the formative stage, ongoing coordination challenges include differentiating
interventions from implementation strategies and identifying appropriate implementation
outcomes. However, many teams have engaged with ISC3I activities and reported them
to be helpful. Additional lessons learned will be discussed.
Conclusions:
ISC3I represents an unprecedented opportunity to expand IS capacity and develop generalizable
knowledge for HIV prevention and treatment in the US. We aim to further codify our
measure harmonization efforts as we move into the next year of EHE.
P28. Implementer and researcher perspectives on sustaining, spreading and scaling
up, quality improvement interventions
Celia Laur1, Ann Marie Corrado1, Jeremy Grimshaw2, Noah Ivers1
1Women’s College Hospital, Toronto, Ontario, M5S 1B2, Canada; 2Ottawa Hospital Research
Institute, Ottawa, Ontario, K1Y 4E9, Canada
Correspondence: Celia Laur (Celia.Laur@wchospital.ca)
Background:
Quality Improvement (QI) programs rarely consider how their intervention can be sustained
long-term. Failing to adequately consider sustainability contributes to research waste
and has the potential to make patient outcomes worse, if patients relied upon the
QI program to improve quality of care. A survey of authors of randomized trials of
diabetes QI interventions included in an ongoing systematic review found that 78%
of trials reported improved quality of care, but 40% of these trials were not sustained
following study completion. This study further explores why and how the effective
interventions were sustained, spread or scaled.
Method:
This study features telephone interviews with those who have implemented diabetes
QI intervention studies between 2004-2014 included in a systematic review, completed
the sustainability survey, and agreed to further contact. Two team members independently
used inductive coding to identify key themes, with case examples used to show trajectories
across projects and people.
Results:
Eleven trial authors (n=9 male; 13 studies) participated. 12/13 studies featured interventions
that were deemed “effective” in the survey; 5/13 reported that the intervention was
“sustained”. Four interacting themes were identified: understanding the concepts of
implementation, sustainability, sustainment, spread and scale; knowing the roles of
the people involved; having the appropriate competencies; and that individual and
organisational capacity is needed. Participant stories highlight the varied trajectories
of projects and people, such as the participant who led an effective intervention,
however left academia in order to implement it at scale.
Conclusion:
Researchers need to think beyond effectiveness and consider if an intervention is
also feasible and sustainable, with potential for spread or scalability. Lessons learned
highlight the potential for collaborating with experts outside of health, such as
those with expertise in business and organizational management.
P29. Application of the Pragmatic-Explanatory Continuum Indicator Summary tool (PRECIS-2)
to two delivery strategies of an eHealth HIV prevention intervention in a hybrid comparative
implementation trial
N. Benbow1, K. Macapagal2, J. Jones2, K. Madkins2, J.D. Smith1, D. H. Li1, B. Mustanski2
1Northwestern University Feinberg School of Medicine, Department of Psychiatry and
Behavioral Sciences, Chicago, IL 60611, United States; 2Northwestern University Feinberg
School of Medicine, Medical Social Sciences, Chicago, IL 60611, United States
Correspondence: N. Benbow (Nanette@northwestern.edu)
Background:
There is still much to understand about scaling-up eHealth HIV prevention interventions.
Implementation research can help bridge the research-to-practice gap, but study conditions
must emulate real-world delivery contexts and procedures to maximize knowledge gained.
In the context of a randomized comparative implementation trial, we evaluated the
pragmatism of two delivery approaches for an evidence-based eHealth HIV prevention
intervention for young men who have sex with men.
Method:
Keep It Up! is an effectiveness-implementation type III hybrid cluster RCT comparing
two strategies designed to resemble real-world implementation: direct-to consumer
(DTC) vs. delivery through community-based organizations (CBO). Using the Pragmatic-Explanatory
Continuum Indicator Summary tool (PRECIS-2) [1], we compared the strategies on nine
domains, each scored on a continuum (1=very explanatory to 5=very pragmatic). Three
coders per arm ranked and provided rationale for each domain and discussed differences
to arrive at consensus ranking. Results were reviewed with three additional coders
to ensure coding standardization across arms.
Results:
Both arms ranked as rather or very pragmatic on most domains. They had equal scores
on seven of nine domains: eligibility, recruitment, flexibility of intervention in
delivery and adherence, follow-up, primary outcome, and primary analysis. CBO delivery
scored lower than DTC on the setting domain due to lower-than-realistic funding for
CBO implementation. DTC delivery scored lower than CBO on the organization domain
based on staff’s expertise and resources delivering DTC that may not be matched under
usual conditions. Interpretation of some PRECIS-2 domains varied between arms, where
DTC focused on individual users of the intervention and CBO focused on implementers.
Conclusion:
Application of the PRECIS-2 helped validate our pragmatic study design and increased
our confidence that both arms highly resembled real-world implementation procedures.
This is one of the few applications of PRECIS-2 to an implementation trial and highlights
the need for minor modifications to the tool for this purpose.
Reference
1. Loudon K, Treweek S, Sullivan F, Donnan P, Thorpe K, Zwarenstein M. The PRECIS-2
tool: designing trials that are fit for purpose. BMJ 2015;350:h2147
O30. Implementation science in marginalised poorly resourced communities: a case study
using the Nurture Early for Optimal Nutrition (NEON) intervention to improve infant
feeding, care and dental hygiene practices in South Asian infants aged < 2 years in
East London
Dr Logan Manikam1,2, Shereen Allaham1,2, Dr Michelle Heys3, Dr Clare Llewellyn4, Dr
Neha Batura5, Prof Andrew Hayward1, Yasmin Bou Karim2,3, Jenny Gilmour6, Kelley Webb-Martin7,
Carol Irish7, Chanel Edwards7, Prof Monica Lakhanpaul3,8
1Department of Epidemiology and Public Health, UCL Institute of Epidemiology and Health
Care (IEHC), London, UK; 2Aceso Global Health Consultants Ltd, London, UK; 3 Population
Policy and Practice (PPP), UCL Great Ormond Street Institute of Child Health (GOS-ICH),
London, UK; 4Department of Behavioural Sciences & Health, UCL IEHC, London, UK; 5UCL
Institute for Global Health, London, UK; 6Tower Hamlets GP Care Group, Mile End Hospital,
London, UK; 7Children’s Health 0-19 Service, Newham Council, London, UK; 8 Whittington
Health NHS Trust, London, UK
Correspondence: Logan Manikam (logan.manikam.10@ucl.ac.uk)
Background:
The first 1,000 days of a child’s life are an important period for growth and cognitive
development. Exposures during pregnancy and infancy may alter lifetime risk of overall
development and dental health [1]. The Participatory Learning and Action (PLA) is
a low-cost bottom-up approach that mobilises communities to identify, prioritise,
implement, and evaluate their needs and solutions through culturally-sensitive group
discussions [2]. Recognising PLA has been successful in LMICs and the importance of
community engagement, the NEON study aimed at improving infant feeding, care, and
dental hygiene practices of South Asians (SA) in two deprived East London boroughs
(Tower Hamlets & Newham) by reverse innovating the WHO-recommended PLA approach from
LMICs.
Method:
Our approach was developed through a series of workshops with community and local
stakeholders facilitated by experts in PLA. Adaptation is supported by multilingual
community facilitators (CFs) and the local health and social care systems. We are
currently co-developing the PLA intervention toolkit consisted of; (i) PLA group facilitator
manual, (ii) picture cards, (iii) healthy food recipes & (iv) community asset map
by undertaking monthly development meetings with SA CFs (n=10) and refinement workshops
with a larger audience of SA residents (n=50). Initially done face-to-face, we are
now utilising blended-approach of online meetings due to COVID-19.
Results:
The PLA approach was highly acceptable to participants. However, the feasibility of
undertaking 12-session PLA cycle was questioned. We have since adapted the model to
shorter cycles (7&6 session). Strong community ownership presented with CFs engaged
in developing culturally-tailored PLA intervention content including a digitally shareable
asset map consisting of local resources and services.
Conclusion:
NEON is an exemplar of how to adapt tailored culturally-sensitive community-based
intervention from LMICs to urban high-income setting. The PLA is an acceptable and
feasible approach to address public health issues in marginalised poorly-resourced
and ethnically-diverse community.
References
1. Aris IM, Bernard JY, Chen LW, Tint MT, Pang WW, Soh S-E, et al. Modifiable risk
factors in the first 1000 days for subsequent risk of childhood overweight in an Asian
cohort: significance of parental overweight status. International Journal of Obesity.
2018;42(1):44.
2. Freire P. Education for critical consciousness: Bloomsbury Publishing; 1973.
O31. Pragmatic parallel mixed methods investigation into implementation of home-based
cardiac rehabilitation for heart failure patients: methodological discussion
Paulina Daw 1, Dr Jet Veldhuijzen van Zanten1, Alexander Harrison2, Dr Hasnain Dalal
3,4, Prof Rod S Taylor 5,3, Prof Patrick J Doherty 2 , Dr Sinead TJ McDonagh3, Prof
Colin J Greaves1
1School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, UK;
2Health Sciences, University of York, UK; 3University of Exeter Medical School, Exeter,
UK; 4Royal Cornwall Hospitals NHS Trust, Cornwall, UK; 5MRC/CSO Social and Public
Health Sciences Unit & Robertson Centre for Biostatistics, Institute of Health and
Well Being, University of Glasgow, Glasgow, UK
Correspondence: Paulina Daw (pxd891@student.bham.ac.uk)
Background:
Low uptake of cardiac rehabilitation (CR) is a global problem, particularly for heart
failure patients (HFPs), who are often older and more frail than other cardiac patients.
Offering alternative forms of CR (e.g. home-based programmes) might improve uptake.
This is especially relevant in the current COVID-19 pandemic where HFPs are asked
to self-isolate.
Rehabilitation Enablement in Chronic Heart Failure (REACH-HF) is a home- and evidence-based
CR programme for HFPs. The effectiveness of REACH-HF has been established in two clinical
trials.[1,2] Subsequently, four NHS Beacon Sites are delivering REACH-HF to 200 patients
in England and Northern Ireland.
Method:
A multi-method study, conducted in five phases (two completed and three ongoing),
to evaluate the implementation of REACH-HF. The Normalisation Process Theory will
be used as a framework to inform data collection/analysis.[3]
1. A systematic review identified professional and system-level factors affecting
the delivery of CR for HFPs.
2. Qualitative in-depth interviews and focus groups with key healthcare professionals
(HCPs). Thematic analysis of qualitative data informed a pragmatic REACH-HF implementation
manual for HCPs.
3. Participatory action research: feedback from key stakeholders will lead to refinement
of the implementation manual. This will be further piloted in an implementation study
in Scotland.
4. Implementation fidelity will be assessed by coding audio recordings of treatments
using the existing REACH-HF fidelity checklist. Scores will be compared to fidelity
achieved in the clinical trial.
5. Audit: pre-post treatment outcomes will be analysed using data from the National
Audit of Cardiac Rehabilitation. Real-world patient outcomes will be compared to outcomes
achieved in the clinical trial.
Results:
Summary data will be presented from the systematic review and qualitative elements
of the study, along with a discussion of the planned synthesis of data from all five
phases using meta-ethnography.[4]
Conclusion:
When completed, this study will identify ways to improve the CR provision for HFPs.
Acknowledgements
REACH-HF Beacon Sites Steering Group
References
1. Dalal H., Taylor R., Jolly K., et al. The effects and costs of home-based rehabilitation
for heart failure with reduced ejection fraction: The REACH-HF multicentre randomized
controlled trial. Eur J Prev Cardiol. 2018;27:3.
2. Lang C., Smith K., Wingham J., et al. A randomised controlled trial of a facilitated
home-based rehabilitation intervention in patients with heart failure with preserved
ejection fraction and their caregivers: the REACH-HFpEF Pilot Study. BMJ Open. 2018;8:4.
3. May C., Mair F., Finch T., et al. Development of a theory of implementation and
integration: Normalization Process Theory. Implement. Sci. 2009;4:29 (2009)
4. Noblit G., Hare R. Meta-ethnography: synthesizing qualitative studies. Volume 11.
California: Sage Publications;1988.
O32. Return on investment analysis of nationwide implementation of the WHO Surgical
Safety Checklist in Madagascar, Benin and Cameroon
Michelle C White1,2,3, Andrew JM Leather1, Nick Sevdalis4, Andy Healey4,5
1Centre for Global Health and Health Partnerships, King’s College London, London,
SE5 9RJ, United Kingdom; 2Great Ormond Street Hospital for Children, London, WC1N
3JH, United Kingdom; 3Mercy Ships UK, The Lighthouse, Stevenage, SG1 2EF, United Kingdom;
4Centre for Implementation Science, Health Service and Population Research Department,
Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London,
SE5 8AB, United Kingdom; 5King’s Health Economics, Health Service and Population Research
Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London,
London, SE5 8AB, United Kingdom
Correspondence: Michelle C White (doctormcw@gmail.com)
Background:
Limited resources in Low and Middle-Income Countries (LMICs) mean health interventions
must compete against other projects for political priority. Policy-makers make decisions
using subjective and objective criteria [1]. The World Health Organisation (WHO) Surgical
Safety Checklist reduces surgical mortality and morbidity [2] but its economic impact
is unknown. We undertook a return-on-investment (ROI) analysis of checklist scale-up
in Madagascar, Benin and Cameroon.
Method:
The ROI analysis used two approaches: cost-effectiveness analysis (CEA) and benefit-cost
analysis, (BCA). We estimated the years of life lost (YLL) due to post-operative mortality
that would be averted through checklist use, and then using total project costs we
estimated incremental cost-effectiveness ratios (ICER) for each country. We estimated
benefit-cost ratios (BCR) using the value of a statistical life-year approach. All
monetary values are expressed in US$ using World Bank purchasing power parity and
discounted at 4%.
Results:
The ICERs are $62, $16 and $74 per YLL averted, and the BCRs are 17, 120 and 55 for
Madagascar, Benin and Cameroon, respectively. The BCRs mean that for every $1 USD
spent, the potential return is $17 – 120. Following WHO criteria [3] checklist scale
up is ‘very cost-effective’; using more stringent criteria, it ranks within the top
33 cost-effective interventions in LMICs (see Table 1) [4].
Conclusion:
Checklist scale-up is very cost-effective and gives a good ROI. This research offers
policy-makers evidence to help make checklist implementation a national priority.
Our methodology offers a ‘blueprint’ for including implementation costs in health
economic evaluations of other safety and quality improvement interventions.
Acknowledgements
The authors wish to thank Mercy Ships for undertaking the WHO checklist implementation
and providing a detailed breakdown of implementation costs.
References
1. Shiffman J, Smith S Generation of political priority for global health initiatives:
a framework and case study of maternal mortality Lancet 2007: 370; 1370-1379
2. Bergs J, Hellings J, Cleemput I, et al. Systematic review and meta-analysis of
the effect of the World Health Organization surgical safety checklist on postoperative
complications Br J Surg 2014: 101; 150-158
3. WHO-CHOICE: CHoosing Interventions that are Cost–Effective, Geneva, World Health
Organisation, 1998.
4. Horton S, Gelband H, Jamison D, et al. Ranking 93 health interventions for low-
and middle-income countries by cost-effectiveness PloS one 2017: 12; e0182951
Table 1 (abstract O32).
Incremental cost effectiveness ratios (ICER) and benefit-cost ratios (BCR) of health
and non-health interventions
Incremental cost effectiveness ratios of surgical interventions and compared with
other public health interventions (cost in USD per DALY or YLL averted)
Surgical Intervention
ICER
Other health intervention
ICER
Male circumcision
$7- $106
Vitamin A supplementation
$6-$12
WHO checklist scale-up
$16 - $74
BCG vaccination
$51 - $220
Cleft lip and palate surgery
$15 - $96
General surgery
$82
Hydrocephalus surgery
$108
Ophthalmic Surgery
$136
Orthopaedic surgery
$381
Anti-retroviral therapy for HIV
$453 - $648
Medical therapy for ischaemic heart disease
$500 - $706
Caesarean Section
$315
Breast-feeding promotion
$930
Oral rehydration solution therapy
$1062
Benefit cost ratios of health and non-health Interventions
Intervention
Benefit-cost ratio
Caesarean section, globally
4
Essential surgical procedures, globally
10
Cleft lip and palate repair, India
14
Investment to retrofit schools in India to better withstand earthquakes, India
0.04 – 5.6
WHO checklist scale-up
17-120
reducing the prevalence of stunting by a package of interventions targeting malnutrition,
India
44 – 138
P33. RECODE-DCM Enviro-Scan: Identifying key agents of change for implementation of
findings from a James Lind Alliance priority partnership
Ben Grodzinski1, Harry Bestwick1, Faheem Bhatti1, Rory Durham1, Maaz Khan1, Celine
Partha-Sarathi1, Jye Quan Teh1, Oliver Mowforth2, Benjamin M. Davies2* (On behalf
of AO Spine RECODE-DCM Consortia)
1School of Clinical Medicine, University of Cambridge, Cambridge, UK; 2Academic Neurosurgery
Unit, Department of Clinical Neurosurgery, University of Cambridge, Cambridge, UK
Correspondence: Ben Grodzinski (bd375@cam.ac.uk)
Background:
Degenerative Cervical Myelopathy (DCM) is a progressive disorder of the spinal cord,
caused by arthritis. It is common (~2% of adults) and has a significant impact on
health-related quality of life. Advances in care are urgently needed.
RECODE-DCM (Research Objectives and Common Data Elements in DCM) is an international
collaboration which aims to improve research efficiency in DCM, and ultimately accelerate advances
in care. As a first step, it has recently completed a James Lind Alliance research
priority-setting process.
RECODE’s success now depends on the dissemination and uptake of these priorities.
However, this is challenging in DCM for a number of reasons, including a lack of recognition,
lack of established lobbying or advocate groups, and the numerous different healthcare
professionals involved in management pathways.
Method:
To facilitate implementation key stakeholders termed ‘Agents of Change’ (AoC) were
identified at a multi-disciplinary workshop. A tailored international search strategy
was then conducted to identify potential agents, itemising with key meta-data and
indexing against relevant research priorities.
Results:
Researchers, funders, non-profit and charities and scientific conferences were identified
as key AoC. These were identified in three project arms. The research arm created
a database of conferences at which to promote the research priorities, a database
of researchers already working on the priorities, and a database of journals in which
this work is being published. The funding arm created a database of current and potential
funders. The organisations arm created a database of charities and non-profit organisations
which could help promote the priorities. Project completion date 20th May 2020.
Conclusion:
Research on DCM, whilst currently under-developed, is rapidly accelerating. The RECODE-DCM
Enviro-Scan has identified and indexed key agents for its implementation.
O34. A co-designed intervention to enhance the national audit of dementia
Michael Sykes1, Richard Thomson1, Niina Kolehmainen1, Louise Allan2, Tracy Finch3
1
Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, NE2
4AX, UK; 2College of medicine and health, University of Exeter, Exeter, EX1 2LU, UK;
3Department of Nursing, Midwifery & Health, Northumbria University, Newcastle upon
Tyne, NE7 7XA, UK
Correspondence: Michael Sykes (michael.sykes@ncl.ac.uk)
Background:
Patients with dementia do not always get best care [1]. Hospitals use audit and feedback
to improve dementia care. Audit and feedback is variably effective at improving care
[2]. There have been calls to test potential enhancements to national audit [3]. Both
evidence and theory describe practices that might affect the effectiveness of audit
and feedback [2,4]. We aimed to describe the content and delivery of the national
audit of dementia, identify potential enhancements and develop a strategy to implement
the enhancements.
Method:
We purposively sampled six hospitals, semi-structured interview participants (n=32),
observations (n=36) and documentary analysis (n=39). We used framework analysis.
Interim analysis was iteratively presented to stakeholders during co-design workshops
(n=9; 18 hours) for challenge and to integrate findings, until a stable description
was developed. The co-design group specified potential enhancements (3 workshops;
6 hours). Further co-design workshops (n=2; 4 hours) used the normalisation process
theory toolkit [5] to identify mechanisms affecting implementation. This analysis
informed a specified [6] implementation strategy.
Results:
Hospital actions were not informed by a robust analysis of performance, were selected
from a narrow range of implementation strategies [7] and were not presented in a way
to gain organisational commitment [8]. We co-designed a training intervention to hospital
dementia leads and clinical governance leads that aims to improve the development
and agreement of hospital-level actions. The intervention trains the leads to present
information which supports governance committee sense-making in relation to implementation
capability (by targeting low baseline, analysing barriers and linking barriers to
actions) and change commitment (by addressing trust and credibility, linking to priorities,
presenting comparators and considering existing work) [2,3,7,8].
Conclusion:
Training clinical leads to analyse performance, investigate barriers, select strategies
and present specific information designed to gain organisational commitment may enhance
the effectiveness of the national audit of dementia.
Acknowledgements
This work is being presented on behalf of the co-design group members, without whom
this work would not have been possible.
Consent to publish
All participant gave their consent for material to be used in this publication.
References
[1] Royal College of Psychiatrists. National Audit of Dementia care in general hospitals
2018-2019: Round four audit report. London: Royal College of Psychiatrists. 2019.
[2] Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard‐Jensen J, French SD, et al.
Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane
database of systematic reviews. 2012. 6.
[3] Colquhoun HL, Carroll K, Eva KW, Grimshaw JM, Ivers N, Michie S, et al. Advancing
the literature on designing audit and feedback interventions: identifying theory-informed
hypotheses. Implement Sci. 2017;12(1):117.
[4] Grimshaw JM, Ivers N, Linklater S, Foy R, Francis JJ, Gude WT et al. Reinvigorating
stagnant science: implementation laboratories and a meta-laboratory to efficiently
advance the science of audit and feedback. BMJ Qual Saf. 2019 May 1;28(5):416-23.
[5] May CR, Finch T, Ballini L, MacFarlane A, Mair F, Murray E, Treweek S, Rapley
T. Evaluating complex interventions and health technologies using normalization process
theory: development of a simplified approach and web-enabled toolkit. BMC health serv
res. 2011;1;11(1):245.
[6] Michie S, Richardson M, Johnston M, Abraham C, Francis J, Hardeman W, Eccles MP,
Cane J, Wood CE. The behavior change technique taxonomy (v1) of 93 hierarchically
clustered techniques: building an international consensus for the reporting of behavior
change interventions. Ann behav med. 2013;1;46(1):81-95.
[7] Powell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, Proctor
EK, Kirchner JE. A refined compilation of implementation strategies: results from
the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci.
2015; 1;10(1):21.
[8] Weiner BJ. A theory of organizational readiness for change. Implement Sci. 2009;1;4(1):67.
O35. Implementing the HOUVAST 2.0 intervention in the Dutch primary care; lessons
learned from a process evaluation
S. Hogervorst1, M.C. Adriaanse1, H.E. Brandt1, M. Vervloet, L3. van Dijk3,4, J.G.
Hugtenburg2
1Department of Health Science and the Amsterdam Public health Institute, Vrije Universiteit,
Amsterdam, The Netherlands; 2Department of Clinical Pharmacology and Pharmacy, Amsterdam
UMC, loc. VUmc, Amsterdam, The Netherlands; 3Netherlands institute for health services
research (NIVEL), Utrecht, The Netherlands; 4Faculty of Science and Engineering, University
of Groningen, The Netherlands
Correspondence: S. Hogervorst (s.hogervorst@vu.nl)
Background:
Despite the existence of many effective adherence interventions, they are rarely used
in routine care. This gap between research and practice calls for more emphasis on
the implementation of adherence interventions. This pilot project aims to implement
an existing adherence intervention (HOUVAST 2.0) in the Dutch primary care.
Method:
A qualitative process evaluation was conducted as part of a medication adherence pilot
project (HOUVAST 2.0). Data were collected through a focus group and four interviews
with ten allied GP and pharmacy staff members. Interviews and focus groups were semi-structured
using topic lists based on the RE-AIM implementation framework. Interviews were audiotaped
and transcribed verbatim. Atlas.ti 8.0 software was used for coding and structuring
of themes. A thematic analysis of the data was performed.
Results:
Main themes that emerged were ‘Training and preparation’, ‘Appreciation for the intervention’
‘Technical barriers to implementation’ and ‘social barriers to implementation’.
The intervention HOUVAST 2.0 proved engaging for clinicians that used the intervention,
but also proved difficult to implement. The main barriers were a suboptimal selection
process based on pharmacy refill data, a difficult target population, nurse practitioners’
difficulties addressing adherence with patients and the project did not align with
goals of GPs.
Conclusion:
Implementation of the HOUVAST 2.0 intervention in the Dutch primary care proved challenging.
A good established collaboration between GPs and pharmacies, better ICT applications
for selecting patients and a training more aimed towards practical communication techniques
are important improvements needed for further implementation.
Consent to publish
Oral informed consent from all patients and healthcare providers to anonymously record
and analyse the data was obtained before conducting the interviews/focus groups
P36. Improving the quality of nursing documentation for surgical patients in a referral
hospital in Freetown, Sierra Leone: a study protocol of a multifaceted quality improvement
project
Nataliya Brima1, Nick Sevdalis2, TB Kamara3, H Wurie4, K Daoh5, B Deen5, Justine Davies6^
and Andrew Leather1^
1King’s Centre for Global Health & Health Partnerships, School of Population Health
& Environmental Sciences, Faculty of Life Sciences and Medicine, King’s College London,
London, UK; 2Centre for Implementation Science, Health Service and Population Research
Department, Kings College London, UK; 3Department of Surgery, College of Medicine
and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone; 4Faculty
of Nursing, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown,
Sierra Leone; 5Connaught Teaching Hospital Complex, Sierra Leone, Freetown, Sierra
Leone; 6Institute of Applied Health Research, University of Birmingham, UK
Correspondence: Nataliya Brima (nataliya.brima@kcl.ac.uk)
^ co-senior authors
Background:
The global health community is placing greater emphasis on quality of care, while
not neglecting access to care, in order to reduce avoidable mortality and morbidity
from surgical diseases in low- and middle-income countries. However, many of these
health systems are weak and provide low quality health care. There is a lack of knowledge
on how health system strengthening quality improvement interventions can be implemented
effectively in these settings. To address this gap, we developed a multifaceted quality
improvement project to improve the quality of nursing documentation, through implementation
and evaluation of a set of hospital-based activities.
Methods:
This multifaced quality improvement, mixed-method, quasi-experimental design interventional
study has been co-designed during an intensive formative phase guided by a theory
of change process. It will take place within the surgical department of a national
referral hospital in Freetown, Sierra Leone.
The study is structured around five distinct phases – pre-implementation, awareness
drive, training package, audit and feedback, and evaluation. Plan-Do-Study-Act quality
improvement method will be used to provide further evidence to optimise the set of
interventions and implementation strategies.
Results:
The primary outcome of the study is composite measure of completeness of the Nurses
Daily Report form. In addition, several process and implementation outcomes will be
evaluated to study effects of interventional components and implementation strategies.
Further information on sustainability of nursing documentation quality improvement
processes will also be collected.
Conclusion:
We seek to test if the quality of nursing documentation can be improved through the
introduction of a set of health system strengthening interventions, using implementation
and improvement sciences methods.
The results will generate knowledge to inform good nursing documentation practices
for surgical patients in Sierra Leone, add to the body of evidence on the development
and implementation of effective health system strengthening quality improvement interventions
in low resource settings.
O37. Barriers and enablers to accessing surveillance tests among childhood cancer
survivors in Ontario, Canada
Jennifer Shuldiner1, Nida Shah2, Ann Marie Corrado3, Paul C. Nathan2,4,5, Noah Ivers1,5,6
1Women’s College Hospital Institute for Health System Solutions and Virtual Care,
Womens College Hospital, Toronto, Ontario, Canada; 2SickKids Research Institute, Toronto,
Ontario, Canada; 3The Peter Gilgan Centre for Women’s Cancers, Womens College Hospital,
Toronto, Ontario, Canada; 4Division of Hematology/Oncology, Hospital for Sick Children, Toronto, Ontario,
Canada; 5Institute of Health Policy, Management and Evaluation, University of Toronto,
Toronto, Ontario, Canada; 6Department of Family and Community Medicine, University
of Toronto, Toronto, Ontario, Canada
Correspondence: Jennifer Shuldiner (Jennifer.shuldiner@wchospital.ca)
Background:
Survivors of childhood cancer require lifelong risk-tailored care to mitigate the
risk of morbidity or premature mortality as a result of their prior cancer treatment
(“late effects”). Despite evidence that surveillance focused on early detection of
late effects improves health and reduces mortality, most adult survivors of childhood
cancer do not complete recommended surveillance tests. We sought to elucidate the
barriers and enablers to accessing evidence-based, high-yield surveillance tests among
childhood cancer survivors.
Method:
This qualitative study involved one-on-one semi-structured interviews with adult survivors
of childhood cancer (N=10). Participants were registered at the largest provincial
cancer survivor program in Ontario, Canada, and eligible for the surveillance tests
of interest but had not attended the clinic in over five years. We framed the interview
guide and content analysis using the Theoretical Domains Framework, a tool specifically
developed for implementation research to identify influences on desired behaviour.
Results:
Key barriers to completing recommended surveillance tests included a lack of knowledge
regarding late effects, physical distance from specialised survivor services, and
a lack of advice from family physicians. These barriers impacted the intention of
survivors to obtain recommended surveillance tests or visit a speciliazed survivor
clinic. Conversely, survivors discussed how they would not be deterred from getting
a test if a physician recommended it, and those who had a health professional who
referred survivors for tests were committed to obtaining them.
Conclusion:
Childhood cancer survivors prioritized their health and valued surveillance testing
for late effects as a means to prevent illness. Poor awareness about the recommendations
among survivors and their physicians must be addressed as a first step to implementation
of guidelines. These findings will inform the planning and implementation of a centralized
system to identify high-risk survivors and provide them and their physicians with
personalized information about recommended surveillance.
O38. A qualitative study to identify the factors influencing the perceived acceptability,
appropriateness and feasibility of implementing a falls risk assessment service for
older people
Susan Calnan, Caragh Flannery, Sheena McHugh
School of Public Health, University College Cork, Western Rd., Cork, Ireland
Correspondence: Susan Calnan (susan.calnan@ucc.ie)
Background
Falls are considered one of the most serious and common threats to older people’s
ability to maintain their independence. In Ireland, a new integrated falls prevention
pathway for older people was introduced in 2015, including multidisciplinary falls
risk assessment clinics in primary care. The aim of this study is to identify the
factors that influenced the acceptability, appropriateness and feasibility of implementation
among those delivering the clinics.
Methods
Methods involved one-to-one interviews with healthcare professionals (physiotherapists,
occupational therapists and nurses) delivering falls risk assessment clinics across
four implementation sites. Interviews were conducted prior to implementation and six
months after implementation had commenced, in 2016 and 2017. Data were analysed using
a combination of the Consolidated Framework for Implementation Research (CFIR) and
Proctor’s implementation outcomes taxonomy.
Results
The study identifies particular aspects of the implementation, as defined by CFIR,
that influenced its acceptability, appropriateness and feasibility. Intervention characteristics,
such as the relative advantages perceived and low complexity of the assessment clinics,
positively influenced its perceived acceptability among service providers. Both outer
setting (patient need for falls services) and inner setting (networks and communications)
factors influenced its perceived appropriateness. Readiness for implementation, in
particular the lack of available resources, strongly influenced the perceived feasibility
of the service.
Conclusion
This study highlights the complex interplay between implementation outcomes. While
an intervention may be deemed acceptable by service providers, for example, its perceived
feasibility may be negatively impacted by practical constraints of the implementation
setting. Results from this study will be used to improve future implementation of
this complex health intervention and to inform the implementation of other falls prevention
services for older people internationally.
P39. Optimising the mining of electronic health records to implement health promotion
apps via electronic messaging (OptiMine study)
Zarnie Khadjesari1, Tracey Brown1 Alex Ramsey2, Henry Goodfellow3, Sherine El-Toukhy4,
Lorien Abroms5, Helena Jopling6, Michael Amato7
1School of Health Sciences, University of East Anglia, Norwich, UK; 2Institute for
Public Health, Washington University in St. Louis, St. Louis, Missouri, USA; 3Department
of Primary Care and Population Health, University College London, London, UK; 4The
National Institute on Minority Health and Health Disparities, The National Institutes
of Health, Bethesda, Maryland, USA; 5Department of Prevention and Community Health,
George Washington University, Washington DC, USA; 6West Suffolk NHS Foundation Trust,
Bury St. Edmunds, Suffolk, UK; 7Truth Initiative, Washington DC, USA
Correspondence: Zarnie Khadjesari (z.khadjesari@uea.ac.uk)
Background:
Health promotion apps offer timely support, privacy and scalability, but are not currently
delivered as part of routine patient care. Leveraging Electronic Health Records (EHR)
to expand the reach of health promotion apps via electronic messaging provides a novel
approach to implementation. We explored the acceptability, feasibility and reach of
electronic messaging as an implementation strategy.
Materials and methods:
Three-phase, mixed-method study in an acute UK hospital. Public Health England apps
were promoted: Smokefree and Drink Free Days. Phase 1: focus groups with patients
and staff on the acceptability of sending electronic messages to patients (pre-implementation).
Phase 2: feasibility of identifying at-risk behaviours and patient characteristics
via EHR. Phase 3: reach of electronic messages to promote apps via an embedded link;
primary outcome was the proportion of patients who click on the link. Online survey
based on the Perceived Attributes of eHealth innovations explored acceptability of
the electronic messages (post-implementation).
Results:
Six focus groups included 10 patients and 14 staff. SMS was the most suitable format
for the messages, reinforced by analysis of the EHR data. Views on targeted vs. universal
messaging were mixed (i.e. messages sent to at-risk patients vs. all patients), other
pros and cons, technical complications and alternative resources were explored. 1526
patients were sent an SMS in January 2020, preliminary findings suggest 13% of patients
accessed the link to the apps, which exceeded our 5% success rate. The online questionnaire
was completed by 3.7%. Most participants were satisfied with the messages (80%), found
them helpful (64%) and easy to comprehend (98%).
Conclusions:
SMS to promote uptake of health promotion apps to patients identified via the EHR
is acceptable and feasible, which led to high reach. Our implementation strategy has
the potential for reducing the burden of preventable death and disease at scale and
low cost.
Acknowledgements
This study was funded by Cancer Research UK in collaboration with the National Cancer
Institute (NCI).
P40. OASI2: a hybrid effectiveness implementation RCT to inform scale up of care bundle
to reduce obstetric anal sphincter injury (OASI) caused during childbirth
Magdalena Jurczuk1, Posy Bidwell1, Daniel Wolstenholme1, Louise Silverton2, Jan Van
Der Meulen3, Nick Sevdalis4§, Ipek Gurol-Urganci1,3§, Ranee Thakar5§
1Centre for Quality Improvement and Clinical Audit, Royal College of Obstetricians
and Gynaecologists, London SE1 1SZ, UK; 2Royal College of Midwives, London W1G 9NH,
UK; 3Department of Health Services Research and Policy, London School of Hygiene and
Tropical Medicine, London WC1H 9SH, UK; 4Centre for Implementation Science, Health
Service and Population Research Department, King’s College London, London SE5 8AF,
UK; 5Croydon University Hospitals NHS Trust, Croydon CR7 7YE, UK
Correspondence: Magdalena Jurczuk (mjurczuk@rcog.org.uk)
§
Authors Ranee Thakar, Nick Sevdalis and Ipek Gurol-Urganci contributed equally to
the study and share senior authorship
Background
Obstetric anal sphincter injuries (OASI) can have severe debilitating consequences
for women. A large-scale quality improvement study (OASI1; 2017-18) implemented a
care bundle (antenatal information to women, manual perineal protection and mediolateral
episiotomy when indicated) in 16 maternity units in Britain [1] which reduced OASI
rates. OASI2 (2021-22) is a scale-up study, which examines strategies used to introduce,
implement and sustain implementation.
Method
OASI2 is a cluster-randomised control trial with two arms. Arm 1 (peer-to-peer implementation,
n=10) is supported by peer units. Arm 2 (lean implementation, n=10) does not receive
any active implementation support. A parallel nonrandomised study group (sustainability
arm) consisting of original OASI1 units, allows study of the care bundle’s sustainability
over time. An estimated 2,750 singleton live births/unit will be eligible for the
care bundle. All three study groups receive an implementation toolkit including training
resources. Table 1 details the expected implementation strategies across the three
arms. Clinical outcomes (OASI rates) are collated from maternity information systems;
implementation outcomes (acceptability, feasibility, appropriateness, sustainability)
are collected through validated surveys [2,3] administered to women and clinicians,
supplemented by qualitative research. Quantitative data are analysed using regression
modelling and descriptive statistics.
Results
The trial will identify the effect of the applied implementation strategies [4] on
implementation success, and link that to the clinical effectiveness of the bundle.
Successful sustainability strategies will be identified.
Conclusion
The study will generate insights into how to effectively scale-up and sustain uptake
and coverage of similar interventions in maternity units. A locally adaptable ‘implementation
blueprint’, will be produced to inform development of future guidelines to prevent
perineal trauma.
Acknowledgements
The study is funded by the Health Foundation. NS’s research is supported by the NIHR
Applied Research Collaboration South London. We are also grateful to our independent
advisory group who have contributed to the conceptualization, design and implementation
of both the OASI1 and the OASI2 studies.
Trial Registration
Trial registration pending completion of research protocol.
References
1. Bidwell P, Thakar R, Sevdalis N, Silverton L, Novis V, Hellyer A, et al. A multi-centre
quality improvement project to reduce the incidence of obstetric anal sphincter injury
(OASI): Study protocol. BMC Pregnancy Childbirth. 2018;18(1):1–33.
2. Weiner BJ, Lewis CC, Stanick C, Powell BJ, Dorsey CN, Clary AS, et al. Psychometric
assessment of three newly developed implementation outcome measures. Implement Sci.
2017;12(1):1–12.
3. University W. Clinical Assessment Sustainability Tool. 2012.
4. Powell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, et al.
A refined compilation of implementation strategies: Results from the Expert Recommendations
for Implementing Change (ERIC) project. Implement Sci. 2015;10(1):1–14.
Table 1 (abstract P40).
Discrete implementation strategies to be used in each group of participating units
Discrete Implementation Strategy/ group of strategies [4]
Sustainability group
Peer implementation
Lean implementation
Implementation requirements
Identify and prepare champions/ Facilitation/ Clinical supervision
x
x
x
Develop and organize quality monitoring systems/ change record systems/ Audit & provide
feedback / facilitate relay of clinical data to providers
x
x
x
Develop a formal implementation blueprint/ develop an implementation glossary
x
x
x
Conduct educational meetings (clinicians)
x
x
x
Use educational materials (toolkit resources)
x
x
x
Remind clinicians: pens, posters, stickers (care bundle launch day and promote the
care bundle continuously)
x
x
x
Obtain and use patient feedback/ Prepare patients/consumers to be active participants
(engage local PPI group)
x
x
x
Strategies exclusive to external facilitation
Centralise technical assistance/ Provide local technical assistance/ Use an implementation
advisor/ Provide ongoing consultation
Centralised technical assistance
Local technical assistance
Organize clinician implementation team meetings (skills development days led by external
facilitators)
x
x
Create a learning collaborative/ Promote network weaving
x
x
Use train the trainer strategies
Project Team > clinicians through cascade
External facilitators > clinicians through cascade
Strategies related to sustainability efforts
Conduct educational outreach visits
Site visits from Project Team
Involve executive boards
Ensure senior-buy in
Mandate change/ Create or change credentialing and/or licensure standards
Bundle introduced into mandatory training/ induction packages
Fund & contract for the clinical innovation
Protected time or champions
Revise professional roles
Formal titles for champions
Recruit, designate, train for leadership
Champions trained for external facilitator role
P41. Healthcare stakeholders’ perceptions and experiences of factors affecting the
implementation of critical care telemedicine (CCT): qualitative evidence synthesis
Andreas Xyrichis, Katerina Iliopoulou
King’s College, London, Strand, WC2R 2LS, UK
Correspondence: Andreas Xyrichis (andreas.xyrichis@kcl.ac.uk)
Background:
Critical care telemedicine (CCT) has long been used to expand the delivery of best
care to critically ill patients located in geographically distant areas [1]. During
the COVID-19 pandemic those health systems with CCT appeared better prepared to respond
to the pandemic [2]. However, several challenges remain for CCT to be effectively
implemented [3]. This review synthesises qualitative evidence on healthcare stakeholders’
perceptions and experiences of factors affecting implementation of CCT, with a view
to developing hypotheses about factors more likely to foster successful implementation.
Method:
We systematically searched five databases for empirical qualitative studies published
in any language. The search combined terms for telemedicine with critical care, decision
support, and remote monitoring. We independently screened the reference lists of included
studies and searched five sources for grey literature. Two reviewers extracted data
and appraised included studies independently and in duplicate. Conflicts were resolved
in the team. We used the CFIR[4] to inform data synthesis. Additional themes not captured
by CFIR were classified under a separate theme. We used GRADE-CERQual [5] to assess
our confidence in the findings.
Results:
Thirteen studies were included representing a range of settings but all from North
America. We identified 20 review findings that affect implementation of CCT. The majority
of factors mapped to three CFIR domains: intervention characteristics, inner setting,
and characteristics of individuals. Factors relating to networks and communication,
along with interactions between hub and bedside teams, were the most prominent review
findings
Conclusion:
We have high or moderate confidence in the evidence contributing to several of the
review findings. Further qualitative research, especially in contexts other than North
America, which are subject to different social and cultural values, would strengthen
the evidence base. Future implementation research is needed to build on our findings
and examine appropriate strategies for further implementation of CCT.
Acknowledgements
This review is being completed with the contribution of Dr Mackintosh NJ, Dr Terblanche
M, Professor Bench S, Dr Philippou J, Professor Sandall J
References
1. Xyrichis A, Mackintosh NJ, Terblanche M, Bench S, Philippou J, Sandall J. Healthcare
stakeholders’ perceptions and experiences of factors affecting the implementation
of critical care telemedicine (CCT): qualitative evidence synthesis. COCHRANE DB SYST REV.
2017; 11.
2. Ohannessian R, Duong TA, Odone A. Global telemedicine implementation and integration
within health systems to fight the COVID-19 pandemic: a call to action. JMIR public
health and surveillance. 2020; 6(2): e18810.
3. Mackintosh N, Terblanche M, Maharaj R, Xyrichis A, Franklin K, Keddie J, Larkins
E, Maslen A, Skinner J, Newman S, Magalhaes JH. Telemedicine with clinical decision
support for critical care: a systematic review. Syst Rev. 2016; 5 (1):176.
4. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering
implementation of health services research findings into practice: a consolidated
framework for advancing Implementation Sci. Implementation Sci. 2009; 4(1):50.
5. Noyes J, Booth A, Lewin S, Carlsen B, Glenton C, Colvin CJ, Garside R, Bohren MA,
Rashidian A, Wainwright M, Tunςalp Ö. Applying GRADE-CERQual to qualitative evidence
synthesis findings–paper 6: how to assess relevance of the data. Implementation Sci.
2018 Jan;13(1):4.
P42. Improving outcomes for children with communication difficulties: Implementing
cross-disciplinary service delivery models in schools
Jessica McCluskey1 2, Patricia Donnelly1 2, Sarah Brady1 2, Sue Franklin1 2, Carol-Anne
Murphy1 2
1School of Allied Health, University of Limerick, Limerick, Ireland; 2 Health Implementation
Science and Technology Cluster, Health Research Institute, (HIST_HRI) University of
Limerick, Ireland
Correspondence: Carol-Anne Murphy (carol-anne.murphy@ul.ie)
Background:
Children and adolescents with speech, language and communication needs (SLCN) comprise
approximately 10% of the school population and are at risk of adverse social, emotional,
academic and vocational outcomes. Providing effective in-school language supports
requires feedback and coaching involving speech and language therapist (SLT)/teacher
collaboration [1, 2, 3]. We describe a model of SLT/teacher support for students with
SLCN, using the Re-Aim framework [4].
Method:
Tailored CPD was offered to 4 schools, followed by coaching; and co-teaching (SLTs
and Special Education teachers) of 10 groups of children with SLCN.
Results:
Re-Aim [4] objectives were achieved as follows
Reach
:
we identified key school leaders and contextualised the proposed work within school
improvement plans (e.g. linking the SLCN programme to literacy and behaviour)
Effectiveness
:
SLTs supported teachers to monitor programme implementation, fidelity and success;
we gathered data on key stakeholder (SLTs, teachers, students and parents) perspectives
Adoption: we attended schools’ special education planning meetings (2) had regular
contact with school leadership (3) provided a flexible support model tailored to the
individual school context.
Implementation: as well as co-teaching, SLTs and teachers engaged in reflective collaborative
meetings regarding delivery
Maintenance of the intervention was achieved through tailored whole school CPD workshops
and building capacity of teachers involved to advocate for the impact of interventions
and strategies on students and teaching practice
Intervention delivery outcomes and key stakeholder perspectives, informed the development
of a revised and updated model of collaborative working. Students clearly benefitted
from the language support, and key personnel have increased capacity for sustained
collaboration.
Conclusion:
The revised model of working, derived from best practice regarding inter-professional
collaboration and school capacity building, is enhanced by knowledge gained through
implementation in a local context. Given national and international policies to embed
therapy in the education context, this can inform cross-sectoral collaboration initiatives.
Acknowledgements
This work is being conducted through a tender (RFT270618)
awarded by the National Council for Special Education (NCSE) in Ireland, to University
of Limerick for the Provision of Speech and Language Therapy Support Services to Schools.
References
1. Starling, J., Munro, N., Togher, L. & Arcuili, J. Training Secondary School Teachers
in Instructional Language Modification Techniques to Support Adolescents with Language
Impairment: A Randomized Controlled Trial. Lang, Speech, Hear Serv School, 2012; 43:
474-495. 10.1044/0161-1461(2012/11-0066)
2. Snow, P.C, Eadie, P.A, Connell, J., Dalheim, B., McCusker, H.J & Munro, J.K Oral
language supports early literacy: A pilot cluster randomized trial in disadvantaged
schools, Int J Speech Lang Pathol, 2019; 16:5: 495-506, 10.3109/17549507.2013.845691
3. Ebbels, S., McCartney, E., Slonims, V., Dockrell, J., & Norbury, C. Evidence-based
pathways to intervention for children with language disorders. Int J Lang Commun Disord,
2019; 54:1: 3-19 10.1111/1460-6984.12387
4. Glasgow RE, Vogt TM, Boles SM: Evaluating the public health impact of health promotion
interventions: The RE-AIM framework. Am J Public Health 1999; 89:1322–1327.
O43. Key findings from an outcomes evaluation of a ‘scaled up’ domestic abuse recovery
programme
Emma Smith, Emma Belton
National Society for the Prevention of Cruelty to Children, London, UK
Correspondence: Emma Smith (Emma.smith@NSPCC.org.uk)
Background
As part of the NSPCC 2016-2021 strategy, the charity scaled up a number of its evidence-based
programmes in order that more children could potentially benefit. This included Domestic
Abuse Recovering Together (DART), a programme designed to support mothers and children
through their recovery from domestic abuse. DART is currently implemented in 28 UK
sites, including local authorities and voluntary organisations.
Following an implementation evaluation, an outcomes evaluation was conducted to see
whether or not non-NSPCC services, supported by the NSPCC to deliver DART, could achieve
similar outcomes for service users as evidenced by the evaluation of the original
service.
Method
A quasi experimental design involved an intervention group (comprised of families
from six scale up sites), a no intervention group (Families from three NSPCC sites
waiting to attend DART) and evaluation data from the original NSPCC DART services.
The same standardised measures were completed by all sites at two time points.
Results
Independent samples t tests revealed significant improvements in all outcomes measured
pre and post DART for scale up sites: Mothers had significantly greater self-esteem,
an improved relationship with their child and their child had fewer emotional and
behavioural difficulties. These improvements were significantly greater than the no-intervention
group, but very similar to the original DART groups run by the NSPCC.
Conclusion
The results suggested that external organisations were equally as successful as the
NSPCC at implementing DART, with very similar positive outcomes for families.
P44. The practical application of a technology implementation framework to the concurrent
development of a medical device and a new clinical service: Custom-made 3D printed
Non-Invasive Ventilation masks for paediatric patients
Katherine Jeays-Ward1, Matt Willox2, Nicki Barker3, Pete Metherall4, Avril McCarthy1,5,
Heath Read2, and Heather Elphick3
1NIHR Devices for Dignity Med Tech Co-operative, Sheffield Teaching Hospitals NHS
Foundation Trust, Sheffield, UK; 2ACES, Sheffield Hallam University, Sheffield, UK;
3Sheffield Children’s NHS Foundation Trust, Sheffield, UK; 43-D Lab, Sheffield Teaching
Hospitals NHS Foundation Trust, Sheffield, UK; 5Clinical Engineering, Sheffield Teaching
Hospitals NHS Foundation Trust, Sheffield, UK
Correspondence: Katherine Jeays-Ward (Katherine.jeays-ward@nihr.ac.uk)
Background
Non-invasive ventilation (NIV) is assisted mechanical ventilation delivered via facemask
for people with chronic respiratory conditions. Masks that fit well are difficult
to find for children who have small or asymmetrical facial features. We are addressing
the need for improved paediatric NIV masks by concurrently developing bespoke 3D printed
masks and a new clinical service to provide them.
The Non-adoption, Abandonment and challenges to Scale-up, Spread and Sustainability
(NASSS) implementation framework [1] is a technology-specific framework that acknowledges
the problematic system complexity associated with sustainable implementation of technology-supported
changes in healthcare.
We present the application of NASSS framework principles to proactively address barriers
to sustainable implementation during device and service development.
Method
The adaptable NASSS framework includes domains specific to Adopters and Technology.
Priority setting events took place with patients and professionals, and detailed assessment
of suitable materials and manufacturing methods. We performed breakdowns of potential
service pathways, identifying where and how individuals would interact with the service
and devices, and challenging the pathway with different eventualities. This was undertaken
iteratively using co-production and formative evaluation methods to concurrently guide
both product and service development.
Results
We worked with multiple stakeholder groups to identify priorities for product development
and aspects of care. Priorities included processes for identification of suitable
patients, prescriptions, mask comfort, and medical device interoperability. Barriers
that were identified and resolved included patient access to 3D scanning facilities,
quality of scan data, and regulatory standards.
Conclusion
By developing a feasible clinical pathway [2] we have bypassed multiple potential
pitfalls to eventual adoption into practice. A clinical trial of the resultant customised
masks is currently underway.
This need-driven project prioritised implementation from the outset. It combined iterative
product development and concurrent service creation, and is a de-risking approach
to NHS-led technology innovation that can be replicated by other medtech developments.
Acknowledgements
This research is funded by the National Institute for Health Research (Invention for
Innovation, i4i; II-LB-0814-20004). The views expressed are those of the author and
not necessarily those of the NHS, the National Institute for Health Research or the
Department of Health and Social Care.
References
1 Greenhalgh T, Abimbola S. The NASSS Framework - A Synthesis of Multiple Theories
of Technology Implementation. Stud Health Technol Inform. 2019; 263:193-204.
2 Willox M, Metherall P, Jeays-Ward K, McCarthy A, Barker N, Reed H, Elphick H. Custom-made
3D printed masks for children using non-invasive ventilation: a feasibility study
of production method and testing of outcomes in adult volunteers. J Med Eng Technol.
2020; Jun 29:1-11.