Using a multimethod approach to develop implementation strategies for a cervical self-sampling program in Kenya.

BACKGROUND: Numerous health policy makers/researchers are concerned about the limitations of research being applied to support informed decision/policy making and the implementation of practical solutions. The aim of the Chaguo Letu project (which means our choice in Swahili) was to determine how local decision makers could apply a multimethod approach to make strategic decisions to effectively implement a Cervical Self-Sampling Program in Kenya. METHODS: A multimethod approach, involving participatory action research, scenario based planning, and phenomenology, was applied in conjunction with two tools to identify relevant factors (negative or positive) that could impact Cervical Self-Sampling Program implementation. A total of 107 stakeholders participated in interviews, focus groups, workshops, and informal interactions. Content analysis, an affinity exercise, and impact analysis were used to analyze data and develop robust strategic directions and supporting implementation strategies. RESULTS: A total of 57 factors thought to impact the implementation of the Cervical Self-Sampling Program were identified and grouped into 13 thematic categories. These themes were instrumental in developing 10 strategic directions and 22 implementation strategies deemed necessary to implement a technically viable, politically supported, affordable, logistically feasible, socially acceptable, and transformative Program. CONCLUSIONS: This study made three conclusions: 1) there is political will and a desire to improve cervical screening across Kenya, but in a period of dynamic change resources are constrained; 2) implementing the Program in urban/rural settings is logistically feasible, but the majority of Kenyan women could not afford screening without some form of a subsidy, and 3) self-sampling is perceived to be much more socially acceptable than the current Pap screening process. The Chaguo Letu study went beyond the traditional strategy development process of determining "what" needs to do done by describing in detail "how" the Program should be implemented to be relevant and accessible to all Kenyan women at risk of cervical cancer. This work could potentially facilitate communities of practice and knowledge sharing when addressing other types of health decisions in other low resource settings beyond Kenya.

Understanding Barriers for Communicating Injury Prevention Messages and Strategies Moving Forward: Perspectives from Community Stakeholders.

OBJECTIVES: The primary objective of this study was to elicit the perspectives of direct care providers on barriers and facilitators to communicating injury prevention messages to parents/caregivers of children under 4 years of age. The secondary objective was to examine characteristics of an injury prevention messaging strategy preferred by direct care providers. DESIGN AND SAMPLE: This qualitative study was conducted across four regions in Ontario Canada. Fifty-nine direct care providers were purposefully sampled and data interpreted using focus group analysis. MEASURES: Transcripts were analyzed verbatim using content and discourse analysis. RESULTS: Several barriers to communicating injury prevention messages were identified encompassing (a) role, (b) parental, (c) social determinants, and (d) evidence impediments. In an effort to offset some of these barriers, participants endorsed the development of a tailored multicomponent injury prevention strategy adopting action-based messages. CONCLUSION: The results of this study provide an in-depth exploration of direct care providers perceptions that can inform the design of materials and dissemination strategies to help increase and optimize access to injury prevention information. Injury prevention messages should be action-oriented, specifically tailored to the stage of child development, and disseminated through both face-to-face interactions and mobile technology.

A qualitative study evaluating causality attribution for serious adverse events during early phase oncology clinical trials.

BACKGROUND: In early phase oncology trials, novel targeted therapies are increasingly being tested in combination with traditional agents creating greater potential for enhanced and new toxicities. When a patient experiences a serious adverse event (SAE), investigators must determine whether the event is attributable to the investigational drug or not. This study seeks to understand the clinical reasoning, tools used and challenges faced by the researchers who assign causality to SAE's. METHODS: Thirty-two semi-structured interviews were conducted with medical oncologists and trial coordinators at six Canadian academic cancer centres. Interviews were recorded and transcribed verbatim. Individual interview content analysis was followed by thematic analysis across the interview set. FINDINGS: Our study found that causality assessment tends to be a rather complex process, often without complete clinical and investigational data at hand. Researchers described using a common processing strategy whereby they gather pertinent information, eliminate alternative explanations, and consider whether or not the study drug resulted in the SAE. Many of the interviewed participants voiced concern that causality assessments are often conducted quickly and tend to be highly subjective. Many participants were unable to identify any useful tools to help in assigning causality and welcomed more objectivity in the overall process. INTERPRETATION: Attributing causality to SAE's is a complex process. Clinical trial researchers apply a logical system of reasoning, but feel that the current method of assigning causality could be improved. Based on these findings, future research involving the development of a new causality assessment tool specifically for use in early phase oncology clinical trials may be useful.

GPs' approach to insulin prescribing in older patients: a qualitative study.

BACKGROUND: Evidence suggests that insulin is under-prescribed in older people. Some reasons for this include physician's concerns about potential side-effects or patients' resistance to insulin. In general, however, little is known about how GPs make decisions related to insulin prescribing in older people. AIM: To explore the process and rationale for prescribing decisions of GPs when treating older patients with type 2 diabetes. DESIGN OF STUDY: Qualitative individual interviews using a grounded theory approach. SETTING: Primary care. METHOD: A thematic analysis was conducted to identify themes that reflected factors that influence the prescribing of insulin. RESULTS: Twenty-one GPs in active practice in Ontario completed interviews. Seven factors influencing the prescribing of insulin for older patients were identified: GPs' beliefs about older people; GPs' beliefs about diabetes and its management; gauging the intensity of therapy required; need for preparation for insulin therapy; presence of support from informal or formal healthcare provider; frustration with management complexity; and GPs' experience with insulin administration. Although GPs indicated that they would prescribe insulin allowing for the above factors, there was a mismatch in intended approach to prescribing and self-reported prescribing. CONCLUSION: GPs' rationale for prescribing (or not prescribing) insulin is mediated by both practitioner-related and patient-related factors. GPs intended and actual prescribing varied depending on their assessment of each patient's situation. In order to improve prescribing for increasing numbers of older people with type 2 diabetes, more education for GPs, specialist support, and use of allied health professionals is needed.

The role of evidence in the decline of antibiotic use for common respiratory infections in primary care.

Antibiotic prescribing in primary care for common respiratory infections increased steadily until the mid 1990s, when the trend reversed noticeably. During the subsequent decade, antibiotic prescribing reduced by up to one-third in some countries. Explanations for this reduction have focused on a decline in the incidence and severity of common respiratory infections, and on the resulting decrease in the number of patients seeking consultation. We argue that evidence from primary-care research had a central role in changing the practice of antibiotic prescribing, and discuss the concern that has arisen among some physicians around this issue. Targeted reductions in antibiotic prescribing constitute a balancing act between individual and societal concerns, pitting the expected gains in preserving the usefulness of an antibiotic against any given reduction in use. There may be unintended consequences for decreasing antibiotic use beyond a certain point without adequate supporting evidence. A new approach to antibiotic prescribing requires comprehensive research to answer why change is necessary, and how that change can be safely implemented. Future policies must move beyond a "one size fits all" mindset if public and provider behaviours are expected to become more congruent with the growing research evidence.

A hybrid qualitative method for pretesting questionnaires: the example of a questionnaire to caregivers of Alzheimer disease patients.

A hybrid method based on cognitive interviewing and consensus panels was developed to pretest a questionnaire for caregivers of persons with Alzheimer disease (AD). The objective of the questionnaire was to elicit caregivers' attitudes and opinions on the use of medications to treat the disease. Thirty-one caregivers were divided into five pretest groups, within which each participant was asked to comment on questionnaire wording and design. The comments from participants in the first three groups were used to revise the questionnaire, and the revised version was given to participants in the remaining two groups. Overall, 81% (118/146) of the participants' comments were implemented. The number of comments made in the last two groups decreased relative to the number of comments made in the first three groups. The hybrid method enhanced the user-friendliness of the questionnaire and can serve as an alternative to common ad hoc pretest approaches that have little basis in theory.