Factors influencing implementation of digital cardiac rehabilitation: A qualitative analysis of health workers perspectives.

Background: Despite growing evidence for the effectiveness of digital cardiac rehabilitation (CR) uptake of this technology remains low. Understanding the factors that influence implementation of digital CR in clinical practice is a growing area of research. The aim of this nested qualitative study was to explore health worker perspectives on factors influencing implementation of a digital CR programme. Methods: Using convenience sampling, semi-structured interviews were conducted with health workers, including health care professionals (nurses, dietitians, physiotherapists) and those in administrative and managerial roles who were involved in delivering and referring patients to Croí MySláinte, a 12-week digital CR intervention delivered during the Coronavirus 2019 pandemic. The updated Consolidated Framework for Implementation Research (CFIR) guided data collection and framework analysis. Results: Interviews were conducted with 14 health workers. Factors influencing implementation of Croí MySláinte were multiple, with some operating independently and others in combination. They related to: (i) characteristics of individuals (e.g., senior leadership support, commitment and motivation of Health workers to meet patient needs, technical capability, workload and perceived fit with role); (ii) features of the programme (e.g., accessibility and convenience for patients, the digital platform, patient self- monitoring tools, the multidisciplinary team and core components); (iii) the external environment (e.g., partnership and connections between organisations, broadband and COVID-19); (iv) the internal environment (e.g., organisational culture, teamwork, resources including funding, digital infrastructure and staffing); and (v) the implementation process (e.g., engaging patients through provision of technical support). Conclusion: The study findings suggest that factors influencing implementation of digital CR operate at multiple levels. Therefore, multi-level implementation strategies are required if the true potential of digital health in improving equitable cardiac rehabilitation access, participation and patient outcomes is to be realised.

Factors influencing participation in an online national diabetes prevention programme: A qualitative study with attenders and educators.

AIM: To explore factors affecting participation in the pilot of the synchronous online national diabetes prevention programme (NDPP) in Ireland from the perspectives of those who attended and the educators who recruited for and delivered the programme. METHODS: A qualitative study involving semi-structured interviews and focus groups with NDPP attenders (attended the assessment and at least one session) and educators (dietitians) on the programme. The Framework Method using the Theoretical Domains Framework (TDF) guided the analysis. RESULTS: Thirteen attenders took part in two online focus groups and five online or phone interviews. Eight educators took part. Four themes which cut across the TDF domains were identified as factors influencing participation; (i) lack of awareness of prediabetes and fear of diabetes, relating to attenders' fear of diabetes and lack of knowledge of prediabetes and diabetes prevention; (ii) perceived need for programme support to change health behaviour, concerning attenders' and educators' recognition of the need for the NDPP; (iii) trust in healthcare professionals (HCPs), relating to trust in HCPs to convey the seriousness of prediabetes and the value of diabetes prevention programmes (DPPs) and (iv) practical and personal ease of joining online, relating to the flexibility and accessibility of the synchronous online group format, the IT skills of attenders and educators and apprehension about group education. CONCLUSIONS: Raising awareness of prediabetes and the need for prevention programmes should be a priority for health services and HCPs. The synchronous online group format was seen as less daunting to join than a face-to-face programme and may be a useful option to encourage participation.

News media framing of food poverty and insecurity in high-income countries: a rapid review.

Food poverty and insecurity have become a public health emergency in many high-income countries. News media coverage can shape public and political views towards such issues. This rapid review synthesizes the evidence on how food poverty and insecurity are represented in the news media. Peer-reviewed publications were accessed through three electronic databases, with reference lists of all included studies screened. Primary research studies conducted in high-income countries and published in English since 1995 were included, with no restrictions on study methods. A combination of deductive coding to Entman's framing theory and inductive analysis was used. Ten studies, mostly rated as low quality, were included in the review. Newspapers were the only type of news media examined. The findings showed a largely absent nuanced understanding of food poverty and insecurity, with the problem often defined by food bank use and the consequences mainly focused on physical health. The causes were mostly attributed to structural factors, with the solutions largely focused on charitable food aid. The discourse of recipient (un)deservingness of food aid was evident. Articles often contained views from government officials and charities, with individuals' experiences of food poverty and insecurity largely absent. The findings of this review highlight that a major shift in print media discourse on food poverty and insecurity is required. More balanced and critical news reporting is required to present a more realistic picture of food poverty and insecurity, including its multi-dimensional nature, limitations of food charity and the need for structural solutions to this important issue.

Understanding tailoring to support the implementation of evidence-based interventions in healthcare: The CUSTOMISE research programme protocol.

Although there are effective evidence-based interventions (EBIs) to prevent, treat and coordinate care for chronic conditions they may not be adopted widely and when adopted, implementation challenges can limit their impact.  Implementation strategies are "methods or techniques used to enhance the adoption, implementation, and sustainment of a clinical program or practice". There is some evidence to suggest that to be more effective,  strategies should be tailored; that is, selected and designed to address specific determinants which may influence implementation in a given context. Despite the growing popularity of tailoring the concept is ill-defined, and the way in which tailoring is applied can vary across studies or lack detail when reported. There has been less focus on the part of tailoring where stakeholders prioritise determinants and select strategies, and the way in which theory, evidence and stakeholders' perspectives should be combined to make decisions during the process. Typically, tailoring is evaluated based on the effectiveness of the tailored strategy, we do not have a clear sense of the mechanisms through which tailoring works, or how to measure the "success" of the tailoring process. We lack an understanding of how stakeholders can be involved effectively in tailoring and the influence of different approaches on the outcome of tailoring. Our research programme, CUSTOMISE (Comparing and Understanding Tailoring Methods for Implementation Strategies in healthcare) will address some of these outstanding questions and generate evidence on  the feasibility, acceptability, and efficiency of different tailoring approaches, and build capacity in implementation science in Ireland, developing and delivering training and supports for, and network of, researchers and implementation practitioners. The evidence generated across the studies conducted as part of CUSTOMISE will bring greater clarity, consistency, coherence, and transparency to tailoring, a key process in implementation science.

Dietary counselling to reduce moderate sodium intake: effects on cardiovascular and renal biomarkers: primary findings of the COSIP and STICK phase II feasibility randomised controlled trials.

Background: While low sodium intake (<2.3 g/day) is recommended, there is uncertainty about long-term feasibility and effects on cardiorenal biomarkers in populations with moderate intake. Methods: In two phase IIb, feasibility, randomised, parallel, open-label, controlled, single-centre trials, individuals aged >40 years with stable blood pressure (BP), without heart failure or postural hypotension were randomised to intensive dietary counselling (target sodium intake <2.3 g/day) or usual care between March 2016 and July 2018. One trial included participants with chronic kidney disease (CKD); the other excluded those with CKD or cardiovascular disease. All participants received healthy eating advice. Primary outcomes were NT-pro B-type natriuretic peptide (NT-proBNP), high sensitivity troponin T (hsTnT), C-reactive protein (CRP), renin, aldosterone and, creatinine clearance (CrCl) at 2-years. These trials are registered with ClinicalTrials.gov, STICK trial (NCT02458248) and COSIP trial (NCT02738736). Findings: 373 participants, with mean 24-h urine sodium 3.16 ± 1.47 g/day, were randomised to intervention (n = 187) or usual care (n = 186). At 3-months, the intervention reduced 24-h urine sodium (intervention -0.11 g/day, usual care +0.28 g/day, p = 0.003), BP (systolic -2.52 mmHg, p = 0.05; diastolic -1.92, p = 0.02) and increased renin (+33.35 mIU/L [95%CI 3.78-62.91]). At 2-years, the intervention significantly reduced self-reported salt use (p < 0.001), but not 24-h urine sodium (intervention -0.23 g/day, usual care +0.05 g/day, p = 0.47). At 2-years, there were no significant between-group differences in BP (systolic p = 0.66; diastolic p = 0.09), NT-proBNP (p = 0.68), hsTnT (p = 0.20), CRP (p = 0.56), renin (p = 0.52), aldosterone (p = 0.61), or CrCl (p = 0.68). Interpretation: Among individuals with moderate sodium intake, intensive dietary counselling resulted in small short-term reductions in sodium intake and BP, but no significant effect on sodium intake, BP, or cardiorenal biomarkers at two years. Our trial suggests that it may not feasible to reduce sodium sustainably in those with a sodium intake around 3.0 g/day, through an intensive dietary counselling intervention. Funding: The STICK trial was funded by the Health Research Board of Ireland and the COSIP trial was funded by the European Research Council.

Characterising processes and outcomes of tailoring implementation strategies in healthcare: a protocol for a scoping review.

Background: Tailoring strategies to target the salient barriers to and enablers of implementation is considered a critical step in supporting successful delivery of evidence based interventions in healthcare. Theory, evidence, and stakeholder engagement are considered key ingredients in the process however, these ingredients can be combined in different ways. There is no consensus on the definition of tailoring or on a single method for tailoring strategies to optimize impact, ensure transparency, and facilitate replication. Aim: The purpose of this scoping review is to describe how tailoring has been undertaken within healthcare to answer questions about how it has been conceptualised, described, and conducted in practice, and to identify research gaps. Methods: The review will be conducted in accordance with best practice guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping reviews (PRISMA-ScR) will be used to guide the reporting. Searches will be conducted of MEDLINE, Embase, Web of Science, Scopus, from 2005 to present. Reference lists of included articles will be searched. Grey literature will be searched on Google Scholar. Screening and data extraction will be conducted by two or more members of the research team, with any discrepancies resolved by consensus discussion with a third reviewer. Initial analysis will be quantitative involving a descriptive numerical summary of the characteristics of the studies and the tailoring process. Qualitative content analysis aligned to the research questions will also be conducted, and data managed using NVivo where applicable. This scoping review is pre-registered with the Open Science Framework. Conclusions: The findings will serve as a resource for implementation researchers and practitioners to guide future research in this field and facilitate systematic, transparent, and replicable development of tailored implementation strategies.

Factors Influencing Fidelity to a Calorie Posting Policy in Public Hospitals: A Mixed Methods Study.

Background: Labelling menus with nutrition information has increasingly become an important obesity policy option. While much research to-date has focused on determining its effectiveness, few studies report the extent to which menu labelling is implemented as designed. The aim of this study was to explore factors influencing fidelity to a calorie posting policy in Irish acute public hospitals. Methods: A mixed methods sequential explanatory study design was employed, with a nested case study for the qualitative component. Quantitative data on implementation fidelity at hospitals were analysed first and informed case sampling in the follow-on qualitative phase. Maximum variation sampling was used to select four hospitals with high and low levels of implementation and variation in terms of geographic location, hospital size, complexity of care provided and hospital type. Data were collected using structured observations, unstructured non-participant observations and in-depth semi-structured interviews. The Consolidated Framework for Implementation Research guided qualitative data collection and analysis. Using framework analysis, factors influencing implementation were identified. A triangulation protocol was used to integrate fidelity findings from multiple sources. Data on influencing factors and fidelity were then combined using joint displays for within and cross-case analysis. Results: Quantitative fidelity data showed seven hospitals were categorised as low implementers and 28 hospitals were high implementers of the policy. Across the four hospitals selected as cases, qualitative analysis revealed factors influencing implementation and fidelity were multiple, and operated independently and in combination. Factors were related to the internal hospital environment (e.g., leadership support, access to knowledge and information, perceived importance of calorie posting implementation), external hospital environment (e.g., national policy, monitoring), features of the calorie posting policy (e.g., availability of supporting materials), and the implementation process (e.g., engaging relevant stakeholders). Integrated analysis of fidelity indicated a pattern of partial adherence to the calorie posting policy across the four hospitals. Across all hospitals, there was a consistent pattern of low adherence to calorie posting across all menu items on sale, low adherence to calorie information displayed per standard portion or per meal, low adherence to standardised recipes/portions, and inaccurate calorie information. Conclusion: Efforts to maximise fidelity require multi-level, multi-component strategies in order to reduce or mitigate barriers and to leverage facilitators. Future research should examine the relative importance of calorie posting determinants and the association between implementation strategies and shifts in fidelity to intervention core components.

Clarifying Optimal Sodium InTake In Cardiovasular and Kidney (COSTICK) Diseases: a study protocol for two randomised controlled trials.

Background: While low sodium intake (<2.3g/day) is recommended for all, there is uncertainty about feasibility and net cardiovascular effects. In COSTICK, we evaluated the effects of a dietary counselling intervention (reduced sodium intake) on intermediate cardiorenal outcomes in patients with (STICK) and without (COSIP) mild/moderate kidney disease. Methods: This is a protocol for two phase IIb randomised, two-group, parallel, open-label, controlled, single centre trials. Participants were aged >40 years with stable blood pressure, unchanged anti-hypertensive medications, willing to modify diet and provided written informed consent. Participants were excluded for abnormal sodium handling, heart failure, high dose diuretics, immunosuppression, pregnancy/lactation, postural hypotension, cognitive impairment, high or low body mass index (BMI) or inclusion in another trial. STICK participants had estimated glomerular filtration rate (eGFR) 30-60ml/min/1.73m 2 and were excluded for acute kidney Injury, rapidly declining eGFR; known glomerular disease or current use of non-steroidal anti-inflammatory drugs. For COSIP, participants were excluded for known kidney or cardiovascular disease. Participants were randomized to usual care only (healthy eating) or an additional sodium lowering intervention (target <100mmol/day) through specific counseling (sodium use in foods, fresh over processed foods, sodium content of foods and eating outside of home). In STICK the primary outcome is change in 24-hour urinary creatinine clearance. In COSIP, the primary outcome is change in five biomarkers (renin, aldosterone, high sensitivity troponin T, pro-B-type natriuretic peptide and C-reactive protein). Our primary report (COSTICK), reports six biomarker outcome measures in the entire population at 2 years follow-up. Discussion: These Phase II trials will explore uncertainty about low sodium intake and cardiovascular and kidney biomarkers, and help determine the feasibility of low sodium intake. Trial results will also provide preliminary information to guide a future definitive clinical trial, if indicated. Trial registration: STICK: ClinicalTrials.gov NCT02738736 (04/04/2016); COSIP: ClinicalTrials.gov NCT02458248 (15/05/2016).

Barriers and facilitators to implementation of menu labelling interventions from a food service industry perspective: a mixed methods systematic review.

BACKGROUND: Eating outside the home contributes to poor dietary habits worldwide and is associated with increased body fat and weight gain. Evidence shows menu labelling is effective in promoting healthier food choices; however, implementation issues have arisen. The purpose of this systematic review was to synthesise the evidence on the perceived barriers and facilitators to implementation of menu labelling interventions from the perspective of the food service industry. METHODS: Peer-reviewed and grey literature were searched using databases, specialised search engines and public health organisation websites. Screening reference lists, citation chaining and contacting authors of all included studies were undertaken. Primary research studies relevant to direct supply-side stakeholders were eligible for inclusion. There were no restrictions on menu labelling scheme or format, study methods, publication year or language. At least two independent reviewers performed study selection, data extraction and quality appraisal. The results were synthesised using the 'best fit' framework synthesis approach, with reference to the Consolidated Framework for Implementation Research (CFIR). RESULTS: Seventeen studies met the eligibility criteria, with the majority rated as average quality (n = 10). The most frequently cited barriers were coded to the CFIR constructs 'Consumer Needs & Resources' (e.g. lack of customer demand for/interest in menu labelling, risk of overwhelmed/confused customers) and 'Compatibility' with organisation work processes (e.g. lack of standardised recipes, limited space on menus). Frequently cited facilitators were coded to the CFIR constructs 'Relative Advantage' of menu labelling (e.g. improved business image/reputation) and 'Consumer Needs & Resources' (e.g. customer demand for/interest in menu labelling, providing nutrition information to customers). An adapted framework consisting of a priori and new constructs was developed, which illustrates the relationships between domains. CONCLUSION: This review generates an adapted CFIR framework for understanding implementation of menu labelling interventions. It highlights that implementation is influenced by multiple interdependent factors, particularly related to the external and internal context of food businesses, and features of the menu labelling intervention. The findings can be used by researchers and practitioners to develop or select strategies to address barriers that impede implementation and to leverage facilitators that assist with implementation effort. TRIAL REGISTRATION: Systematic review registration: PROSPERO CRD42017083306.

Barriers and facilitators to the implementation of nutrition standards for school food: a mixed-methods systematic review protocol.

Background: The importance of nutrition during childhood and the high prevalence of child and adolescent obesity has resulted in several countries implementing nutritional standards for school food as a way of providing healthy school food environments. Yet, there has been less focus on the barriers and facilitators influencing the process of implementing school food standards. This mixed-methods systematic review aims to address this evidence gap by synthesising the empirical evidence on the factors that may influence the implementation of school food standards. Methods: This mixed-methods systematic review will use qualitative, quantitative and mixed-methods evidence from peer-reviewed publications retrieved from the following databases; PubMed, CINAHL, Scopus, EMBASE, Medline, PsycINFO and Web of Science. Grey literature will be accessed through Google Scholar, Open Access Theses and Dissertations, OpenGrey, RIAN, EThOS, ProQuest, WorldCat, Networked Digital Library of Theses and Dissertations, and public health organisation websites will also be accessed. Screening reference lists and citation chaining of all included studies will also be undertaken. No restrictions on publication date or language will be applied, however, only primary research studies relevant to supply-side stakeholders will be eligible for inclusion. Study quality will be assessed using the Mixed Methods Appraisal Tool. Study titles and abstracts will be screened to decide whether the full-text manuscript should be retrieved. For screening reliability, a second review author will assess a random sample of 20%. Kappa statistics will be used to assess inter-rater reliability, with values of 0.75 and higher representing high agreement. Two authors will independently extract data and factors reported to influence implementation. This will be synthesized using the Theoretical Domains Framework. Discussion: A comprehensive understanding of these factors can provide guidance to relevant stakeholders to enhance the adoption, implementation and sustainability of nutrition standards for school meals. Systematic review registration: PROSPERO CRD42019117904.

Barriers and facilitators to implementation of menu labelling interventions to support healthy food choices: a mixed methods systematic review protocol.

BACKGROUND: Menu labelling is continuing to gather public and legislative support as one of the potential environmental strategies for addressing the obesity pandemic. However, issues relating to implementation have been reported in countries where menu labelling has been introduced on a voluntary or mandatory basis. The aim of this mixed methods systematic review is to synthesise the empirical evidence on the barriers and facilitators to implementation of menu labelling interventions to support healthy food choices. METHODS: This review will use the 'best fit' framework synthesis approach to synthesise qualitative, quantitative and mixed methods evidence. Peer-reviewed publications will be accessed through PubMed, EMBASE, CINAHL, PsycINFO, Web of Science and Scopus. Grey literature will be accessed through Google Scholar, OpenGrey, RIAN, EThOS, ProQuest, WorldCat, Networked Digital Library of Theses and Dissertations, Open Access Theses and Dissertations, and public health organisation websites. Screening reference lists, citation chaining and contacting authors of all included studies will be undertaken. There will be no restriction on menu labelling scheme or format, publication year or language; however, only primary research studies relevant to supply-side stakeholders will be eligible for inclusion. Study quality will be assessed using the Mixed Methods Appraisal Tool. At least two independent reviewers will perform study selection, data extraction and quality appraisal; if consensus is required, another independent reviewer will be consulted. A combination of deductive coding, using the Consolidated Framework for Implementation Research as the a priori framework, and inductive analysis, using secondary thematic analysis, will be used. The overall process will assist in the construction of a new evidence-based conceptual model regarding the implementation of menu labelling interventions. The new model will be assessed for bias and a sensitivity analysis performed. DISCUSSION: Given the growing consensus that a systemic, sustained portfolio of obesity prevention strategies, delivered at scale, is needed to address the obesity epidemic, greater understanding of the practical issues relating to implementation of such strategies is required. Findings from this review will be used to develop a set of best-practice guidelines to enhance the adoption, implementation and sustainability of menu labelling interventions across countries worldwide. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017083306.

Effects of an icon-based menu labelling initiative on consumer food choice.

AIMS: The purpose of this study was to examine the impact of an icon-based menu labelling initiative on consumer buying behaviour. METHODS: This quasi-experimental study recruited a convenience sample of eight food service establishments, all with at least one menu item meeting the heart healthy criteria. Data from sales of all menu items sold over an 8-week period were collated 4 weeks prior to and 4 weeks during the display of information icons related to healthy food choices on menus. RESULTS: The absolute change in menu item sales showed a non-significant trend towards an increase in healthier menu item selections. Furthermore, there was no association between the type of food service establishment and the percentage change in labelled menu item sales. CONCLUSION: The study did not find a statistically significant influence of the icon-based menu labels on consumer food choice. Given the limited amount of research that examines alternative menu labelling formats in real-world settings, more studies are necessary to confirm these results. Further research is needed to identify the optimal format, content and impact of menu labels on consumer behaviour.

Effects of an eight-week supervised, structured lifestyle modification programme on anthropometric, metabolic and cardiovascular risk factors in severely obese adults.

BACKGROUND: Lifestyle modification is fundamental to obesity treatment, but few studies have described the effects of structured lifestyle programmes specifically in bariatric patients. We sought to describe changes in anthropometric and metabolic characteristics in a cohort of bariatric patients after participation in a nurse-led, structured lifestyle programme. METHODS: We conducted a retrospective, observational cohort study of adults with a body mass index (BMI) ≥ 40 kgm(-2) (or ≥ 35 kgm(-2) with significant co-morbidity) who were attending a regional bariatric service and who completed a single centre, 8-week, nurse-led multidisciplinary lifestyle modification programme. Weight, height, waist circumference, blood pressure, HbA1c, fasting glucose and lipid profiles as well as functional capacity (Incremental Shuttle Walk Test) and questionnaire-based anxiety and depression scores before and after the programme were compared in per-protocol analyses. RESULTS: Of 183 bariatric patients enrolled, 150 (81.9%) completed the programme. Mean age of completers was 47.9 ± 1.2 years. 34.7% were male. There were statistically significant reductions in weight (129.6 ± 25.9 v 126.9 ± 26.1 kg, p < 0.001), BMI (46.3 ± 8.3 v 44.9 ± 9.0 kgm(-2), p < 0.001), waist circumference (133.0 ± 17.1 v 129.3 ± 17.5 cm in women and 143.8 ± 19.0 v 135.1 ± 17.9 cm in men, both p < 0.001) as well as anxiety and depression scores, total- and LDL-cholesterol and triglyceride levels, with an increase in functional capacity (5.9 ± 1.7 v 6.8 ± 2.1 metabolic equivalents of thermogenesis (METS), p < 0.001) in completers at the end of the programme compared to the start. Blood pressure improved, with reductions in systolic and diastolic blood pressure from 135 ± 16.2 to 131.6 ± 17.1 (p = 0.009) and 84.7 ± 10.2 to 81.4 ± 10.9 mmHg (p < 0.001), respectively. The proportion of patients achieving target blood pressure increased from 50.3 to 59.3% (p = 0.04). The proportion of patients with diabetes achieving HbA1c <53 mmol/mol increased from 28.6 to 42.9%, p = 0.02. CONCLUSIONS: Bariatric patients completing an 8 week, nurse-led structured lifestyle programme had improved adiposity, fitness, lipid profiles, psychosocial health, blood pressure and glycaemia. Further assessment of this programme in a pragmatic randomised controlled trial seems warranted.

Translating guidelines to practice: findings from a multidisciplinary preventive cardiology programme in the west of Ireland.

AIMS: The aim of this observational, descriptive study is to evaluate the impact of an intensive, evidence-based preventive cardiology programme on medical and lifestyle risk factors in patients at high risk of developing cardiovascular disease (CVD). METHODS: Increased CVD risk patients and their family members/partners were invited to attend a 16-week programme consisting of a professional multidisciplinary lifestyle intervention, with appropriate risk factor and therapeutic management in a community setting. Smoking, dietary habits, physical activity levels, waist circumference and body mass index, and medical risk factors were measured at initial assessment, at end of programme, and at 1-year follow up. RESULTS: Adherence to the programme was high, with 375 (87.2%) participants and 181 (84.6%) partners having completed the programme, with 1-year data being obtained from 235 (93.6%) patients and 107 (90.7%) partners. There were statistically significant improvements in both lifestyle (body mass index, waist circumference, physical activity, Mediterranean diet score, fish, fruit, and vegetable consumption, smoking cessation rates), psychosocial (anxiety and depression scales and quality of life indices), and medical risk factors (blood pressure, lipid and glycaemic targets) between baseline and end of programme, with these improvements being sustained at 1-year follow up. CONCLUSIONS: These findings demonstrate how a holistic model of CVD prevention can improve cardiovascular risk factors by achieving healthier lifestyles and optimal medical management.