Integrative oncology in cancer care - implementation factors: mixed-methods systematic review.

BACKGROUND: Integrative oncology (IO) appears to be beneficial to patients with cancer, but its implementation remains a challenge. Guided by the Theoretical Domains Framework (TDF) and the Capability-Opportunity-Motivation-Behaviour (COM-B) model, this systematic review identified the barriers to and facilitators of IO implementation in conventional cancer care settings. METHODS: We searched eight electronic databases from their inception until February 2022 for qualitative, quantitative or mixed-methods empirical studies reporting the implementation outcomes for IO services. Critical appraisal approach was tailored according to study types. The identified implementation barriers and facilitators were mapped onto TDF domains and the COM-B model, and subsequently onto the behavioural change wheel (BCW) for formulating behavioural change interventions. RESULTS: We included 28 studies (11 qualitative, 6 quantitative, 9 mixed-methods and 2 Delphi studies) of satisfied methodological quality. The main implementation barriers were the lack of IO knowledge, the absence of funding and healthcare professionals' low level of IO receptiveness. The key implementation facilitators were the dissemination of evidence on IO clinical benefits, the equipping of professionals with IO service delivery skills and the provision of a supportive organisational climate. CONCLUSION: Multifaceted implementation strategies are needed to address the determinants influencing IO service delivery. Based on our BCW-based analysis of the included studies, the key behavioural change techniques are: (1) educating healthcare professionals about the value and application of traditional and complementary medicine; (2) ensuring access to actionable clinical evidence on IO effectiveness and safety and (3) designing guidelines on communicating traditional and complementary medicine interventions with patients and caregivers for biomedically trained doctors and nurses.

Implementation science in traditional, complementary and integrative medicine: An overview of experiences from China and the United States.

BACKGROUND: The introduction of traditional, complementary and integrative medicine (TCIM) services into health systems has been advocated by the World Health Organization, but there is a paucity of reviews synthesising the experiences of (i) implementing TCIM services in conventional healthcare settings and (ii) introducing evidence-based practice in TCIM. Knowledge of the first issue will assist policymakers to innovate implementation interventions in their own health system contexts. Addressing the second issue will facilitate the closure of the evidence-practice gap in TCIM and improve the translation of research evidence into health outcome benefits. PURPOSE: The aim of this study was to identify, describe and analyse publications on these two key TCIM policy issues via an overview from an implementation science perspective. METHODS: Publications describing international experiences of implementing TCIM services or evidence for TCIM practices were identified by searching MEDLINE, EMBASE and Global Health databases in November 2021. The findings were summarised using a narrative synthesis approach. RESULTS: Sixty-three relevant publications were included in the analysis. Current experiences in China and the United Sates (US) reflect varying policy priorities at different stages of implementing TCIM services. In the US, where TCIM have yet to be introduced into mainstream healthcare settings, implementation interventions were designed to facilitate the provision of specific, evidence-based TCIM modalities via referrals from conventional clinicians. The application of these strategies at the health system, regulatory, financial, community, provider and patient levels provided a comprehensive picture of how TCIM implementation may be facilitated via multi-level interventions. In China, the major form of TCIM is traditional Chinese medicine (TCM), for which service provision has already been adopted at all levels of healthcare. With the high volume of clinical research that has been generated in the past several decades, a key policy question at this stage is how to translate TCM-related clinical evidence into practice. The development of clinical practice guidelines (CPGs) is the main implementation intervention, but adherence by TCM clinicians has been poor, due to the conflict between classical individualised practice and CPG standardisation. While tailoring interventions to facilitate CPG uptake is indicated, concurrent innovations in TCM clinical research methods would improve the compatibility between classical and CPG-based practice. CONCLUSION: Policymakers managing different stages of TCIM implementation will benefit from the experiences of practitioners in the US and China. Multi-level implementation interventions launched in the US provide ideas for the initial introduction of TCIM into a conventional medicine-dominated health system. As TCIM service provision and related clinical research become more common, China's experience will inform how clinical evidence related to TCIM may be disseminated and implemented to improve service quality.

Barriers and facilitators to promoting evidence uptake in Chinese medicine: a qualitative study in Hong Kong.

BACKGROUND: In response to the World Health Organization's recommendation, policy makers have been adopting evidence-based healthcare approach to promote the development of traditional, complementary and integrative medicine (TCIM) into Hong Kong's health system. Disseminating synopses of clinical evidence from systematic reviews or randomized trials is regarded as a potentially effective strategy to promote evidence uptake. The study aimed to identify barriers and facilitators to implementing this strategy among Hong Kong Chinese medicine practitioners (CMPs). METHODS: Twenty-five CMPs aged under 45 years and trained in Hong Kong after reunification with China in 1997 were interviewed individually. Four clinical evidence synopses of randomized trials and systematic reviews on Chinese medicine interventions were presented, and CMPs were asked to comment on their applicability in routine practice. The Consolidated Framework for Implementation Research (CFIR) was applied to guide interview and analysis. RESULTS: The barriers included: i) CMPs' perceived difficulties in applying complex evidence in decision-making and ii) inadequate training and limited consultation time. The facilitators were i) availability of publicly accessible and user-friendly synopses, ii) formation of community of evidence-based practice among CMPs with input from key opinion leaders, iii) opportunity for interprofessional collaborations with conventional healthcare providers, and iv) patients' demand for evidence-based clinical advice. Besides, i) CMPs' knowledge and beliefs in evidence-based healthcare approach, ii) presentations of evidence-based information in the synopses, and iii) clinical decision making as influenced by quality of evidence reported acted as both barriers and facilitators. CONCLUSIONS: This CFIR-based qualitative study investigated how the World Health Organization recommendation of promoting evidence use in routine practice was perceived by CMPs trained in Hong Kong after reunification with China in 1997. Key barriers and facilitators to applying evidence were identified. Such results will inform tailoring of implementation strategies for promoting evidence uptake, in the context of a well-developed health system dominated by conventional medicine.

MINISTOP 2.0: a smartphone app integrated in primary child health care to promote healthy diet and physical activity behaviours and prevent obesity in preschool-aged children: protocol for a hybrid design effectiveness-implementation study.

BACKGROUND: Childhood obesity is still a major health problem in many countries, including Sweden. Childhood obesity and obesity-related behaviours in childhood, such as low physical activity and unhealthy eating habits, tend to track into adulthood, which highlights the need for early prevention. Our aims are to evaluate whether a parent-oriented mobile health app (the MINISTOP 2.0 app) integrated into primary child health care can improve diet and physical activity behaviours and reduce the prevalence of overweight and obesity in preschool-aged children as well as to evaluate the implementation among child health care nurses and parents. METHODS: This trial uses a hybrid type 1 effectiveness-implementation design. Families (n = 500) who attend a routine visit to one of 15-20 primary child health care centres throughout Sweden, when their child is 2.5 years, are offered participation in a randomised controlled trial (effectiveness evaluation). After acceptance, families will be randomised (1:1) to control or intervention groups. The intervention group receives a 6-month parent-oriented smartphone intervention aimed at improving the dietary and activity behaviours of their child (the MINISTOP 2.0 app) and the control group receives routine child health care. Dietary habits, physical activity and screen time (primary outcomes), body weight and height in children, and parental self-efficacy (secondary outcomes) are measured at baseline and at 6 months post randomisation. Implementation outcomes (i.e. perceived acceptability, appropriateness, and feasibility) of the intervention will be assessed among primary child health care nurses and parents in the trial through questionnaires and qualitative interviews. DISCUSSION: This trial will evaluate whether the MINISTOP 2.0 app can be used in primary child health care to improve diet and physical activity behaviours, and prevent overweight and obesity, in preschool-aged children. If effectiveness is proven, and the MINISTOP 2.0 app is considered acceptable, appropriate and feasible, it can be implemented nationally as part of the preventive strategies to combat childhood obesity provided by routine child health care. TRIAL REGISTRATION: The trial was registered at the Clinicaltrials.gov register platform (ID NCT04147039 ) on 31 October 2019.

[Appropriate use of vitamin D assessments in primary health care: Impact of new strategies for the introduction and follow-up of analyses in Östergötland]. / D-vitaminanalyser i primärvård måste användas ändamålsenligt - Ny strategi i Östergötland för införande och uppföljning av analyser gav bra resultat.

Systematic reviews and meta-analyses have shown that there is little justification for vitamin D supplements to prevent infections, cancer and cardiovascular disease. Despite the limited evidence of effectiveness, the total number of ordered serum 25-hydroxyvitamin D (25(OH)D) tests has increased considerably in recent years. There seems to be an overuse of this test that does not provide meaningful benefit for patients. A passive introduction of new tests leads generally to a slow initiation of value-based diagnostics, as well as overuse and underuse of diagnostic tests. In this study, in Region Östergötland, we applied a ¼Choosing wisely« model that reversed a rising trend of 25(OH)D tests and reduced the number of unnecessary tests. The findings point to the need for strategic plans for introducing new analyses and approaches to counteract misuse of laboratory diagnostics. We recommend ¼Choosing wisely« models for the introduction of new analyses to facilitate appropriate laboratory diagnostics and to counteract long-term overuse.

Alcohol consumption among partners of pregnant women in Sweden: a cross sectional study.

BACKGROUND: Antenatal care in Sweden involves a visit in pregnancy week 6-7 for counseling about lifestyle issues, including alcohol. The aim of this study was to investigate alcohol consumption among partners of pregnant women, their motives for changing drinking patterns when becoming a parent and their perceptions of the midwife's counseling about alcohol. METHOD: The study was conducted at 30 antenatal care centers across Sweden in 2009-2010. All partners who accompanied a pregnant women in pregnancy week >17 were asked to participate. The questionnaire included questions on alcohol consumption. RESULTS: Questionnaires from 444 partners were analyzed. Most, 95 %, of the partners reported alcohol consumption before pregnancy; 18 % were binge drinking (6 standard drinks or more per occasion, each drink containing 12 grams of pure alcohol) at least once every month during the last year. More than half, 58 %, of all partners had decreased their alcohol consumption following pregnancy recognition and a higher proportion of binge drinkers decreased their consumption compared to non-frequent binge drinkers (p = 0.025). Their motives varied; the pregnancy itself, fewer social gatherings (potentially involving alcohol consumption) and a sense of responsibility for the pregnant partner were reported. Of the partners, 37 % reported support for decreased drinking from others (pregnant partner, parents, friend or workmates). Further, most partners appreciated the midwife's counseling on alcohol. CONCLUSION: A majority of partners decreased their alcohol consumption in transition to parenthood, which also appears to be a crucial time for changing alcohol-drinking patterns. The partners with higher AUDIT-C scores reported more support for decreased drinking. Most partners appreciated the midwife's talk about alcohol and pregnancy and those who filled out AUDIT in early pregnancy reported that the counseling was more engaging. During pregnancy it is possible to detect partners with high alcohol consumption, and promote interventions for decreased drinking, also for the partners. Written information addressing alcohol use and directed to partners is needed.

Towards improved alcohol prevention in Swedish antenatal care?

OBJECTIVE: to evaluate an education effort and revised alcohol-preventive routine in Swedish antenatal care; to generate more knowledge for further development of alcohol issues in antenatal care. DESIGN: two national cross-sectional surveys of Swedish midwives were conducted. Baseline data were collected in 2006 and follow-up data in 2009. SETTING: antenatal care centres in Sweden. PARTICIPANTS: 974 midwives in 2006 and 1108 midwives in 2009. MEASUREMENT: amount and content of continuing professional education, work with alcohol-related issues, identification of women with risky consumption of alcohol, and action after identifying women with risky consumption. FINDINGS: the amount of continuing professional education undertaken by midwives on handling risky drinking increased significantly between 2006 and 2009. The routine to detect risky drinking changed between the baseline and follow-up data collection, as nearly all midwives reported the use of an alcohol screening questionnaire in 2009. The most confident midwives in 2009 had taken part in more days of education, more often stated it was their own initiative to participate, and had more often taken part in education regarding MI, provision of advice and information on the health risks associated with alcohol and, screening. KEY CONCLUSIONS: our results indicate that a broad, national education effort can be successful in enhancing knowledge and changing antenatal care practice. However, generalisation to other countries or cultures may be limited because the usage of new routines is affected by many organisational and contextual factors.

Approaches to assessment of alcohol intake during pregnancy in Swedish maternity care--a national-based investigation into midwives' alcohol-related education, knowledge and practice.

OBJECTIVE: to evaluate how much education midwives in Sweden have undertaken to help them assess alcohol intake during pregnancy, and what tools they use to identify women who may be at risk of drinking during pregnancy. DESIGN: a national survey was conducted in March 2006, using a questionnaire constructed by a Swedish team of researchers and clinicians. SETTING: maternity health-care centres in Sweden. PARTICIPANT: 2106 midwives. FINDINGS: nearly all midwives stated that they had excellent or good knowledge concerning the risks associated with drinking during pregnancy. They considered themselves less knowledgeable about detecting pregnant women with risky alcohol consumption before pregnancy. The majority of the midwives had participated in some education in handling risky drinking. Almost half of the midwives assessed women's alcohol intake before pregnancy. Important facilitators for increased activity concerned recommendations and decisions at different levels (national, local and management) on how to address alcohol with expectant parents and work with risky drinkers. KEY CONCLUSIONS: more education was associated with more common use of a questionnaire for assessment of women's alcohol intake before pregnancy, and more frequent counselling when identifying a pregnant woman whose pre-pregnancy consumption was risky.