An evaluation of the quality of ear health services for Aboriginal children living in remote Australia: a cascade of care analysis.

BACKGROUND: In the Northern Territory (NT) the prevalence of otitis media (OM) in young Aboriginal children living in remote communities has persisted at around 90% over the last few decades. OM-associated hearing loss can cause developmental delay and adversely impact life course trajectories. This study examined the 5-year trends in OM prevalence and quality of ear health services in remote NT communities. METHODS: A retrospective analysis was performed on de-identified clinical data for 50 remote clinics managed by the NT Government. We report a 6-monthly cascade analysis of the proportions of children 0-16 years of age receiving local guideline recommendations for surveillance, OM treatment and follow-up at selected milestones between 2014 and 2018. RESULTS: Between 6,326 and 6,557 individual children were included in the 6-monthly analyses. On average, 57% (95%CI: 56-59%) of eligible children had received one or more ear examination in each 6-monthly period. Of those examined, 36% (95%CI: 33-40%) were diagnosed with some type of OM, of whom 90% had OM requiring either immediate treatment or scheduled follow-up according to local guidelines. Outcomes of treatment and follow-up were recorded in 24% and 23% of cases, respectively. Significant decreasing temporal trends were found in the proportion diagnosed with any OM across each age group. Overall, this proportion decreased by 40% over the five years (from 43 to 26%). CONCLUSIONS: This cascade of care analysis found that ear health surveillance and compliance with otitis media guidelines for treatment and follow-up were both low. Further research is required to identify effective strategies that improve ear health services in remote settings.

Organizational Characteristics and Readiness for Tobacco-Free Workplace Program Implementation Moderates Changes in Clinician's Delivery of Smoking Interventions within Behavioral Health Treatment Clinics.

BACKGROUND: Smoking is elevated amongst individuals with behavioral health disorders, but not commonly addressed. Taking Texas Tobacco Free is an evidence-based, tobacco-free workplace program that addresses this, in-part, by providing clinician training to treat tobacco use in local mental health authorities (LMHAs). This study examined organizational moderators of change in intervention delivery from pre- to post-program implementation. METHODS: LMHA leaders completed the Organizational Readiness for Implementing Change (ORIC) and provided organization demographics pre-implementation. Clinicians (N = 1237) were anonymously surveyed about their consistent use of the 5As (Asking about smoking; Advising clientele to quit; Assessing willingness to quit; Assisting them to quit; Arranging follow-up) pre- and post-program implementation. Adjusted generalized linear mixed models were used for analyses (responses nested within LMHAs), with interaction terms used to assess moderation effects. RESULTS: Clinician delivery of 5As increased pre- to post-implementation (p < .001). LMHAs with fewer employees (ref = ≤300) demonstrated greater increases in Asking, Assessing, and Assisting over time. LMHAs with fewer patients (ref = ≤10 000) evinced greater changes in Asking over time. Less initial ORIC Change Efficacy, Change Commitment, and Task Knowledge were each associated with greater pre- to post-implementation changes in Asking. Less initial Task Knowledge was associated with greater increases in Advising, Assessing, and Assisting. Finally, less initial Resource Availability was associated with greater increases in Assisting (all moderation term ps < .025). CONCLUSION: The smallest and least ready LMHAs showed the largest gains in tobacco cessation intervention delivery; thus, low initial readiness was not a barrier for program implementation, particularly when efficacy-building training and resources are provided. IMPLICATIONS: This study examined organizational moderators of increases in tobacco cessation treatment delivery over time following the implementation of a comprehensive tobacco-free workplace program within 20 of 39 LMHAs across Texas (hundreds of clinics; servicing >50% of the state) from 2013 to 2018. Overall, LMHAs with fewer employees and patients, and that demonstrated the least initial readiness for change, evinced greater gains in intervention delivery. Findings add to dissemination and implementation science by supporting that low initial readiness was not a barrier for this aspect of tobacco-free workplace program implementation when resources and clinician training sessions were provided.

How public health services pay for radiotherapy in Europe: an ESTRO-HERO analysis of reimbursement.

Reimbursement is a key factor in defining which resources are made available to ensure quality, efficiency, availability, and access to specific health-care interventions. This Policy Review assesses publicly funded radiotherapy reimbursement systems in Europe. We did a survey of the national societies of radiation oncology in Europe, focusing on the general features and global structure of the reimbursement system, the coverage scope, and level for typical indications. The annual expenditure covering radiotherapy in each country was also collected. Most countries have a predominantly budgetary-based system. Variability was the major finding, both in the components of the treatment considered for reimbursement, and in the fees paid for specific treatment techniques, fractionations, and indications. Annual expenses for radiotherapy, including capital investment, available in 12 countries, represented between 4·3% and 12·3% (average 7·8%) of the cancer care budget. Although an essential pillar in multidisciplinary oncology, radiotherapy is an inexpensive modality with a modest contribution to total cancer care costs. Scientific societies and policy makers across Europe need to discuss new strategies for reimbursement, combining flexibility with incentives to improve productivity and quality, allowing radiation oncology services to follow evolving evidence.

Global Prison Health Care Governance and Health Equity: A Critical Lack of Evidence.

The large and growing population of people who experience incarceration makes prison health an essential component of public health and a critical setting for reducing health inequities. People who experience incarceration have a high burden of physical and mental health care needs and have poor health outcomes. Addressing these health disparities requires effective governance and accountability for prison health care services, including delivery of quality care in custody and effective integration with community health services.Despite the importance of prison health care governance, little is known about how prison health services are structured and funded or the methods and processes by which they are held accountable. A number of national and subnational jurisdictions have moved prison health care services under their ministry of health, in alignment with recommendations by the World Health Organization and the United Nations Office on Drugs and Crime. However, there is a critical lack of evidence on current governance models and an urgent need for evaluation and research, particularly in low- and middle-income countries.Here we discuss why understanding and implementing effective prison health governance models is a critical component of addressing health inequities at the global level.

Outcome choice and definition in systematic reviews leads to few eligible studies included in meta-analyses: a case study.

BACKGROUND: There is broad recognition of the importance of evidence in informing clinical decisions. When information from all studies included in a systematic review ("review") does not contribute to a meta-analysis, decision-makers can be frustrated. Our objectives were to use the field of eyes and vision as a case study and examine the extent to which authors of Cochrane reviews conducted meta-analyses for their review's pre-specified main outcome domain and the reasons that some otherwise eligible studies were not incorporated into meta-analyses. METHODS: We examined all completed systematic reviews published by Cochrane Eyes and Vision, as of August 11, 2017. We extracted information about each review's outcomes and, using an algorithm, categorized one outcome as its "main" outcome. We calculated the percentage of included studies incorporated into meta-analyses for any outcome and for the main outcome. We examined reasons for non-inclusion of studies into the meta-analysis for the main outcome. RESULTS: We identified 175 completed reviews, of which 125 reviews included two or more studies. Across these 125 reviews, the median proportions of studies incorporated into at least one meta-analysis for any outcome and for the main outcome were 74% (interquartile range [IQR] 0-100%) and 28% (IQR 0-71%), respectively. Fifty-one reviews (41%) could not conduct a meta-analysis for the main outcome, mostly because fewer than two included studies measured the outcome (21/51 reviews) or the specific measurements for the outcome were inconsistent (16/51 reviews). CONCLUSIONS: Outcome choice during systematic reviews can lead to few eligible studies included in meta-analyses. Core outcome sets and improved reporting of outcomes can help solve some of these problems.

Effectiveness of palliative care consultation service on caregiver burden over time between terminally ill cancer and non-cancer family caregivers.

PURPOSE: The responsibility of taking care of terminal patients is accepted as a role of family members in Taiwan. Only a few studies have focused on the effect of palliative care consultation service (PCCS) on caregiver burden between terminal cancer family caregivers (CFCs) and non-cancer family caregivers (NCFCs). Therefore, the purpose of this study is to address the effect of PCCS on caregiver burden between CFC and NCFC over time. METHODS: A prospective longitudinal study was conducted in a medical center in northern Taiwan from July to November 2017. The participants were both terminally ill cancer and non-cancer patients who were prepared to receive PCCS, as well as their family caregivers. Characteristics including family caregivers and terminal patients and Family Caregiver Burden Scale (FCBS) were recorded pre-, 7, and 14 days following PCCS. A generalized estimating equation model was used to analyze the change in the level of family caregiver burden (FCB) between CFC and NCFC. RESULTS: The study revealed that there were no statistically significant differences in FCB between CFC and NCFC 7 days and 14 days after PCCS (p > 0.05). However, FCB significantly decreased in both CFC and NCFC from pre-PCCS to 14 days after PCCS (ß = - 12.67, p = 0.013). PPI of patients was the key predictor of FCB over time following PCCS (ß = 1.14, p = 0.013). CONCLUSIONS: This study showed that PCCS can improve FCB in not only CFC but also NCFC. We suggest that PCCS should be used more widely in supporting family caregivers of terminally ill patients to reduce caregiver burden.

Characterizing health state utilities associated with Duchenne muscular dystrophy: a systematic review.

BACKGROUND: Preferences for health states for Duchenne muscular dystrophy (DMD) are necessary to assess costs and benefits of novel therapies. Because DMD progression begins in childhood, the impact of DMD on health-related quality-of-life (HRQoL) affects preferences of both DMD patients and their families. The objective of this review was to synthesize published evidence for health state utility from the DMD patient and caregiver perspectives. METHODS: A systematic review was performed using MEDLINE and Embase, according to best practices. Data were extracted from studies reporting DMD patient or caregiver utilities; these included study and patient characteristics, health states considered, and utility estimates. Quality appraisal of studies was performed. RESULTS: From 888 abstracts, eight publications describing five studies were identified. DMD utility estimates were from preference-based measures presented stratified by ambulatory status, ventilation, and age. Patient (or patient-proxy) utility estimates ranged from 0.75 (early ambulatory DMD) to 0.05 (day-and-night ventilation). Caregiver utilities ranged from 0.87 (for caregivers of adults with DMD) to 0.71 (for caregivers of predominantly childhood patients). Both patient and caregiver utilities trended lower with higher disease severity. Variability in utilities was observed based on instrument, respondent type, and country. Utility estimates for health states within non-ambulatory DMD are under reported; nor were utilities for DMD-related health states such as scoliosis or preserved upper limb function identified. CONCLUSION: Published health state utilities document the substantial HRQoL impacts of DMD, particularly with disease progression. Additional research in patient utilities for additional health states, particularly in non-ambulatory DMD patients, is warranted.

Strengthening retina eye care services in Nepal: retina eye care of Nepal project.

BACKGROUND: Retinal diseases are very difficult to treat. So, early diagnoses and preventions are very important. But, few eye doctors can treat patients with retinal diseases in Nepal. Retina Eye Care of Nepal (RECON) project was designed to strengthen retina eye care services in Nepal. METHODS: RECON was implemented from May 2016 to February 2019 in Nepal. Four Master Eye Doctors (MED) received Training of Trainers (TOT) from Tokushima University, Japan. MEDs developed training materials for different cadres of ophthalmic human resources, enhanced retina eye care facilities, and conducted retina-screening camp in Nepal. RESULTS: Twenty ophthalmologists, 16 optometrists, 48 ophthalmic assistants and 17 ophthalmic nurses, 76 physicians and 28 health workers were trained in retina care. Eight outreach retina camps were conducted. CONCLUSIONS: The project was a novel approach to strengthen retina services in Nepal. The aim of the project was accomplished with the ultimate benefits to the needy retina patients who otherwise were going to miss the retina services.

The Value of Data: Applying a Public Value Model to the English National Health Service.

Research and innovation in biomedicine and health care increasingly depend on electronic data. The emergence of data-driven technologies and associated digital transformations has focused attention on the value of such data. Despite the broad consensus of the value of health data, there is less consensus on the basis for that value; thus, the nature and extent of health data value remain unclear. Much of the existing literature presupposes that the value of data is to be understood primarily in financial terms, and assumes that a single financial value can be assigned. We here argue that the value of a dataset is instead relational; that is, the value depends on who wants to use it and for what purposes. Moreover, data are valued for both nonfinancial and financial reasons. Thus, it may be more accurate to discuss the values (plural) of a dataset rather than the singular value. This plurality of values opens up an important set of questions about how health data should be valued for the purposes of public policy. We argue that public value models provide a useful approach in this regard. According to public value theory, public value is created, or captured, to the extent that public sector institutions further their democratically established goals, and their impact on improving the lives of citizens. This article outlines how adopting such an approach might be operationalized within existing health care systems such as the English National Health Service, with particular focus on actionable conclusions.

Information Needs of Breast Cancer Patients: Theory-Generating Meta-Synthesis.

BACKGROUND: Breast cancer has become one of the most frequently diagnosed carcinomas and the leading cause of cancer deaths. The substantial growth in the number of breast cancer patients has put great pressure on health services. Meanwhile, the information patients need has increased and become more complicated. Therefore, a comprehensive and in-depth understanding of their information needs is urgently needed to improve the quality of health care. However, previous studies related to the information needs of breast cancer patients have focused on different perspectives and have only contributed to individual results. A systematic review and synthesis of breast cancer patients' information needs is critical. OBJECTIVE: This paper aims to systematically identify, evaluate, and synthesize existing primary qualitative research on the information needs of breast cancer patients. METHODS: Web of Science, EBSCO, Scopus, ProQuest, PubMed, PsycINFO, The Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature were searched on February 12 and July 9, 2019, to collect relevant studies. A Google Scholar search, interpersonal network recommendations, and reference chaining were also conducted. Eligible studies included qualitative or mixed-methods studies focusing on the information needs (across the cancer continuum) of breast cancer patients or their social networks. Subsequently, a Critical Appraisals Skills Programme checklist was used to assess the quality of included research. The results, findings, and discussions were extracted. Data analysis was guided by the theory-generating meta-synthesis and grounded theory approach. RESULTS: Three themes, 19 categories, and 55 concepts emerged: (1) incentives (physical abnormality, inquiry from others, subjective norm, and problems during appointments); (2) types of information needs (prevention, etiology, diagnosis, clinical manifestation, treatment, prognosis, impact and resumption of normal life, scientific research, and social assistance); (3) moderating variables (attitudes, health literacy, demographic characteristics, disease status, as well as political and cultural environment). The studies revealed that the information needs of breast cancer patients were triggered by different incentives. Subsequently, the patients sought a variety of information among different stages of the cancer journey. Five types of variables were also found to moderate the formation of information needs. CONCLUSIONS: This study contributes to a thorough model of information needs among breast cancer patients and provides practical suggestions for health and information professionals.

Impact of an Electronic Health Service on Child Participation in Pediatric Oncology Care: Quasiexperimental Study.

BACKGROUND: For children 6-12 years old, there is a shortage of electronic Health (eHealth) services that promote their participation in health care. Therefore, a digital communication tool, called Sisom, was developed to give children a voice in their health care. Children with long-term diseases want to be more involved in their health care and have the right to receive information, be listened to, express their opinions, and participate in decision making in health care. However, the outcomes of using Sisom in practice at pediatric oncology clinics have not been investigated. OBJECTIVE: The aim of this study was to investigate children's participation during appointments with pediatricians at pediatric oncology clinics, with or without the use of the eHealth service Sisom. METHODS: A quasiexperimental design with mixed methods was used. We analyzed 27 filmed appointments with pediatricians for 14 children (8 girls and 6 boys) aged 6-12 years (mean 8.3 years) with a cancer diagnosis. The intervention group consisted of children who used Sisom prior to their appointments with pediatricians at a pediatric oncology clinic, and the control group consisted of children who had appointments with pediatricians at 4 pediatric oncology clinics. Data from observations from the videos were quantitatively and qualitatively analyzed. The quantitative analysis included manual calculations of how many times the pediatricians spoke directly to the children, the proportion of the appointment time that the children were talking, and levels of participation by the children. For the qualitative analysis, we used directed content analysis to analyze the children's levels of participation guided by a framework based on Shier's model of participation. RESULTS: Pediatricians directed a greater proportion of their discussion toward the child in the intervention group (731 occasions) than in the control group (624 occasions), but the proportion of the appointment time the children talked was almost the same for both the intervention and control groups (mean 17.0 minutes vs 17.6 minutes). The levels of participation corresponded to the first three levels of Shier's participation model: children were listened to, children were supported to express their views, and children's views were taken into account. The results showed an increased level of participation by the children in the intervention group. Several codes that were found did not fit into any of the existing categories, and a new category was thus formed: children received information. CONCLUSIONS: This study shows that the eHealth service Sisom can increase children's participation during appointments with health care professionals. Further studies employing a randomized control design focusing on the effects of eHealth services on children's health outcomes, perceived participation, and cost-effectiveness could make a significant contribution to guiding the implementation of eHealth services in pediatric care.

Exploring the Factors Influencing Consumers to Voluntarily Reward Free Health Service Contributors in Online Health Communities: Empirical Study.

BACKGROUND: Rewarding health knowledge and health service contributors with money is one possible approach for the sustainable provision of health knowledge and health services in online health communities (OHCs); however, the reasons why consumers voluntarily reward free health knowledge and health service contributors are still underinvestigated. OBJECTIVE: This study aimed to address the abovementioned gap by exploring the factors influencing consumers' voluntary rewarding behaviors (VRBs) toward contributors of free health services in OHCs. METHODS: On the basis of prior studies and the cognitive-experiential self-theory (CEST), we incorporated two health service content-related variables (ie, informational support and emotional support) and two interpersonal factors (ie, social norm compliance and social interaction) and built a proposed model. We crawled a dataset from a Chinese OHC for mental health, coded it, extracted nine variables, and tested the model with a negative binomial model. RESULTS: The data sample included 2148 health-related questions and 12,133 answers. The empirical results indicated that the effects of informational support (ß=.168; P<.001), emotional support (ß=.463; P<.001), social norm compliance (ß=.510; P<.001), and social interaction (ß=.281; P<.001) were significant. The moderating effects of social interaction on informational support (ß=.032; P=.02) and emotional support (ß=-.086; P<.001) were significant. The moderating effect of social interaction on social norm compliance (ß=.014; P=.38) was insignificant. CONCLUSIONS: Informational support, emotional support, social norm compliance, and social interaction positively influence consumers to voluntarily reward free online health service contributors. Social interaction enhances the effect of informational support but weakens the effect of emotional support. This study contributes to the literature on knowledge sharing in OHCs by exploring the factors influencing consumers' VRBs toward free online health service contributors and contributes to the CEST literature by verifying that the effects of experiential and rational systems on individual behaviors can vary while external factors change.

Digitalizing Health Services by Implementing a Personal Electronic Health Record in Germany: Qualitative Analysis of Fundamental Prerequisites From the Perspective of Selected Experts.

BACKGROUND: The implementation of a personal electronic health record (PHR) is a central objective of digitalization policies in the German health care system. Corresponding legislation was passed with the 2015 Act for Secure Digital Communication and Applications in the Health Sector (eHealth Act). However, compared with other European countries, Germany still lags behind concerning the implementation of a PHR. OBJECTIVE: In order to explore potential barriers and facilitators for the adoption of a PHR in routine health care in Germany, this paper aims to identify policies, structures, and practices of the German health care system that influence the uptake and use of a PHR. METHODS: A total of 33 semistructured interviews were conducted with a purposive sample of experts: 23 interviews with different health care professionals and 10 interviews with key actors of the German health care system who were telematics, eHealth, and information technology experts (eHealth experts). The interviews were transcribed verbatim and subjected to a content analysis. RESULTS: From the expert perspective, a PHR was basically considered desirable and unavoidable. At the same time, a number of challenges for implementation in Germany have been outlined. Three crucial themes emerged: (1) documentation standards: prevailing processes of the analog bureaucratic paper world, (2) interoperability: the plurality of actors and electronic systems, and (3) political structure: the lack of clear political regulations and political incentive structures. CONCLUSIONS: With regard to the implementation of a PHR, an important precondition of a successful digitalization will be the precedent reform of the system to be digitized. Whether the recently passed Act for Faster Appointments and Better Care will be a step in the right direction remains to be seen.

Adherence to Electronic Health Tools Among Vulnerable Groups: Systematic Literature Review and Meta-Analysis.

BACKGROUND: Electronic health (eHealth) tools are increasingly being applied in health care. They are expected to improve access to health care, quality of health care, and health outcomes. Although the advantages of using these tools in health care are well described, it is unknown to what extent eHealth tools are effective when used by vulnerable population groups, such as the elderly, people with low socioeconomic status, single parents, minorities, or immigrants. OBJECTIVE: This study aimed to examine whether the design and implementation characteristics of eHealth tools contribute to better use of these tools among vulnerable groups. METHODS: In this systematic review, we assessed the design and implementation characteristics of eHealth tools that are used by vulnerable groups. In the meta-analysis, we used the adherence rate as an effect size measure. The adherence rate is defined as the number of people who are repetitive users (ie, use the eHealth tool more than once). We also performed a meta-regression analysis to examine how different design and implementation characteristics influenced the adherence rate. RESULTS: Currently, eHealth tools are continuously used by vulnerable groups but to a small extent. eHealth tools that use multimodal content (such as videos) and have the possibility for direct communication with providers show improved adherence among vulnerable groups. CONCLUSIONS: eHealth tools that use multimodal content and provide the possibility for direct communication with providers have a higher adherence among vulnerable groups. However, most of the eHealth tools are not embedded within the health care system. They are usually focused on specific problems, such as diabetes or obesity. Hence, they do not provide comprehensive services for patients. This limits the use of eHealth tools as a replacement for existing health care services.

Examining the Potential of Blockchain Technology to Meet the Needs of 21st-Century Japanese Health Care: Viewpoint on Use Cases and Policy.

Japan is undergoing a major population health transition as its society ages, and it continues to experience low birth rates. An aging Japan will bring new challenges to its public health system, highlighted as a model for universal health coverage (UHC) around the world. Specific challenges Japan's health care system will face include an increase in national public health expenditures, higher demand for health care services, acute need for elder and long-term care, shortage of health care workers, and disparities between health care access in rural versus urban areas. Blockchain technology has the potential to address some of these challenges, but only if a health blockchain is conceptualized, designed, localized, and deployed in a way that is compatible with Japan's centralized UHC-centric public health system. Blockchain solutions must also be adaptive to opportunities and barriers unique to Japan's national health and innovation policy, including its regulatory sandbox system, while also seeking to learn from blockchain adoption in the private sector and in other countries. This viewpoint outlines the major opportunities and potential challenges to blockchain adoption for the future of Japan's health care.

Sijilli: A Scalable Model of Cloud-Based Electronic Health Records for Migrating Populations in Low-Resource Settings.

The world is witnessing an alarming rate of displacement and migration, with more than 70.8 million forcibly displaced individuals, including 26 million refugees. These populations are known to have increased vulnerability and susceptibility to mental and physical health problems due to the migration journey. Access of these individuals to health services, whether during their trajectory of displacement or in refugee-hosting countries, remains limited and challenging due to multiple factors, including language and cultural barriers and unavailability of the refugees' health records. Cloud-based electronic health records (EHRs) are considered among the top five health technologies integrated in humanitarian crisis preparedness and response during times of conflict. This viewpoint describes the design and implementation of a scalable and innovative cloud-based EHR named Sijilli, which targets refugees in low-resource settings. This paper discusses this solution compared with other similar practices, shedding light on its potential for scalability.

The patient encounter index: a novel method of measuring clinical workload in a paediatric cardiology service.

Technological advances have led to better patient outcomes and the expansion of clinical services in paediatric cardiology. This expansion creates an ever-growing workload for clinicians, which has led to workflow and staffing issues that need to be addressed. The objective of this study was the development of a novel tool to measure the clinical workload of a paediatric cardiology service in Cape Town, South Africa: The patient encounter index is a tool designed to quantify clinical workload. It is defined as a ratio of the measured duration of clinical work to the total time available for such work. This index was implemented as part of a prospective cross-sectional study design. Clinical workload data were collected over a 10-day period using time-and-motion sampling. Clinicians were contractually expected to spend 50% of their daily workload on patient care. The median patient encounter index for the Western Cape Paediatric Cardiac Service was 0.81 (range 0.19-1.09), reflecting that 81% of total contractual working time was spent on clinical activities. This study describes the development and implementation of a novel tool for clinical workload quantification and describes its application to a busy paediatric cardiology service in Cape Town, South Africa. This tool prospectively quantifies clinical workload which may directly influence patient outcomes. Implementation of this novel tool in the described setting clearly demonstrated the excessive workload of the clinical service and facilitated effective motivation for improved allocation of resources.

Factors that predict good Active Support in services for people with intellectual disabilities: A multilevel model.

BACKGROUND: Active Support, now widely adopted by disability support organizations, is difficult to implement. The study aim was to identify the factors associated with good Active Support. METHODS: Data on service user and staff characteristics, quality of Active Support and practice leadership were collected from a sample of services from 14 organizations annually for between 2 and 7 years, using questionnaires, structured observations and interviews. Data were analysed using multilevel modelling (MLM). RESULTS: Predictors of good Active Support were adaptive behaviour, practice leadership, Active Support training, and time since its implementation. Heterogeneity, having more than six people in a service and larger organizations were associated with lower quality of Active Support. CONCLUSIONS: In order to ensure that Active Support is consistently implemented, and thus, quality of life outcomes improved, organizations need to pay attention to both service design and support for staff through training and practice leadership.