Digital transformation in schools of two southern regions of Sweden through implementation-informed approach: A mixed-methods study protocol.

BACKGROUND: The enhancement of-or even a shift from-traditional teaching and learning processes to corresponding digital practices has been rapidly occurring during the last two decades. The evidence of this ongoing change is still modest or even weak. However, the adaptation of implementation science in educational settings, a research approach which arose in the healthcare field, offers promising results for systematic and sustained improvements in schools. The aim of this study is to understand how the systematic professional development of teachers and schools principals (the intervention) to use digital learning materials and learning analytics dashboards (the innovations) could allow for innovative and lasting impacts in terms of a sustained implementation strategy, improved teaching practices and student outcomes, as well as evidence-based design of digital learning material and learning analytics dashboards. METHODS: This longitudinal study uses a quasi-experimental cluster design with schools as the unit. The researchers will enroll gradually 145 experimental schools in the study. In the experimental schools the research team will form a School Team, consisting of teachers/learning-technologists, school principals, and researchers, to support teachers' use of the innovations, with student achievement as the dependent variable. For the experimental schools, the intervention is based on the four longitudinal stages comprising the Active Implementation Framework. With an anticipated student sample of about 13,000 students in grades 1-9, student outcomes data are going to be analyzed using hierarchical linear models. DISCUSSION: The project seeks to address a pronounced need for favorable conditions for children's learning supported by a specific implementation framework targeting teachers, and to contribute with knowledge about the promotion of improved teaching practices and student outcomes. The project will build capacity using implementation of educational technology in Swedish educational settings.

Built to last? Barriers and facilitators of healthcare program sustainability: a systematic integrative review.

OBJECTIVE: To identify barriers and facilitators associated with the sustainability of implemented and evaluated improvement programs in healthcare delivery systems. DATA SOURCES AND STUDY SETTING: Six academic databases were searched to identify relevant peer-reviewed journal articles published in English between July 2011 and June 2022. Studies were included if they reported on healthcare program sustainability and explicitly identified barriers to, and facilitators of, sustainability. STUDY DESIGN: A systematic integrative review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Study quality was appraised using Hawker's Quality Assessment Tool. DATA COLLECTION/EXTRACTION METHODS: A team of reviewers screened eligible studies against the inclusion criteria and extracted the data independently using a purpose-designed Excel spreadsheet. Barriers and facilitators were extracted and mapped to the Integrated Sustainability Framework (ISF). Frequency counts of reported barriers/facilitators were performed across the included studies. RESULTS: Of the 124 studies included in this review, almost half utilised qualitative designs (n = 52; 41.9%) and roughly one third were conducted in the USA (n = 43; 34.7%). Few studies (n = 29; 23.4%) reported on program sustainability beyond 5 years of program implementation and only 16 of them (55.2%) defined sustainability. Factors related to the ISF categories of inner setting (n = 99; 79.8%), process (n = 99; 79.8%) and intervention characteristics (n = 72; 58.1%) were most frequently reported. Leadership/support (n = 61; 49.2%), training/support/supervision (n = 54; 43.5%) and staffing/turnover (n = 50; 40.3%) were commonly identified barriers or facilitators of sustainability across included studies. Forty-six (37.1%) studies reported on the outer setting category: funding (n = 26; 56.5%), external leadership by stakeholders (n = 16; 34.8%), and socio-political context (n = 14; 30.4%). Eight studies (6.5%) reported on discontinued programs, with factors including funding and resourcing, poor fit, limited planning, and intervention complexity contributing to discontinuation. CONCLUSIONS: This review highlights the importance of taking into consideration the inner setting, processes, intervention characteristics and outer setting factors when sustaining healthcare programs, and the need for long-term program evaluations. There is a need to apply consistent definitions and implementation frameworks across studies to strengthen evidence in this area. TRIAL REGISTRATION: https://bmjopen.bmj.com/content/7/11/e018568 .

Essential content for teaching implementation practice in healthcare: a mixed-methods study of teams offering capacity-building initiatives.

BACKGROUND: Applying the knowledge gained through implementation science can support the uptake of research evidence into practice; however, those doing and supporting implementation (implementation practitioners) may face barriers to applying implementation science in their work. One strategy to enhance individuals' and teams' ability to apply implementation science in practice is through training and professional development opportunities (capacity-building initiatives). Although there is an increasing demand for and offerings of implementation practice capacity-building initiatives, there is no universal agreement on what content should be included. In this study we aimed to explore what capacity-building developers and deliverers identify as essential training content for teaching implementation practice. METHODS: We conducted a convergent mixed-methods study with participants who had developed and/or delivered a capacity-building initiative focused on teaching implementation practice. Participants completed an online questionnaire to provide details on their capacity-building initiatives; took part in an interview or focus group to explore their questionnaire responses in depth; and offered course materials for review. We analyzed a subset of data that focused on the capacity-building initiatives' content and curriculum. We used descriptive statistics for quantitative data and conventional content analysis for qualitative data, with the data sets merged during the analytic phase. We presented frequency counts for each category to highlight commonalities and differences across capacity-building initiatives. RESULTS: Thirty-three individuals representing 20 capacity-building initiatives participated. Study participants identified several core content areas included in their capacity-building initiatives: (1) taking a process approach to implementation; (2) identifying and applying implementation theories, models, frameworks, and approaches; (3) learning implementation steps and skills; (4) developing relational skills. In addition, study participants described offering applied and pragmatic content (e.g., tools and resources), and tailoring and evolving the capacity-building initiative content to address emerging trends in implementation science. Study participants highlighted some challenges learners face when acquiring and applying implementation practice knowledge and skills. CONCLUSIONS: This study synthesized what experienced capacity-building initiative developers and deliverers identify as essential content for teaching implementation practice. These findings can inform the development, refinement, and delivery of capacity-building initiatives, as well as future research directions, to enhance the translation of implementation science into practice.

Problematic substance use among patients in a Swedish outpatient psychiatry setting: staff and manager perceptions of digital options for increased intervention access.

BACKGROUND: Approximately 50% of the patients who globally seek help in psychiatry have been assessed with problematic substance use or been diagnosed with substance use disorder (SUD). Given the high treatment gap for mental health care, in particular SUD, these individuals risk poorer treatment outcomes in psychiatry. Integrated treatment for psychiatric and SUD disorders has been proposed to reduce the treatment gap for SUD, but access to integrated treatment is low. Digital interventions addressing SUD in psychiatry could potentially make treatment available to patients who otherwise would not have access. In this study "digital interventions" comprise an umbrella term covering all kinds of interventions from minimal motivational app-based interventions to internet-based interventions with and without human guidance, up to remote sessions in telepsychiatry. This study aims to explore healthcare staff perceptions of referring patients to digital interventions for reducing problematic substance use, whether or not diagnosed as SUD, in the psychiatric outpatient setting. METHOD: The study was exploratory with a qualitative design. Data were collected in the Swedish outpatient psychiatry setting, via individual semi-structured interviews with managers, and focus groups with healthcare staff. An adapted form of phenomenological hermeneutical analysis was used to analyze the data. RESULTS: Three themes emerged from the analysis. The first theme was Encountering obstacles on the path to future implementation of digital interventions, with sub-themes: Lacking resources and Feeling concerned about technical solutions. The second theme was Searching for ways forward to achieve increased access to care, with sub-themes: Blended care could facilitate integrated care and Addressing variations in patients' technical skills. The third theme was Taking steps towards the future, with sub-themes: Wanting to know more about digital interventions and Formulating a vision for the future. CONCLUSIONS: The study reveals a concern that implementing digital interventions in psychiatry will create additional work or be technically challenging. The staff see significant advantages from the patient perspective, but they feel that they themselves need training in implementing digital interventions. In order to establish constructive implementation of digital interventions for SUD in psychiatry, staff attitudes and concerns need to be considered and addressed. This study was conducted within the Swedish healthcare system and the findings may not generalize to other countries with differing healthcare systems.

Information and support to patients when the waiting time guarantee cannot be fulfilled: a qualitative study.

BACKGROUND: Long waiting times for health care services are a prominent health policy issue. Waiting time guarantees may limit time to assessment and treatment. METHODS: This study aims to investigate the information and support given to patients when the waiting time guarantee cannot be fulfilled from a care provider and administrative management perspective. Semi-structured interviews (N = 28) were conducted with administrative management and care providers (clinic staff and clinic line managers) in specialized clinics in the Stockholm Region, Sweden. Clinics were purposefully sampled for maximum variation in ownership (private, public), complexity of care, geographical location, volume of production, and waiting times. Thematic analysis was applied. RESULTS: Care providers reported that patients received inconsistent information and support with regard to the waiting time guarantee and that information was not adapted to health literacy or individual patient needs. Contrary to local law, they made some patients responsible for finding a new care provider or arranging a new referral. Furthermore, financial interests affected whether patients were referred to other providers. Administrative management steered care providers' informing practices at specific time points (upon establishment of a new unit and after six months of operation). A specific regional support function, Region Stockholm's Care Guarantee Office, helped patients change care providers when long waiting times occurred. However, administrative management perceived that there was no established routine to assist care providers in informing patients. CONCLUSIONS: Care providers did not consider patients' health literacy when informing them about the waiting time guarantee. Administrative management's attempts to provide information and support to care providers are not producing the results they expect. Soft-law regulations and care contracts seem insufficient, and economic mechanisms undermine care providers' willingness to inform patients. The described actions are unable to mitigate the inequality in health care that arises from differences in care-seeking behavior.

Strategies to reduce low-value care - An applied behavior analysis using a single-case design.

Introduction: Implementation science has traditionally focused on the implementation of evidence-based practices, but the field has increasingly recognized the importance of addressing de-implementation (i.e., the process of reducing low-value care). Most studies on de-implementation strategies have used a combination of strategies without addressing factors that sustain the use of LVC and there is a lack of information about which strategies are most effective and what mechanisms of change might underlie these strategies. Applied behavior analysis is an approach that could be a potential method to gain insights into the mechanisms of de-implementation strategies to reduce LVC. Three research questions are addressed in this study: What contingencies (three-term contingencies or rule-governing behavior) related to the use of LVC can be found in a local context and what strategies can be developed based on an analysis of these contingencies?; Do these strategies change targeted behaviors?; How do the participants describe the strategies' contingencies and the feasibility of the applied behavior analysis approach? Materials and methods: In this study, we used applied behavior analysis to analyze contingencies that maintain behaviors related to a chosen LVC, the unnecessary use of x-rays for knee arthrosis within a primary care center. Based on this analysis, strategies were developed and evaluated using a single-case design and a qualitative analysis of interview data. Results: Two strategies were developed: a lecture and feedback meetings. The results from the single-case data were inconclusive but some of the findings may indicate a behavior change in the expected direction. Such a conclusion is supported by interview data showing that participants perceived an effect in response to both strategies. Conclusion: The findings illustrate how applied behavior analysis can be used to analyze contingencies related to the use of LVC and to design strategies for de-implementation. It also shows an effect of the targeted behaviors even though the quantitative results are inconclusive. The strategies used in this study could be further improved to target the contingencies better by structuring the feedback meetings better and including more precise feedback.

Organizational influences on the use of low-value care in primary health care - a qualitative interview study with physicians in Sweden.

AIM: The aim was (1) to explore organizational factors influencing the use of low-value care (LVC) as perceived by primary care physicians and (2) to explore which organizational strategies they believe are useful for reducing the use of LVC. DESIGN: Qualitative study with semi-structured focus group discussions (FGDs) analyzed using qualitative content analysis. SETTING: Six publicly owned primary health care centers in Stockholm. SUBJECTS: The participants were 31 primary care physicians. The number of participants in each FGD varied between 3 and 7. MAIN OUTCOME MEASURES: Categories and subcategories reporting organizational factors perceived to influence the use of LVC and organizational strategies considered useful for reducing the use of LVC. RESULTS: Four types of organizational factors (resources, care processes, improvement activities, and governance) influenced the use of LVC. Resources involved time to care for patients, staff knowledge, and working tools. Care processes included work routines and the ways activities and resources were prioritized in the organization. Improvement activities involved performance measurement and improvement work to reduce LVC. Governance concerned organizational goals, higher-level decision making, and policies. Physicians suggested multiple strategies targeting these factors to reduce LVC, including increased patient-physician continuity, adjusted economic incentives, continuous professional development for physicians, and gatekeeping functions which prevent unnecessary appointments and guide patients to the appropriate point of care. . CONCLUSION: The influence of multiple organizational factors throughout the health-care system indicates that a whole-system approach might be useful in reducing LVC.KEY POINTSWe know little about how organizational factors influence the use of low-value care (LVC) in primary health care.Physicians perceive organizational resources, care processes, improvement activities, and governance as influences on the use of LVC and LVC-reducing strategies.This study provides insights about how these factors influence LVC use.Strategies at multiple levels of the health-care system may be warranted to reduce LVC.

Effects of a co-created occupational health intervention on stress and psychosocial working conditions within the construction industry: A controlled trial.

Background: Work-related stress problems, i.e., burnout, depression, and anxiety, is a rising global health challenge. Poor mental health also appears to be a challenge for the construction industry, even though the occupational health focus has traditionally been on the physical work environment and musculoskeletal disorders. Yet, studies targeting the organisational level (i.e., work environment, policy) to enhance mental health within the construction industry are scant. Therefore, our first objective was to evaluate the effectiveness of a co-created occupational health intervention on stress and psychosocial working conditions within the construction industry in Sweden. The second objective was to evaluate whether the intervention was implemented as intended, i.e., implementation fidelity. The trial is registered in the ISRCTN clinical trial registry (ISRCTN16548039, http://isrctn.com/). Methods: This is a controlled trial with one intervention and one matched control group. We co-created the program logic with stakeholders from the intervention group. The essence of the chosen intervention components, duties clarification, and structured roundmaking was enhanced planning and role clarification. We assessed adherence to the intervention and dose delivered (i.e., fidelity). We collected data on the outcomes (role clarity, team effectiveness, planning, staffing, quantitative demands, and the psychosocial safety climate) with online questionnaires at baseline, 12, and 24 months. Marginal means models adjusting for missing data patterns were applied to estimate potential differences in outcomes between groups over time. Results: Fidelity was considered reasonably high. Yet, we found no intervention effects on the primary outcome stress. All outcomes, except role clarity deteriorated during the trial in the intervention and control group. However, the results indicate a positive effect of the intervention components on professionals' role clarity. The pandemic appears to have negatively affected stress and psychosocial working conditions. Conclusion: The study's results suggest that co-creating occupational health interventions could be one solution for improved implementation fidelity. More studies are needed to evaluate these intervention components. Also, we recommend researchers of future intervention studies consider using missing not at random, sensitivity analysis.

Strategies for de-implementation of low-value care-a scoping review.

BACKGROUND: The use of low-value care (LVC) is a persistent problem that calls for knowledge about strategies for de-implementation. However, studies are dispersed across many clinical fields, and there is no overview of strategies that can be used to support the de-implementation of LVC. The extent to which strategies used for implementation are also used in de-implementing LVC is unknown. The aim of this scoping review is to (1) identify strategies for the de-implementation of LVC described in the scientific literature and (2) compare de-implementation strategies to implementation strategies as specified in the Expert Recommendation for Implementing Change (ERIC) and strategies added by Perry et al. METHOD: A scoping review was conducted according to recommendations outlined by Arksey and O'Malley. Four scientific databases were searched, relevant articles were snowball searched, and the journal Implementation Science was searched manually for peer-reviewed journal articles in English. Articles were included if they were empirical studies of strategies designed to reduce the use of LVC. Two reviewers conducted all abstract and full-text reviews, and conflicting decisions were discussed until consensus was reached. Data were charted using a piloted data-charting form. The strategies were first coded inductively and then mapped onto the ERIC compilation of implementation strategies. RESULTS: The scoping review identified a total of 71 unique de-implementation strategies described in the literature. Of these, 62 strategies could be mapped onto ERIC strategies, and four strategies onto one added category. Half (50%) of the 73 ERIC implementation strategies were used for de-implementation purposes. Five identified de-implementation strategies could not be mapped onto any of the existing strategies in ERIC. CONCLUSIONS: Similar strategies are used for de-implementation and implementation. However, only a half of the implementation strategies included in the ERIC compilation were represented in the de-implementation studies, which may imply that some strategies are being underused or that they are not applicable for de-implementation purposes. The strategies assess and redesign workflow (a strategy previously suggested to be added to ERIC), accountability tool, and communication tool (unique new strategies for de-implementation) could complement the existing ERIC compilation when used for de-implementation purposes.

National governance of de-implementation of low-value care: a qualitative study in Sweden.

BACKGROUND: The de-implementation of low-value care (LVC) is important to improving patient and population health, minimizing patient harm and reducing resource waste. However, there is limited knowledge about how the de-implementation of LVC is governed and what challenges might be involved. In this study, we aimed to (1) identify key stakeholders' activities in relation to de-implementing LVC in Sweden at the national governance level and (2) identify challenges involved in the national governance of the de-implementation of LVC. METHODS: We used a purposeful sampling strategy to identify stakeholders in Sweden having a potential role in governing the de-implementation of LVC at a national level. Twelve informants from nine stakeholder agencies/organizations were recruited using snowball sampling. Semi-structured interviews were conducted, transcribed and analysed using inductive thematic analysis. RESULTS: Four potential activities for governing the de-implementation of LVC at a national level were identified: recommendations, health technology assessment, control over pharmaceutical products and a national system for knowledge management. Challenges involved included various vested interests that result in the maintenance of LVC and a low overall priority of working with the de-implementation of LVC compared with the implementation of new evidence. Ambiguous evidence made it difficult to clearly determine whether a practice was LVC. Unclear roles, where none of the stakeholders perceived that they had a formal mandate to govern the de-implementation of LVC, further contributed to the challenges involved in governing that de-implementation. CONCLUSIONS: Various activities were performed to govern the de-implementation of LVC at a national level in Sweden; however, these were limited and had a lower priority relative to the implementation of new methods. Challenges involved relate to unfavourable change incentives, ambiguous evidence, and unclear roles to govern the de-implementation of LVC. Addressing these challenges could make the national-level governance of de-implementation more systematic and thereby help create favourable conditions for reducing LVC in healthcare.

Management strategies to de-implement low-value care-an applied behavior analysis.

BACKGROUND: There is a lack of knowledge about management strategies being used to de-implement low-value care (LVC). Furthermore, it is not clear from the current literature what mechanisms are involved in such strategies and how they can change physicians' behaviors. Understanding the mechanisms is important for determining a strategy's potential impact. Applied behavior analysis focuses on processes involved in increasing and decreasing behaviors. Therefore, the aim of this study is to understand what management strategies are being used to de-implement LVC and the possible mechanisms involved in those strategies, using concepts from applied behavior analysis. METHOD: We applied a qualitative study design using an inductive approach to understand what management strategies are in use and then employed applied behavior analysis concepts to deductively analyze the mechanisms involved in them. RESULTS: We identified eight different management strategies intended to influence LVC. Five of the strategies were developed at a regional level and had the potential to influence physicians' LVC-related behaviors either by functioning as rules on which LVC to de-implement or by initiating local strategies in each health care center that in turn could influence LVC practices. The local strategies had a stronger potential for influencing de-implementation. CONCLUSION: Both strategies at a systemic level (regional) and on a local level (health care centers) must be considered to influence LVC-related behaviors. Strategies at the center level have a specific opportunity to impact LVC-related behaviors because they can be tailored to specific circumstances, even though some of them probably were initiated as an effect of strategies on a regional level. Using applied behavior analysis to understand these circumstances can be helpful for tailoring strategies to reduce LVC use.

Co-Creating an Occupational Health Intervention within the Construction Industry in Sweden: Stakeholder Perceptions of the Process and Output.

One way to prevent work-related stress, is to implement primary occupational health interventions aimed at improving the psychosocial work environment. However, such interventions have shown a limited effect, often due to implementation failure and poor contextual fit. Co-creation, where researchers, together with end-users and other relevant stakeholders, develop the intervention is increasingly encouraged. However, few studies have evaluated the effects of co-created interventions, and participants' experience of the co-creation process. This is one of the first studies evaluating stakeholder perceptions of co-creating an occupational health intervention. We applied a thematic analysis, with data from 12 semi-structured interviews with stakeholders involved in the co-creation. Our results show that the respondents, in general, were satisfied with engaging in the co-creation, and they reported an increased awareness regarding risk factors of stress and how these should be handled. Additionally, the respondents described trust in the intervention activities and a good fit into the context. The study indicates that co-creating occupational health interventions can enhance the implementation and the contextual fit.

Building implementation capacity in health care and welfare through team training-study protocol of a longitudinal mixed-methods evaluation of the building implementation capacity intervention.

BACKGROUND: To ensure the provision of high-quality safety and cost-effective health and welfare services, managers and professionals are required to introduce and ensure the routine use of clinical guidelines and other evidence-based interventions. Despite this, they often lack training and support in implementation. This project aims to investigate how a team training intervention, with the goal to build implementation capacity, influences participants' implementation knowledge and skills, as well as how it influences implementation activities and implementation capacity within participating health and welfare organizations. Furthermore, the aim is to investigate how the organizations' contexts influence the intervention outcomes. METHODS: The building implementation capacity (BIC) intervention builds on the behavior change wheel, which considers implementation as a matter of behavior change. The intervention will be provided to teams of managers and professionals working in health and welfare organizations and seeking support to implement a guideline- or evidence-based intervention. The intervention consists of a series of interactive workshops that provides the participating teams with the knowledge and skills to apply a systematic implementation model. A longitudinal mixed-methods evaluation, including interviews, surveys, and document analysis, will be applied over 24 months. The normalization process theory measure will be used to assess how the intervention influences implementation activities in practice and implementation capacity in the teams and the wider organizations. DISCUSSION: This project has an ambition to add to the knowledge concerning how to promote the uptake of research findings into health care by building implementation capacity through team training in implementation. The project's uniqueness is that it is designed to move beyond individual-level outcomes and evaluate implementation activities and implementation capacity in participating organizations. Further, the intervention will be evaluated over 24 months to investigate long-term outcomes of implementation training.

Challenges to ensuring valid and useful waiting time monitoring - a qualitative study in Swedish specialist care.

BACKGROUND: Access to health care is an essential health policy issue. In several countries, waiting time guarantees mandate set time limits for assessment and treatment. High-quality waiting time data are necessary to evaluate and improve waiting times. This study's aim was to investigate health care providers and administrative management professionals' perceptions of validity and usefulness of waiting time reporting in specialist care. METHODS: Semi-structured interviews (n = 28) were conducted with administrative management and care professionals (line managers and care providers) in specialized clinics in the Stockholm Region, Sweden. Clinic-specific data from the waiting time registry was used in the care provider interviews to assess face validity. Clinics were purposefully sampled for maximum variation in complexity of care, volume of production, geographical location, private or public ownership, and local waiting times. Thematic analysis was used. RESULTS: The waiting time registry was perceived to have low validity and usefulness. Perceived validity and usefulness were interconnected, with mechanisms that reinforced the connection. Structural and cognitive barriers to validity included technical and procedural errors, errors caused by role division, misinterpretation of guidelines, diverging interpretations of nonregulated cases and extensive willful manipulation of data. CONCLUSIONS: We identify four misconceptions underpinning the current waiting time reporting system: passive dissemination of guidelines is sufficient as implemented, cognitive load of care providers to report waiting times is negligible, soft-law regulation and presentation of outcome data is sufficient to drive improvement, and self-reported data linked to incentives poses a low risk of data corruption. To counter low validity and usefulness, we propose the following for policy makers and administrative management when developing and implementing waiting time monitoring: communicate guidelines with instructions for operationalization, address barriers to implementation, ensure quality through monitoring of implementation and adherence to guidelines, develop IT ontology together with professionals, avoid parallel measurement infrastructures, ensure waiting times are presented to suit management needs, provide timely waiting time data, enable the study of single cases, minimize manual data entry, and perform spot-checks or external validity checks. Several of these strategies should be transferable to waiting time monitoring in other contexts.

Effect and process evaluation of a multicomponent public health intervention to increase the use of primary care-based mental health services amongst children with a migrant background in Stockholm, Sweden: a protocol for a mixed-methods study.

INTRODUCTION: The overall aim of the project is to understand how to increase access to, and use of, primary care-based mental health services for children and youth from a migrant background with mild to moderate mental health problems. METHODS AND ANALYSIS: The study will be undertaken in Haninge municipality in Stockholm, Sweden. The study has three intervention components: (1) A health communication intervention targeting parents of children/youth with a migrant background; (2) Training of professionals and volunteers who potentially have contact with parents and children with a migrant background, in order to increase the number of referrals to primary care-based mental health services, and (3) Increasing access to care at a primary care-based mental health service for children, using various strategies to lower barriers to care. The complex multicomponent intervention will be studied with an effect and a process evaluation methodology. ETHICS AND DISSEMINATION: All planned studied are approved by the Swedish Ethical Review Authority dnr 2017-135-31/5, 2019-06275, 2020-03640, 2020-06341, 2020-03642 and 2020-04180. Informed consent, written or verbal, will be obtained from all participants. The results of the project will be published continually in peer-reviewed scientific journals and disseminated to relevant stakeholders nationally and within Haninge municipality.

How do healthcare professionals make decisions concerning low-value care practices? Study protocol of a factorial survey experiment on de-implementation.

BACKGROUND: A large number of practices used in health care lack evidence of effectiveness and may be unnecessary or even cause harm. As such, they should be de-implemented. While there are multiple actors involved in de-implementation of such low-value care (LVC) practices, ultimately, the decision to abandon a practice is often made by each health care professional. A recent scoping review identified 6 types of factors affecting the utilization vs. abandonment of LVC practices. These factors concern health care professionals, patients, outer context, inner context, processes, and the characteristics of LVC practice itself. However, it is unclear how professionals weigh these different factors in and how these determinants influence their decisions about abandoning LVC practices. This project aims to investigate how health care professionals account for various factors as they make decisions regarding de-implementation of LVC practices. METHODS: This project will be carried out in two main steps. First, a factorial survey experiment (a vignette study) will be applied to empirically test the relevance of factors previously identified in the literature for health care professionals' decision-making about de-implementation. Second, interactive workshops with relevant stakeholders will be carried out to develop a framework for professionals' decision-making and to offer suggestions for interventions to support de-implementation of LVC practices. DISCUSSION: The project has the potential to contribute to improved understanding of the decision-making involved in de-implementation of LVC practices. We will identify which factors are more important when they make judgments about utilizing versus abandoning LVC practices. The results will provide the basis for recommendations concerning appropriate interventions to support de-implementation decision-making processes.

A Participatory Intervention to Improve the Psychosocial Work Environment and Mental Health in Human Service Organisations. A Mixed Methods Evaluation Study.

Work-related stress is a global problem causing suffering and economic costs. In Sweden, employees in human service occupations are overrepresented among persons on sick leave due to mental health problems such as stress-related disorders. The psychosocial work environment is one contributing factor for this problem, making it urgent to identify effective methods to decrease stress at the workplace. The aim of the study is to evaluate a participatory intervention to improve the psychosocial work environment and mental health using an embedded mixed methods design. The study is a controlled trial with a parallel process evaluation exploring fidelity and participants' reactions to the intervention activities, experiences of learning and changes in behaviours and work routines. We collected data through documentation, interviews and three waves of questionnaires. Our results show small changes in behaviours and work routines and no positive effects of the intervention on the psychosocial work environment nor health outcomes. One explanation is end-users' perceived lack of involvement over the process causing the intervention to be seen as a burden. Another explanation is that the intervention activities were perceived targeting the wrong organisational level. A representative participation over both content and process can be an effective strategy to change psychosocial working conditions and mental health.

A dynamic systems view of clinical genomics: a rich picture of the landscape in Australia using a complexity science lens.

BACKGROUND: Clinical genomics represents a paradigm shifting change to health service delivery and practice across many conditions and life-stages. Introducing this complex technology into an already complex health system is a significant challenge that cannot be managed in a reductionist way. To build robust and sustainable, high quality delivery systems we need to step back and view the interconnected landscape of policymakers, funders, managers, multidisciplinary teams of clinicians, patients and their families, and health care, research, education, and philanthropic institutions as a dynamic whole. This study holistically mapped the landscape of clinical genomics within Australia by developing a complex graphic: a rich picture. Using complex systems theory, we then identified key features, challenges and leverage points of implementing clinical genomics. METHODS: We used a multi-stage, exploratory, qualitative approach. We extracted data from grey literature, empirical literature, and data collected by the Australian Genomic Health Alliance. Nine key informants working in clinical genomics critiqued early drafts of the picture, and validated the final version. RESULTS: The final graphic depicts 24 stakeholder groups relevant to implementation of genomics into Australia. Clinical genomics lies at the intersection of four nested systems, with interplay between government, professional bodies and patient advocacy groups. Barriers and uncertainties are also shown. Analysis using complexity theory showed far-reaching interdependencies around funding, and identified unintended consequences. CONCLUSION: The rich picture of the clinical genomic landscape in Australia is the first to show key stakeholders, agencies and processes and their interdependencies. Participants who critiqued our results were instantly intrigued and engaged by the graphics, searching for their place in the whole and often commenting on insights they gained from seeing the influences and impacts of other stakeholder groups on their own work. Funding patterns showed unintended consequences of increased burdens for clinicians and inequity of access for patients. Showing the system as a dynamic whole is the only way to understand key drivers and barriers to largescale interventions. TRIAL REGISTRATION: Not applicable.

Determinants for the use and de-implementation of low-value care in health care: a scoping review.

BACKGROUND: A considerable proportion of interventions provided to patients lack evidence of their effectiveness. This implies that patients may receive ineffective, unnecessary or even harmful care. However, despite some empirical studies in the field, there has been no synthesis of determinants impacting the use of low-value care (LVC) and the process of de-implementing LVC. AIM: The aim was to identify determinants influencing the use of LVC, as well as determinants for de-implementation of LVC practices in health care. METHODS: A scoping review was performed based on the framework by Arksey and O'Malley. We searched four scientific databases, conducted snowball searches of relevant articles and hand searched the journal Implementation Science for peer-reviewed journal articles in English. Articles were included if they were empirical studies reporting on determinants for the use of LVC or de-implementation of LVC. The abstract review and the full-text review were conducted in duplicate and conflicting decisions were discussed until consensus was reached. Data were charted using a piloted data charting form and the determinants were inductively coded and categorised in an iterative process conducted by the project group. RESULTS: In total, 101 citations were included in the review. Of these, 92 reported on determinants for the use of LVC and nine on determinants for de-implementation. The studies were conducted in a range of health care settings and investigated a variety of LVC practices with LVC medication prescriptions, imaging and screening procedures being the most common. The identified determinants for the use of LVC as well as for de-implementation of LVC practices broadly concerned: patients, professionals, outer context, inner context, process and evidence and LVC practice. The results were discussed in relation to the Consolidated Framework for Implementation Research. CONCLUSION: The identified determinants largely overlap with existing implementation frameworks, although patient expectations and professionals' fear of malpractice appear to be more prominent determinants for the use and de-implementation of LVC. Thus, existing implementation determinant frameworks may require adaptation to be transferable to de-implementation. Strategies to reduce the use of LVC should specifically consider determinants for the use and de-implementation of LVC. REGISTRATION: The review has not been registered.

Change and improvement 50 years in the making: a scoping review of the use of soft systems methodology in healthcare.

INTRODUCTION: Improving the quality of healthcare has proven to be a challenging task despite longstanding efforts. Approaches to improvements that consider the strong influence of local context as well as stakeholders' differing views on the situation are warranted. Soft systems methodology (SSM) includes contextual and multi-perspectival features. However, the way SSM has been applied and the outcomes of using SSM to stimulate productive change in healthcare have not been sufficiently investigated. AIM: This scoping review aimed to examine and map the use and outcomes of SSM in healthcare settings. METHOD: The review was based on Arksey and O'Malley's framework. We searched six academic databases to January 2019 for peer-reviewed journal articles in English. We also reviewed reference lists of included citations. Articles were included if they were empirical studies focused on the application of SSM in a healthcare setting. Two reviewers conducted the abstract review and one reviewer conducted the full-text review and extracted data on study characteristics, ways of applying SSM and the outcomes of SSM initiatives. Study quality was assessed using Hawker's Quality Assessment Tool. RESULT: A total of 49 studies were included in the final review. SSM had been used in a range of healthcare settings and for a variety of problem situations. The results revealed an inconsistent use of SSM including departing from Checkland's original vision, applying different tools and involving stakeholders idiosyncratically. The quality of included studies varied and reporting of how SSM had been applied was sometimes inadequate. SSM had most often been used to understand a problem situation and to suggest potential improvements to the situation but to a lesser extent to implement and evaluate these improvements. CONCLUSION: SSM is flexible and applicable to a range of problem situations in healthcare settings. However, better reporting of how SSM has been applied as well as evaluation of different types of outcomes, including implementation and intervention outcomes, is needed in order to appreciate more fully the utility and contribution of SSM in healthcare.