Understanding the behavioral determinants that predict barriers and enablers of screening and treatment behaviors for diabetic retinopathy among Bangladeshi women: findings from a barrier analysis.

BACKGROUND AND AIM: While early detection and timely treatments can prevent diabetic retinopathy (DR) related blindness, barriers to receiving these DR services may cause permanent sight loss. Despite having similar prevalence to diabetes and DR, women are less likely than men to perform these behaviors due to multi-faced barriers in screening and receiving follow-up treatments for DR. This study, therefore, aimed at identifying the barriers to - and enablers of - screening and follow-up treatments behaviors for DR among women aged more than 40 years with diabetes from the behavioral perspectives in Bangladesh. METHODS: This Barrier Analysis study interviewed 360 women (180 "Doers" and 180 "Non-doers") to explore twelve behavioral determinants of four DR behaviors including screening, injection of anti-vascular endothelial growth factor (anti-VEGF medication), laser therapy and vitro-retinal surgery. The data analysis was performed to calculate estimated relative risk to identify the degree of association between the determinants and behaviors, and to find statistically significant differences (at p < 0.05) in the responses between the Doers and Non-doers. RESULTS: Access to healthcare facilities was the major barrier impeding women from performing DR behaviors. Difficulty in locating DR service centers, the need to travel long distances, the inability to travel alone and during illness, challenges of paying for transportation and managing workload significantly affected women's ability to perform the behaviors. Other determinants included women's perceived self-efficacy, perceived negative consequences (e.g. fear and discomfort associated with injections or laser treatment), and cues for action. Significant perceived enablers included low cost of DR treatments, supportive attitudes by healthcare providers, government policy, and perceived social norms. CONCLUSION: The study found a host of determinants related to the barriers to and enablers of DR screening and treatment behaviors. These determinants included perceived self-efficacy (and agency), positive and negative consequences, perceived access, perceived social norms, culture, and perceived risk. Further investments are required to enhance the availability of DR services within primary and secondary health institutions along with health behavior promotion to dispel misconceptions and fears related to DR treatments.

How human ecology landscapes shape the circulation of H5N1 avian influenza: A case study in Indonesia.

Background: Highly pathogenic avian influenza H5N1 virus consistently threatens global public health. A better understanding of the virus' circulation mechanism is needed for future epidemic prevention. Previous studies have focused on the correlations between the presence of H5N1 virus and wild bird populations, domestic poultry production, and sociodemographic factors. However, human cultural landscapes and their impact on H5N1 spread have not been adequately explored. Methods: Using 196 HA gene sequences of H5N1 influenza viruses from Indonesia with district-level geographic information, we performed Monmonier barrier and Louvain community detection analyses to explore how human ecological factors impact the circulation of virus and identify barriers to or corridors of dispersal. Results: Spatial discontinuity in the genetic characteristics identified by the Monmonier algorithm were found to mirror the differences in key landscape factors. Our Louvain community detection analysis also found the co-existence of different geographic circulation patterns. The community detection analysis suggests that direct human-related interactions such as poultry transportations between remote areas may result in similar viruses spreading in two distant regions whilst dense localities supported genetically heterogeneous viruses in geographically adjacent areas. Conclusion: Human ecological landscapes shape the circulation mechanism of H5N1 virus in multiple ways contingent upon local context. Physical and cultural barriers may impede its movement between adjacent areas, while natural or human-induced corridors such as wild bird flyways and poultry production networks facilitate its spread between geographically distant areas. Further focus on the importance of cultural landscapes has great potential for increasing our understanding of the circulation of pathogenic H5N1 avian influenza virus in Southeast Asia.

Development of a growth monitoring and promotion index to improve child health in Zimbabwe.

In Zimbabwe, growth monitoring and promotion as conducted by community health workers are part of the nutritional surveillance system. This study seeks to develop a new index which will combine both caregiver behaviours, attitudes and CHW growth monitoring and promotion activities. An explanatory sequential mixed method design will be conducted in three phases. Phase one will comprise a scoping literature review. The second phase will comprise a needs analysis through quantitative data collection using two surveys of community health workers and caregivers of children under five years. Thereafter, qualitative data will be collected from caregivers of children under five years. The quantitative data will be analysed using SPSS while qualitative data will be collected and analysed using Atlas-ti. Phase three will be the development phase for the growth monitoring and promotion Index. The growth monitoring and promotion Index will be used to classify the GMP performance of districts through the DHIS2 thus strengthening the quality of growth monitoring and promotion. Recommendations on the findings and the adoption of the Index will be shared with the Ministry of Health and Child Care and key stakeholders implementing maternal, newborn and child health programmes in Zimbabwe for adoption and use in growth monitoring and promotion programming.

Use of designing for behaviour change framework in identifying and addressing barriers to and enablers of animal source feeding to children ages 8-23 months in Bandarban Hill District in Bangladesh: Implications for a nutrition-sensitive agriculture programme.

Inadequate diet quality is a cause of undernutrition among children 6-23 months of age in Bangladesh, particularly in remote and isolated areas such as Bandarban District. Feeding animal source foods can help to combat stunting and wasting problems among children, but it may not be accessible or acceptable. A barrier analysis using the Designing for Behavior Change Framework was conducted in Bandarban district with participants from 4 ethnic groups, to explore potential barriers and key motivators by examining 12 behavioural determinants of consumption of animal-source food in complementary feeding for children 8-23 months. Data were collected from 45 mothers of children 8-23 months, who provided animal-source foods to their children (doers), and from 45 mothers who did not (non-doers), for a total of 90 interviews. Nine determinants were statistically significantly different between doers and non-doers as follows: self-efficacy, positive consequences, negative consequences, social norms, access, reminders, perceived risk, perceived severity and perceived action efficacy. Nearby access to purchase animal-source foods, rearing poultry or livestock at home and the support of household and community members are enablers to feeding animal-source food. In contrast, these same factors are barriers for non-doers. The lack of money to spend on animal-source foods is also a barrier. An integrated nutrition-sensitive and gender-transformative animal-based food production, and inclusive market programme could increase access to meat and eggs at the household level, increase opportunities to earn income and support gender-equitable household workloads and decision-making for optimal child feeding.

Barriers and facilitators to exclusive breastfeeding among Black mothers: A qualitative study utilizing a modified Barrier Analysis approach.

Breastfeeding has health benefits for both infants and mothers, yet Black mothers and infants are less likely to receive these benefits. Despite research showing no difference in breastfeeding intentions by race or ethnicity, inequities in breastfeeding rates persist, suggesting that Black mothers face unique barriers to meeting their breastfeeding intentions. The aim of this study is to identify barriers and facilitators that Black women perceive as important determinants of exclusively breastfeeding their children for at least 3 months after birth. Utilizing a Barrier Analysis approach, we conducted six focus group discussions, hearing from Black mothers who exclusively breastfed for 3 months and those who did not. Transcripts were coded starting with a priori parent codes based on theory-derived determinants mapped onto the Socioecological Model; themes were analysed for differences between groups. Facilitators found to be important specifically for women who exclusively breastfed for 3 months include self-efficacy, lactation support, appropriate lactation supplies, support of mothers and partners, prior knowledge of breastfeeding, strong intention before birth and perceptions of breastfeeding as money-saving. Barriers that arose more often among those who did not exclusively breastfeed for 3 months include inaccessible lactation support and supplies, difficulties with pumping, latching issues and perceptions of breastfeeding as time-consuming. Lack of access to and knowledge of breastfeeding laws and policies, as well as negative cultural norms or stigma, were important barriers across groups. This study supports the use of the Socioecological Model to design multicomponent interventions to increase exclusive breastfeeding outcomes for Black women.

Behavioral determinants for COVID-19 vaccine acceptance among students, faculty, and staff at a rural public university.

Background: Vaccine hesitancy for COVID-19 is a major obstacle to achieving high vaccine coverage. Low vaccine confidence among college students is one factor fueling the COVID-19 pandemic in the U.S. Objective: The purpose of this study was to evaluate COVID-19 vaccine hesitancy and barriers to vaccine uptake among students, faculty, and staff at a rural public university. Method: We used the Barrier Analysis (BA) mixed-methods approach, which explores determinants of the desired behavior using the Health Belief Model and Theory of Reasoned Action. We developed a BA questionnaire and distributed it through Qualtrics to 4,600 randomly selected students (n = 4,000), faculty (n = 300), and staff (n = 300) from March 11 to April 1, 2021. We defined Acceptors as those who were willing to be vaccinated and Non-acceptors as those who were not. Results: Our analysis found that among Non-acceptors, perceived social norms, perceived negative consequences, and trust had the highest association with COVID-19 vaccine hesitancy among students, faculty, and staff. Conclusion: These findings illustrate the need to develop effective behavior change strategies for COVID-19 vaccines uptake that identify sources of trusted information among vaccine-hesitant college students, faculty, and staff, while leveraging enablers to increase COVID-19 vaccination coverage on university campuses.

Adapting a Dementia Care Management Intervention for Regional Implementation: A Theory-Based Participatory Barrier Analysis.

Dementia is a leading cause of disability and dependency in older people worldwide. As the number of people affected increases, so does the need for innovative care models. Dementia care management (DCM) is an empirically validated approach for improving the care and quality of life for people with dementia (PwD) and caregivers. The aim of this study is to investigate the influencing factors and critical pathways for the implementation of a regionally adapted DCM standard in the existing primary care structures in the German region of Siegen-Wittgenstein (SW). Utilizing participatory research methods, five local health care experts as co-researchers conducted N = 13 semi-structured interviews with 22 local professionals and one caregiver as peer reviewers. Data collection and analysis were based on the Consolidated Framework for Implementation Research (CFIR). Our results show that among the most mentioned influencing factors, three CFIR constructs can be identified as both barriers and facilitators: Patients' needs and resources, Relative advantage, and Cosmopolitanism. The insufficient involvement of relevant stakeholders is the major barrier and the comprehensive consideration of patient needs through dementia care managers is the strongest facilitating factor. The study underlines the vital role of barrier analysis in site-specific DCM implementation.

Barriers to the uptake of community-based curative child health services in Ethiopia.

BACKGROUND: Uptake of services to treat newborns and children has been persistently low in Ethiopia, despite being provided free-of-charge by Health Extension Workers (HEWs). In order to increase the uptake of these services, the Optimizing the Health Extension Project was designed to be implemented in four regions in Ethiopia. This study was carried out to identify barriers to the uptake of these services and potential solutions to inform the project. METHODS: Qualitative data were collected in October and November 2015 in 15 purposely selected districts in four regions. We conducted 90 focus group discussions and 60 in-depth interviews reaching a total of 664 participants. Thematic analysis was used to identify key barriers and potential solutions. RESULTS: Five demand-side barriers to utilization of health services were identified. Misconceptions about illness causation, compounded with preference for traditional healers has affected service uptake. Limited awareness of the availability of free curative services for children at health posts; along with the prevailing perception that HEWs were providing preventive services only had constrained uptake. Geographic challenge that made access to the health post difficult was the other barrier. Four supply-side barriers were identified. Health post closure and drug stock-out led to inconsistent availability of services. Limited confidence and skill among HEWs and under-resourced physical facilities affected the service delivery. Study participants suggested demand creation solutions such as increasing community awareness on curative service availability and educating them on childhood illness causation. Maintaining consistent supplies and ensuring service availability; along with regular support to build HEWs' confidence were the suggested supply-side solutions. Creating community feedback mechanisms was suggested as a way of addressing community concerns on the health services. CONCLUSION: This study explored nine demand- and supply-side barriers that decreased the uptake of community-based services. It indicated the importance of increasing awareness of new services and addressing prevailing barriers that deprioritize health services. At the same time, supply-side barriers would have to be tackled by strengthening the health system to uphold newly introduced services and harness sustainable impact.

Barriers Against Prevention Programs for Iodine Deficiency Disorders in Europe: A Delphi Study.

Background: Although substantial progress has been made in recent decades in eliminating iodine deficiency, iodine deficiency disorders (IDDs) are still prevalent in European countries. Challenges include ineffective public health programs and discontinuation of IDD prevention. However, the barriers against the implementation and continuation of prevention and monitoring of IDD remain unclear. Therefore, the objective of our study was to identify potential barriers against pan-European IDD prevention and monitoring programs and to find solutions for the different challenges. Methods: We conducted a Delphi study consisting of three rounds. We identified potential participants with expertise and experience in relevant fields from all European countries, including policy makers, health care professionals, health scientists, and patient representatives. The Delphi method was conducted with open-ended questions and item ranking to achieve group consensus on potential barriers against national and pan-European IDD prevention and monitoring programs and related solutions to overcome those barriers. The answers of the Delphi rounds were analyzed using qualitative content analysis and descriptive analysis methods. In addition, we conducted two expert interviews to analyze and discuss the study results. Results: Eighty experts from 36 countries and different fields of work participated in the first Delphi round, 52 in the second, and 46 in the third. Potential barriers include challenges in the fields of knowledge and information, implementation and management, communication and cooperation, political support, and differences between the European countries. Ranked solutions addressing these barriers include cooperation with different stakeholders, gaining knowledge, sharing information, the development of a European program with national specification, European guidelines/recommendations, and European monitoring. The ranking gives a first overview as to which of these barriers would need to be solved most urgently and which solutions may be most helpful. Conclusion: In our study, we derived key information and first insights with regard to barriers against IDD prevention programs from a broad range of stakeholders. Most barriers were found in the category of implementation and management. Also a lack of political support seems to play an important role. The findings of our study may help decision makers in health policy to develop more effective IDD prevention and monitoring strategies.

The value of real-world testing: a qualitative feasibility study to explore staff and organisational barriers and strategies to support implementation of a clinical pathway for the management of anxiety and depression in adult cancer patients.

BACKGROUND: Effective translation of evidence-based research into clinical practice requires assessment of the many factors that can impact implementation success. Research methods that draw on recognised implementation frameworks, such as the Promoting Action Research in Health Services (PARiHS) framework, and that test feasibility to gain information prior to full-scale roll-out, can support a more structured approach to implementation. OBJECTIVE: This paper presents qualitative findings from a feasibility study in one cancer service of an online portal to operationalise a clinical pathway for the screening, assessment and management of anxiety and depression in adult cancer patients. The aim of this study was to explore staff perspectives on the feasibility and acceptance of a range of strategies to support implementation in order to inform the full-scale roll-out. METHODS: Semi-structured interviews were conducted with fifteen hospital staff holding a range of clinical, administrative and managerial roles, and with differing levels of exposure to the pathway. Qualitative data were analysed thematically, and themes were subsequently organised within the constructs of the PARiHS framework. RESULTS: Barriers and facilitators that affected the feasibility of the online portal and implementation strategies were organised across eight key themes: staff perceptions, culture, external influences, attitudes to psychosocial care, intervention fit, familiarity, burden and engagement. These themes mapped to the PARiHS framework's three domains of evidence, context and facilitation. CONCLUSIONS: Implementation success may be threatened by a range of factors related to the real-world context, perceptions of the intervention (evidence) and the process by which it is introduced (facilitation). Feasibility testing of implementation strategies can provide unique insights into issues likely to influence full-scale implementation, allowing for early tailoring and more effective facilitation which may save time, money and effort in the long-term. Use of a determinant implementation framework can assist researchers to synthesise and effectively respond to barriers as they arise. While the current feasibility study related to a specific implementation, strategies such as regular engagement with local stakeholders, and discussion of barriers arising in real-time during early testing is likely to be of benefit to all researchers and clinicians seeking to maximise the likelihood of long-term implementation success.

Identifying the barriers to effective breast, cervical and colorectal cancer screening in thirty one European countries using the Barriers to Effective Screening Tool (BEST).

The aim of this study was to identify barriers to effective breast, cervical and colorectal cancer screening programmes throughout the whole of the European region using the Barriers to Effective Screening Tool (BEST). The study was part of the scope of the EU-TOPIA (TOwards imProved screening for breast, cervical and colorectal cancer In All of Europe) project and respondents were European screening organisers, researchers and policymakers taking part in a workshop for the project in Budapest in September 2017. 67 respondents from 31 countries responded to the online survey. The study found that there are many barriers to effective screening throughout the system from identification of the eligible population to ensuring appropriate follow-up and treatment for the three cancers. The most common barriers were opportunistic screening, sub-optimal participation, limited capacity (including trained human resource), inadequate and/or disjointed information technology systems and complex administration procedures. Many of the barriers were reported consistently across different countries. This study identified the barriers that, in general, require further investment of resources.

Seascape genetics and biophysical connectivity modelling support conservation of the seagrass Zostera marina in the Skagerrak-Kattegat region of the eastern North Sea.

Maintaining and enabling evolutionary processes within meta-populations are critical to resistance, resilience and adaptive potential. Knowledge about which populations act as sources or sinks, and the direction of gene flow, can help to focus conservation efforts more effectively and forecast how populations might respond to future anthropogenic and environmental pressures. As a foundation species and habitat provider, Zostera marina (eelgrass) is of critical importance to ecosystem functions including fisheries. Here, we estimate connectivity of Z. marina in the Skagerrak-Kattegat region of the North Sea based on genetic and biophysical modelling. Genetic diversity, population structure and migration were analysed at 23 locations using 20 microsatellite loci and a suite of analytical approaches. Oceanographic connectivity was analysed using Lagrangian dispersal simulations based on contemporary and historical distribution data dating back to the late 19th century. Population clusters, barriers and networks of connectivity were found to be very similar based on either genetic or oceanographic analyses. A single-generation model of dispersal was not realistic, whereas multigeneration models that integrate stepping-stone dispersal and extant and historic distribution data were able to capture and model genetic connectivity patterns well. Passive rafting of flowering shoots along oceanographic currents is the main driver of gene flow at this spatial-temporal scale, and extant genetic connectivity strongly reflects the "ghost of dispersal past" sensu Benzie, 1999. The identification of distinct clusters, connectivity hotspots and areas where connectivity has become limited over the last century is critical information for spatial management, conservation and restoration of eelgrass.

Hospital-based interventions: a systematic review of staff-reported barriers and facilitators to implementation processes.

BACKGROUND: Translation of evidence-based interventions into hospital systems can provide immediate and substantial benefits to patient care and outcomes, but successful implementation is often not achieved. Existing literature describes a range of barriers and facilitators to the implementation process. This systematic review identifies and explores relationships between these barriers and facilitators to highlight key domains that need to be addressed by researchers and clinicians seeking to implement hospital-based, patient-focused interventions. METHODS: We searched MEDLINE, PsychInfo, Embase, Web of Science, and CINAHL using search terms focused specifically on barriers and facilitators to the implementation of patient-focused interventions in hospital settings. To be eligible, papers needed to have collected formal data (qualitative or quantitative) that specifically assessed the implementation process, as experienced by the staff involved. RESULTS: Of 4239 papers initially retrieved, 43 papers met inclusion criteria. Staff-identified barriers and facilitators to implementation were grouped into three main domains: system, staff, and intervention. Bi-directional associations were evident between these domains, with the strongest links evident between staff and intervention. CONCLUSIONS: Researchers and health professionals engaged in designing patient-focused interventions need to consider barriers and facilitators across all three identified domains to increase the likelihood of implementation success. The interrelationships between domains are also crucial, as resources in one area can be leveraged to address barriers in others. These findings emphasize the importance of careful intervention design and pre-implementation planning in response to the specific system and staff context in order to increase likelihood of effective and sustainable implementation. TRIAL REGISTRATION: This review was registered on the PROSPERO database: CRD42017057554  in February 2017.

Transition from the Lactational Amenorrhea Method to other modern family planning methods in rural Bangladesh: barrier analysis and implications for behavior change communication program intervention design.

The timely transition from Lactational Amenorrhea Method (LAM)(2) to another modern family planning method contributes to healthy spacing of pregnancies by increasing the adoption of family planning during the first year postpartum. Yet, literature suggests challenges in completing a timely LAM transition. To guide program implementation in Bangladesh, this study identified factors influencing women's transition decisions. Eighty postpartum women, comprising 40 who transitioned from LAM(3) and 40 who did not,(4) participated. Half of each group participated in in-depth interviews to explore the decision-making process. All participants responded to a "Barrier Analysis" questionnaire to identify differences in eight behavioral determinants. More than half of transitioners switched to another modern method before or within the same month that LAM ended. Of the 18 transitioners who delayed,(5) 15 waited for menses to return. For non-transitioners, key barriers included waiting for menses to return, misconceptions on return to fertility, and perceived lack of familial support. The LAM transition can help women prevent unintended pregnancy during the first year postpartum. Increased emphasis on counseling women about the risk of pregnancy, and misconceptions about personal fertility patterns are critical for facilitating the transition. Strategies should also include interventions that train health workers and improve social support.

Using formative research to design a context-specific behaviour change strategy to improve infant and young child feeding practices and nutrition in Nepal.

Global recommendations on strategies to improve infant feeding, care and nutrition are clear; however, there is limited literature that explains methods for tailoring these recommendations to the local context where programmes are implemented. This paper aims to: (1) highlight the individual, cultural and environmental factors revealed by formative research to affect infant and young child feeding and care practices in Baitadi district of Far Western Nepal; and (2) outline how both quantitative and qualitative research methods were used to design a context-specific behaviour change strategy to improve child nutrition. Quantitative data on 750 children aged 12-23 months and their families were collected via surveys administered to mothers. The participants were selected using a multistage cluster sampling technique. The survey asked about knowledge, attitude and behaviours relating to infant and young child feeding. Qualitative data on breastfeeding and complementary feeding beliefs and practices were also collected from a separate sample via focus group discussions with mothers, and key informant interviews with mothers-in-law and husbands. Key findings revealed gaps in knowledge among many informants resulting in suboptimal infant and young child feeding practices - particularly with relation to duration of exclusive breastfeeding and dietary diversity of complementary foods. The findings from this research were then incorporated into a context-specific nutrition behaviour change communication strategy.