Barriers and Facilitators to the Implementation of an Electronic Patient-Reported Outcome System at Cancer Hospitals in Japan.

Background and objective Implementing electronic patient-reported outcomes (ePROs) in oncology practice has shown substantial clinical benefits. However, it can be challenging in routine practice, warranting strategies to adapt to different clinical contexts. In light of this, this study aimed to describe the implementation process of the ePRO system and elucidate the provider-level implementation barriers and facilitators to a novel ePRO system at cancer hospitals in Japan. Methods We implemented an ePRO system linked to electronic medical records at three cancer hospitals. Fifteen patients with solid cancers at the outpatient oncology unit were asked to regularly complete the Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE™) questionnaire and European Organization for Research and Treatment Core Quality of Life questionnaire (EORTC QLQ C30) by using the smartphone app between October 2021 and June 2022. Thirteen healthcare professionals were interviewed to identify implementation barriers and facilitators to the ePRO system by using the Consolidated Framework for Implementation Research framework. Results The healthcare professionals identified a lack of clinical resources and a culture and system that emphasizes treatment over care as the main barriers; however, the accumulation of successful cases, the leadership of managers, and the growing needs of patients can serve as facilitators to the implementation. Conclusions Our experience implementing an ePRO system in a few Japanese oncology practices revealed comprehensive barriers and facilitators. Further efforts are warranted to develop more successful implementation strategies.

Barriers to implementing problem-based learning at the school of medicine of Debre Berhan University, Ethiopia.

BACKGROUND: Implementing PBL in teaching and learning can be challenging due to a variety of complex barriers. Studies on barriers to the implementation of problem-based learning in Ethiopia are scarce. This study aimed to explore the barriers to the implementation of problem-based learning at the Debre Berhan University Medical School. METHODS: A qualitative study was conducted among faculty and medical students at the medical school. Purposive sampling was used to select participants. Semi-structured interviews were conducted with tutors and academic leaders, including the problem-based learning coordinator, the biomedical sciences coordinator, and the school dean. Data was also collected from students through focus group discussions. All interviews and discussions were recorded. The four steps of data analysis of Spradley, including domain analysis, taxonomic analysis, componential analysis, and theme analysis, were employed. RESULTS: The study identified student-related, tutor-related, case scenario-related, and assessment-related barriers as the most significant obstacles to implementing problem-based learning. These barriers included work overload for both students and tutors, lack of training and experience among tutors, student reluctance, absence of standardized case scenarios, subjectivity of assessment methods, and on-the-spot assessment of students. CONCLUSIONS AND RECOMMENDATIONS: Lack of both tutor and student commitment, lack of standardized cases, absence of a recognition of staff input, gap in communication skills, work overload, lack of continuous training, and at-spot evaluation of students were identified as the main barriers to the implementation of PBL.

Hospital-Based Health Professionals' Perceptions of Frailty in Older People.

BACKGROUND AND OBJECTIVES: There is a high prevalence of frailty amongst older patients in hospital settings. Frailty guidelines exist but implementation to date has been challenging. Understanding health professional attitudes, knowledge, and beliefs about frailty is critical in understanding barriers and enablers to guideline implementation, and the aim of this study was to understand these in rehabilitation multidisciplinary teams in hospital settings. RESEARCH DESIGN AND METHODS: Twenty-three semistructured interviews were conducted with health professionals working in multidisciplinary teams on geriatric and rehabilitation wards in Adelaide and Sydney, Australia. Interviews were audio recorded, transcribed, and coded by 2 researchers. A codebook was created and interviews were recoded and applied to the Framework Method of thematic analysis. RESULTS: Three domains were developed: diagnosing frailty, communicating about frailty, and managing frailty. Within these domains, 8 themes were identified: (1) diagnosing frailty has questionable benefits, (2) clinicians don't use frailty screening tools, (3) frailty can be diagnosed on appearance and history, (4) frailty has a stigma, (5) clinicians don't use the word "frail" with patients, (6) frailty isn't always reversible, (7) there is a lack of continuity of care after acute admission, and (8) the community setting lacks resources. DISCUSSION AND IMPLICATIONS: Implementation of frailty guidelines will remain challenging while staff avoid using the term "frail," don't perceive benefit of using screening tools, and focus on the individual aspects of frailty rather than the syndrome holistically. Clinical champions and education about frailty identification, reversibility, management, and communication techniques may improve the implementation of frailty guidelines in hospitals.

Barriers and co-designed strategies for the implementation of negative pressure wound therapy in acute pediatric burn care in Australia: A mixed method study.

PURPOSE: Pediatric burn injuries are a global clinical issue causing significant morbidity. Early adjunctive negative pressure wound therapy improves re-epithelialization rates in children with burns, yet adoption in acute burn care is inconsistent. This investigation aimed to determine barriers to the implementation of adjunctive negative pressure wound therapy for the acute management of pediatric burns and co-design targeted implementation strategies. METHODS: A sequential mixed methods design was used explore barriers to adjunctive negative pressure wound therapy implementation in acute pediatric burn care. An online questionnaire was disseminated to healthcare professionals within four major Australian pediatric hospitals, each with a dedicated burns service. Barriers were coded according to the Consolidated Framework for Implementation Research (CFIR). Semi-structured interviews with senior clinicians tailored implementation strategies to local contexts. A stakeholder consensus meeting consolidated implementation strategies and local processes. RESULTS: Sixty-three healthcare professionals participated in the questionnaire, and semi-structured interviews involved nine senior burn clinicians. We identified eight implementation barriers across all five CFIR domains then co-designed targeted strategies to address identified barriers. Barriers included lack of available resources, limited access to knowledge and information, individual stage of change, patient needs and resources, limited knowledge and beliefs about the intervention, lack of external policies, intervention complexity, and poor implementation planning. CONCLUSION: Multiple contextual factors affect negative pressure wound therapy uptake in acute pediatric burn settings. Results will inform a multi-state stepped-wedge cluster randomized controlled trial. Additional resources, education, training, updated policies, and guidelines are required for successful implementation. It is anticipated that adjunctive negative pressure wound therapy, in conjunction with tailored implementation strategies, will enhance adoption and sustainability. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry: ACTRN12622000166774. Registered 1 February 2022.

Barriers and enablers for externally and internally driven implementation processes in healthcare: a qualitative cross-case study.

BACKGROUND: Quality in healthcare is a subject in need of continuous attention. Quality improvement (QI) programmes with the purpose of increasing service quality are therefore of priority for healthcare leaders and governments. This study explores the implementation process of two different QI programmes, one externally driven implementation and one internally driven, in Norwegian nursing homes and home care services. The aim for the study was to identify enablers and barriers for externally and internally driven implementation processes in nursing homes and homecare services, and furthermore to explore if identified enablers and barriers are different or similar across the different implementation processes. METHODS: This study is based on an exploratory qualitative methodology. The empirical data was collected through the 'Improving Quality and Safety in Primary Care - Implementing a Leadership Intervention in Nursing Homes and Homecare' (SAFE-LEAD) project. The SAFE-LEAD project is a multiple case study of two different QI programmes in primary care in Norway. A large externally driven implementation process was supplemented with a tracer project involving an internally driven implementation process to identify differences and similarities. The empirical data was inductively analysed in accordance with grounded theory. RESULTS: Enablers for both external and internal implementation processes were found to be technology and tools, dedication, and ownership. Other more implementation process specific enablers entailed continuous learning, simulation training, knowledge sharing, perceived relevance, dedication, ownership, technology and tools, a systematic approach and coordination. Only workload was identified as coincident barriers across both externally and internally implementation processes. Implementation process specific barriers included turnover, coping with given responsibilities, staff variety, challenges in coordination, technology and tools, standardizations not aligned with work, extensive documentation, lack of knowledge sharing. CONCLUSION: This study provides understanding that some enablers and barriers are present in both externally and internally driven implementation processes, while other are more implementation process specific. Dedication, engagement, technology and tools are coinciding enablers which can be drawn upon in different implementation processes, while workload acted as the main barrier in both externally and internally driven implementation processes. This means that some enablers and barriers can be expected in implementation of QI programmes in nursing homes and home care services, while others require contextual understanding of their setting and work.

Strategies to improve implementation of collaborative care for functional disorders and persistent somatic symptoms: A qualitative study using a Research World Café design.

INTRODUCTION: Persistent somatic symptoms and functional disorders (PSS/FD) are often complex conditions requiring care from multiple disciplines. One way of bringing the different disciplines together is through collaborative care. Little is known about the implementation barriers faced and relevant strategies to tackle the barriers in this field. Therefore, using expert knowledge, we aim to develop realistic strategies for dealing with implementation barriers of collaborative care in PSS/FD. METHODS: The Research World Café method is a single-session, expert-based method with multiple focus-groups forming and reforming to answer a set of inter-related questions, under the guidance of moderators. Using this method, participants involved in PSS/FD care across different areas of healthcare in the Netherlands developed several realistic strategies for dealing with ten implementation barriers for collaborative care in PSS/FD that were previously identified in a Delphi study. Strategies were grouped into strategy clusters using a card-sorting task. RESULTS: Thirty-three participants took part, representing ten different disciplines, most commonly physiotherapists, psychologists, and physicians. In total, 54 strategies, identified in response to the ten barriers, were grouped into eight strategy clusters. The strategy clusters were professional education, communication, care coordination, care pathways, joint consults, funding, patient involvement, and prevention. CONCLUSION: We identified a number of useful strategies for dealing with implementation barriers for collaborative care in PSS/FD. Many strategies provided ways to deal with multiple barriers at once. The effects of applying these strategies in collaborative care in PSS/FD will need testing through implementation studies, as well as in other areas needing multidisciplinary care.

Facilitators and barriers for implementation of health programmes with Maori communities.

BACKGROUND: Addressing health inequities that Maori (Indigenous peoples) communities face in New Zealand is a key aim of researchers and practitioners. However, there is limited understanding of the implementation processes and outcomes of health programmes for addressing these inequities. The aim of this study was twofold: (a) to identify correlates of implementation outcomes and (b) to identify facilitators and barriers to implementation effectiveness. METHODS: The study involved a concurrent mixed method approach. Through an online survey, 79 participants with experience in implementing a health programme with a Maori community identified outcomes and processes of the programme. Additionally, nine Maori community providers shared their perceptions and experience of facilitators and barriers to implementation effectiveness through an in-depth interview. The quantitative and qualitative findings were integrated to address the aims of the study. RESULTS: For the first aim, we identified two key outcomes: overall health impacts and sustainability. Three of the variables had significant and positive bivariate correlations with health impacts: cultural alignment, community engagement, and individual skills. The only significant correlate of sustainability was evidence-based. For the second aim, participants described four facilitators (leadership, whanaungatanga [relationships], sharing information, digestible information) and four barriers (system constraints, lack of funding, cultural constraints, lack of engagement) to effective implementation. CONCLUSION: Overall, leadership, aligning culture, and building on whanaungatanga, while getting financial resources and systems support, are the core elements to supporting implementation efforts in Maori communities.

Views of German mental health professionals on the use of digital mental health interventions for eating disorders: a qualitative interview study.

INTRODUCTION: Digital mental health interventions (DMHIs) are getting increasingly important for mental health care. In the case of eating disorders (EDs), DMHIs are still in early stages. Few studies so far investigated the views of mental health professionals for EDs on the integration of DMHIs in routine care. OBJECTIVE: To gain insights into the experiences, perspectives, and expectations of mental health professionals for EDs regarding DMHIs and to identify requirements for the future integration of DMHIs into routine care. METHODS: Semi-structured qualitative telephone interviews with 24 German mental health professionals treating patients with EDs were conducted. A content analysis following a deductive-inductive approach asked for experiences, advantages and chances, disadvantages and boundaries, desired functions and properties, target groups, and general conditions and requirements for DMHIs for patients with EDs. RESULTS: Only few professionals reported experiences with DMHIs besides video-based psychotherapy during the pandemic. From the therapists' point of view, DMHIs have the potential to deliver low-threshold access for patients with EDs. Useful functionalities were seen in digital meal records, skills training, and psychoeducation. However, a stable therapeutic alliance was reported as an important prerequisite for the successful integration into care. Therapists expressed concerns in case of severe anorexia nervosa or suicidality. The participants felt to be informed inadequately on recent developments and on the evidence base of DMHIs. CONCLUSIONS: Mental health professionals for EDs show positive attitudes towards DMHIs, however many barriers to the integration in routine care were observed. The highest potential was seen for the use of DMHIs in addition to outpatient care and in aftercare. Specific requirements for DMHIs are related to different areas of the healthcare spectrum and for the different symptom profiles in anorexia nervosa, bulimia nervosa and binge eating disorder. Targeted DMHIs are needed and appropriate especially for concepts of blended care.

Digital mental health interventions are therapeutic services for people with a mental disorder that can be delivered on electronic devices. They are getting increasingly important, as many patients have to wait long for a therapy. In eating disorders these interventions are still in early stages. Twenty-four telephone interviews were held with German professionals treating adolescent and adult patients with eating disorders. The aim was to understand their experiences, perspectives, and expectations regarding digital mental health interventions and to find out what is needed to integrate them into care in the future. In general, the interview partners showed positive attitudes towards these interventions. However, only few reported experiences and many obstacles were observed. The highest potential was seen for the use in addition to care outside the hospital setting and after treatment has ended. However, in case of a severe eating disorder, such as anorexia, or self-harm and suicidality, they were against the use of digital interventions. A stable personal relationship to their patients was seen as particularly important before recommending a digital intervention. Finally, the interview partners felt not informed in a sufficient way on the scientific basis and regulations regarding digital mental health interventions.

District health information system (DHIS2) as integrated antimicrobial resistance surveillance platform: An exploratory qualitative investigation of the one health stakeholders' viewpoints in Ethiopia.

INTRODUCTION: There is an unmet need for One Health (OH) surveillance and reporting systems for antimicrobial resistance (AMR) in resource poor settings. District health information system, version 2 (DHIS2), is a globally recognized digital surveillance platform which has not been widely utilized for AMR data yet. Our study aimed to understand the local stakeholders' viewpoints on DHIS2 as OH-AMR surveillance platform in Jimma, Ethiopia which will aid its further context specific establishment. METHODS: We performed an exploratory qualitative study using semi-structured key informant interviews (KIIs) in Jimma Zone at Southwest Ethiopia. We interviewed 42 OH professionals between November 2020 and February 2021. Following verbatim transcription of the audio recordings of KIIs, we conducted thematic analysis. RESULTS: We identified five major themes which are important for understanding the trajectory of OH-AMR surveillance in DHIS2 platform. The themes were: (1) Stakeholders' current knowledge on digital surveillance platforms including DHIS2. (2) Stakeholders' perception on digital surveillance platform including DHIS2. (3) Features suggested by stakeholders to be included in the surveillance platform. (4) Comments from stakeholders on system implementation challenges. (5) Stakeholders' perceived role in the process of implementation. Despite several barriers and challenges, most of the participants perceived and suggested DHIS2 as a suitable OH-AMR surveillance platform and were willing to contribute at their current professional roles. CONCLUSIONS: Our study demonstrates the potential of the DHIS2 as a user friendly and acceptable interoperable platform for OH-AMR surveillance if the technology designers accommodate the stakeholders' concerns. Piloting at local level and using performance appraisal tool in all OH disciplines should be the next step before proceeding to workable format.

Hotspots and bottlenecks for the enhancement of the environmental sustainability of pig systems, with emphasis on European pig systems.

Although pig systems start from a favourable baseline of environmental impact compared to other livestock systems, there is still scope to reduce their emissions and further mitigate associated impacts, especially in relation to nitrogen and phosphorous emissions. Key environmental impact hotspots of pig production systems are activities associated with feed production and manure management, as well as direct emissions (such as methane) from the animals and energy use. A major contributor to the environmental impacts associated with pig feed is the inclusion of soya in pig diets, especially since European pig systems rely heavily on soya imported from areas of the globe where crop production is associated with significant impacts of land use change, deforestation, carbon emissions, and loss of biodiversity. The "finishing" pig production stage contributes most to these environmental impacts, due to the amount of feed consumed, the efficiency with which feed is utilised, and the amount of manure produced during this stage. By definition therefore, any substantial improvements pig system environmental impact would arise from changes in feed production and manure management. In this paper, we consider potential solutions towards system environmental sustainability at these pig system components, as well as the bottlenecks that inhibit their effective implementation at the desired pace and magnitude. Examples include the quest for alternative protein sources to soya, the limits (perceived or real) to the genetic improvement of pigs, and the implementation of alternative manure management strategies, such as production of biogas through anaerobic digestion. The review identifies and discusses areas that future efforts can focus on, to further advance understanding around the potential sustainability benefits of modifications at various pig system components, and key sustainability trade-offs across the environment-economy-society pillars associated with synergistic and antagonistic effects when joint implementation of multiple solutions is considered. In this way, the review opens a discussion to facilitate the development of holistic decision support tools for pig farm management that account for interactions between the "feed * animal * manure" system components and trade-offs between sustainability priorities (e.g., environmental vs economic performance of pig system; welfare improvements vs environmental impacts).

Implementing patient-centred outcome measures in palliative care clinical practice for adults (IMPCOM): Protocol for an update systematic review of facilitators and barriers.

Background: Despite the development of patient-centred or patient-reported outcome measures (PCOMs or PROMs) in palliative and end-of-life care over recent years, their routine use in practice faces continuing challenges. Objective: To update a highly cited literature review, identify and synthesise new evidence on facilitators, barriers, lessons learned, PCOMs used, models of implementation, implementation outcomes, costs, and consequences of implementing PCOMs in palliative care clinical practice. Methods: We will search MEDLINE, PsycINFO, CINAHL, Embase, Emcare, SCI-Expanded, SSCI, ESCI, and BNI. The database search will be supplemented by a list of studies from the expert advisory committee, hand-searching of reference lists for included articles, and citations of the original review. We will include primary studies using a PCOM during clinical care of adult patients with advanced disease in palliative care settings and extract data on reported models of implementation, PCOMs, facilitators, barriers, lessons learned, costs, and implementation outcomes. Gough's Weight of Evidence Framework will be used to assess the robustness and relevance of the studies. We will narratively synthesise and tabulate the findings. This review will follow PRISMA, PRISMA-Abstract, PRISMA-P, and PRISMA-Search as the reporting guidelines. Source of funding: Marie Curie. The funder is not involved in designing or conducting this study. Protocol registration: CRD42023398653 (13/02/2023).

Restorative clinical supervision: a chance for change but are we ready?

In the wake of the COVID-19 pandemic, nurses are experiencing increasing stress, burnout and mental health problems. The Advocating and Educating for Quality ImProvement (A-EQUIP) model of clinical supervision aims to support staff wellbeing, promote positive work cultures and improve patient care. Although a growing body of empirical evidence supports the positive impact of clinical supervision, several individual and organisational barriers may impede the implementation of A-EQUIP in practice. Organisational culture, staffing and workforce pressures all affect employees' ability to engage with supervision, and organisations and clinical leaders must consciously work to sustain lasting change.

Swedish parents' satisfaction and experience of facilitators and barriers with Family Check-up: A mixed methods study.

Family Check-up (FCU) was introduced in Sweden more than a decade ago. Little is known about what parents experience as FCU's key mechanisms leading to changes in parenting. The aim of this study was to investigate Swedish parents' satisfaction with FCU, and their experiences of facilitators and barriers for making changes in their parenting. A mixed methods approach was employed using a parent satisfaction questionnaire (n = 77) and focus groups (n = 15). General satisfaction with FCU was adequate, with an average rating of 4 on a five-point scale (range 3.1-4.6). The analysis of quantitative and qualitative data resulted in eight themes representing facilitators and four themes representing barriers, organized into three categories: (1) access and engagement; (2) therapeutic process; and (3) program components. Ease of access to FCU facilitated initial engagement. Individual tailoring and access to FCU during different phases of change facilitated sustained engagement and change. Therapeutic process facilitators were a meaningful, supportive relationship with the provider, psychological benefits for parents and benefits for the whole family. Program components that facilitated change in parenting were new learning of parenting strategies and use of helpful techniques such as videotaping and home practice. Negative experiences with service systems prior to starting FCU, parent psychological barriers, and parent-provider mismatch were described as potential barriers. Some parents desired other program formats that were not offered, and some felt that new learning was insufficient to improve child behavior. Understanding the parent perspective can contribute to successful future work with implementing FCU.

Barriers to employing digital technologies for a circular economy: A multi-level perspective.

Industry 4.0 and digital technologies might significantly impact resource optimization in a smart circular economy. However, adopting digital technologies is not easy due to barriers that may arise during this process. While prior literature offers initial insights into barriers at the firm level, these studies pay less attention to these barriers' multi-level nature. Focusing only on one particular level while ignoring others may not unleash the full potential of DTs in a circular economy. To overcome barriers, it's necessary to have a systemic understanding of the phenomenon, which is missing in previous literature. By combining a systematic literature review and multiple case studies of nine firms, this study aims to unpack the multi-level nature of barriers to a smart circular economy. The primary contribution of this study is a new theoretical framework composed of eight dimensions of barriers. Each dimension provides unique insights related to the multi-level nature of the smart circular economy transition. In total, 45 barriers were identified and categorized into the following dimensions: 1. Knowledge management (five barriers), 2. Financial (three barriers), 3. Process management & Governance (eight barriers), 4. Technological (ten barriers), 5. Product & Material (three barriers), 6. Reverse logistic infrastructure (four barriers), 7. Social behaviour (seven barriers), and 8. Policy & Regulatory (five barriers). This study examines how each dimension and multi-level barrier affects the transitions toward a smart circular economy. An effective transition copes with complex, multidimensional, multi-level barriers, which might require mobilization beyond a single firm. Government actions need to be more effective and correlated with sustainable initiatives. Policies also should focus on mitigating barriers. Overall, the study contributes to smart circular economy literature by increasing theoretical and empirical understanding of digital transformation barriers towards circularity.

Long-Acting Injectable Therapy for People with HIV: Looking Ahead with Lessons from Psychiatry and Addiction Medicine.

Long-acting injectable antiretroviral medications are new to HIV treatment. People with HIV may benefit from a treatment option that better aligns with their preferences, but could also face new challenges and barriers. Authors from the fields of HIV, substance use treatment, and mental health collaborated on this commentary on the issues surrounding equitable implementation and uptake of LAI ART by drawing lessons from all three fields. We employ a socio-ecological framework beginning at the policy level and moving through the community, organizational, interpersonal, and patient levels. We look at extant literature on the topic as well as draw from the direct experience of our clinician-authors.

Healthier Lives Implementation Research Network for Maori and Pacific community health providers in Aotearoa New Zealand: a study protocol with an observational mixed methods design.

BACKGROUND: Despite incremental gains in the Aotearoa New Zealand health sector, Maori and Pacific peoples still experience poorer health outcomes than non-Maori and non-Pacific. Access to the latest research and innovation is critical to improving and addressing health outcomes and health inequities in particular. However, there are numerous challenges to translating research into practice including that there is currently no known a specific infrastructure in Aotearoa New Zealand to facilitate this process. The aim of the project is to develop a network of community providers, researchers and health systems representatives that can help facilitate the implementation of novel and innovative programmes and products that help to meet the health needs of Maori and Pacific communities. METHODS: This project has three stages, one of which has been completed. In Stage 1, we engaged with key leaders of organisations from various components in the health system through a co-design process to identify parameters and infrastructure of the network. In Stage 2, we propose to construct the network involving approximately 20-30 community providers (and other affiliated researchers and health system representatives) and refine its parameters through an additional co-design process. Additionally, we will use a mixed methods research design using survey and interviews to identify perceived implementation needs, facilitators and barriers to help inform the work in the third stage. In Stage 3, we will support the active implementation of evidence-based programmes with a smaller number of providers (approximately four to eight community providers depending on the complexity of the implementation). Mixed methods research will be conducted to understand facilitators and barriers to implementation processes and outcomes. DISCUSSION: The proposed network infrastructure is an equity-oriented strategy focused on building capacity through a strength-based approach that can help address inequities over time. Our "proof-of-concept" study will not be able to change inequities in that time period given its relatively small scale and time period, but it should set the foundation for continued equity-oriented work.

A scoping review of applications of the Consolidated Framework for Implementation Research (CFIR) to telehealth service implementation initiatives.

BACKGROUND: The Consolidated Framework for Implementation Research (CFIR), introduced in 2009, has the potential to provide a comprehensive understanding of the determinants of implementation-effectiveness of health service innovations. Although the CFIR has been increasingly used in recent years to examine factors influencing telehealth implementation, no comprehensive reviews currently exist on the scope of knowledge gained exclusively from applications of the CFIR to telehealth implementation initiatives. This review sought to address this gap. METHODS: PRISMA-ScR criteria were used to inform a scoping review of the literature. Five academic databases (PUBMED, PROQUEST, SCIDIRECT, CINAHL, and WoS) were searched for eligible sources of evidence from 01.01.2010 through 12.31.2021. The initial search yielded a total of 18,388 records, of which, 64 peer-reviewed articles met the inclusion criteria for the review. Included articles were reviewed in full to extract data, and data collected were synthesized to address the review questions. RESULTS: Most included articles were published during or after 2020 (64%), and a majority (77%) were qualitative or mixed-method studies seeking to understand barriers or facilitators to telehealth implementation using the CFIR. There were few comparative- or implementation-effectiveness studies containing outcome measures (5%). The database search however, revealed a growing number of protocols for implementation-effectiveness studies published since 2020. Most articles (91%) reported the CFIR Inner Setting domain (e.g., leadership engagement) to have a predominant influence over telehealth implementation success. By comparison, few articles (14%) reported the CFIR Outer Setting domain (e.g., telehealth policies) to have notable influence. While more (63%) telehealth initiatives were focused on specialty (vs primary) care, a vast majority (78%) were focused on clinical practice over medical education, healthcare administration, or population health. CONCLUSIONS: Organized provider groups have historically paid considerable attention to advocating for telehealth policy (Outer Setting) reform. However, results suggest that for effective telehealth implementation, provider groups need to refocus their efforts on educating individual providers on the complex inter-relationships between Inner Setting constructs and telehealth implementation-effectiveness. On a separate note, the growth in implementation-effectiveness study protocols since 2020, suggests that additional outcome measures may soon be available, to provide a more nuanced understanding of the determinants of effective telehealth implementation based on the CFIR domains and constructs.

Potential barriers in implementing the rural toilet retrofitting project: A qualitative study in Jiaozuo, China.

Background: China has launched a large "toilet revolution" in rural areas, but the results show that sanitation has not always been markedly improved. Few scholars have paid attention to this issue, and the list of the reasons is scattered and incomplete. Method: Using the qualitative research method, this study interviewed seven village cadres and 39 villagers in three villages of Jiaozuo City to examine the implementation barriers to rural toilet retrofitting (RTR) projects in China. Results: Using the Van Meter and Van Horn policy implementation approach, the research has found that: (a) unreasonable standards and objectives fail to incorporate local conditions and improve the actual quality; (b) lack of capital and human resources cannot renovate new toilets; (c) uncoordinated inter-organizational communication and enforcement activities by top-down mechanism lead to policy implementers and target groups' dissatisfaction with the policy; (d) weak and unenthusiastic, inadequate implementing agencies, reduce their working ability; (e) inappropriate economic, social and political conditions impede the villagers' acceptance; and (f) an attitude of passive acceptance by the implementers reduce the working motivation. Conclusion: To improve sanitation in rural China, it is necessary to solve the six barriers. The findings of this study can provide recommendations and guidance for implementing the RTR and related public health policies.

Implementation barriers and remedial strategies for community-based health insurance in Bangladesh: insights from national stakeholders.

BACKGROUND: Community-based health insurance (CBHI) is a part of the health system in Bangladesh, and overcoming the obstacles of CBHI is a significant policy concern that has received little attention. The purpose of this study is to analyze the implementation barriers of voluntary CBHI schemes in Bangladesh and the strategies to overcome these barriers from the perspective of national stakeholders. METHODS: This study is exploratory qualitative research, specifically case study design, using key informant interviews to investigate the barriers of CBHI that are faced during the implementation. Using a topic guide, we conducted thirteen semi-structured in-depth interviews with key stakeholders directly involved in the CBHI implementation process. The data were analyzed using the Framework analysis method. RESULTS: The implementation of CBHI schemes in Bangladesh is being constrained by several issues, including inadequate population coverage, adverse selection and moral hazard, lack of knowledge about health insurance principles, a lack of external assistance, and insufficient medical supplies. Door-to-door visits by local community-health workers, as well as regular promotional and educational campaigns involving community influencers, were suggested by stakeholders as ways to educate and encourage people to join the schemes. Stakeholders emphasized the necessity of external assistance and the design of a comprehensive benefits package to attract more people. They also recommended adopting a public-private partnership with a belief that collaboration among the government, microfinance institutions, and cooperative societies will enhance trust and population coverage in Bangladesh. CONCLUSIONS: Our research concludes that systematically addressing implementation barriers by including key stakeholders would be a significant reform to the CBHI model, and could serve as a foundation for the planned national health protection scheme for Bangladesh leading to universal health coverage.

Implementing a text-messaging intervention for unhealthy alcohol use in emergency departments: protocol for implementation strategy development and a pilot cluster randomized implementation trial.

BACKGROUND: Unhealthy alcohol use (UAU) is a leading cause of premature mortality among adults in the USA. Emergency departments (EDs) are key intervention settings for UAU but often have limited time and resources. One low-burden, scalable approach to address UAU is text-messaging interventions. Despite strong research support and promise for scalability, there is little research on how to implement such interventions in healthcare settings. The process of providers making them available to patients in an efficient way within already busy and overburdened ED workflows and patients adopting them remains a new area of research. The purpose of this three-phase study is to develop and test an implementation strategy for UAU text-messaging interventions in EDs. METHOD: Our first aim is to examine barriers and facilitators to staff offering and patients accepting a text-messaging intervention in the ED using an explanatory, sequential mixed methods approach. We will examine alcohol screening data in the electronic health records of 17 EDs within a large integrated health system in the Northeast and conduct surveys among chairpersons in each. This data will be used to purposively sample 4 EDs for semi-structured interviews among 20 clinical staff, 20 patients, and 4 chairpersons. Our second aim is to conduct a stakeholder-engaged intervention mapping process to develop a multi-component implementation strategy for EDs. Our third aim is to conduct a mixed method 2-arm cluster randomized pilot study in 4 EDs that serve ~11,000 UAU patients per year to assess the feasibility, acceptability, and preliminary effectiveness of the implementation strategy. The Integrated Promoting Action on Research Implementation in Health Services framework will guide study activities. DISCUSSION: Low-burden technology, like text messaging, along with targeted implementation support and strategies driven by identified barriers and facilitators could sustain large-scale ED-based alcohol screening programs and provide much needed support to patients who screen positive while reducing burden on EDs. The proposed study would be the first to develop and test this targeted implementation strategy and will prepare for a larger, fully powered hybrid effectiveness-implementation trial. Findings may also be broadly applicable to implementation of patient-facing mobile health technologies. TRIAL REGISTRATION: This study was registered at ClinicalTrials.gov (NCT05350878) on 4/28/2022.