Intervention-related, contextual and personal factors affecting the implementation of an evidence-based digital system for prevention and treatment of malnutrition in elderly institutionalized patients: a qualitative study.

BACKGROUND: Malnutrition in elderly institutionalized patients is a significant challenge associated with adverse health outcomes. The 'MyFood' decision support system was designed to prevent and treat malnutrition and has previously been studied in a hospital setting. The aim of this study was to explore the experiences of nursing staff regarding the implementation of MyFood in settings treating elderly patients. METHODS: The study was conducted in two settings treating elderly patients in Norway. Nursing staff received training in how to follow-up patients with MyFood. Qualitative interviews were conducted with 12 nursing staff. The Consolidated Framework for Implementation Research (CFIR) was used to guide the data collection and the thematic data analysis. RESULTS: The implementation of a digital decision support system to prevent and treat malnutrition into settings treating elderly patients was found to be affected by intervention-related, contextual, and personal factors. Although nursing staff experienced several advantages, the leadership engagement was low and hampered the implementation. CONCLUSION: Nursing staff experienced several advantages with implementing a digital decision support system for the prevention and treatment of malnutrition in institutionalized elderly patients, including quality improvements and time savings. The results indicate that the leadership engagement was weak and that some nursing staff experienced low self-efficacy in digital competence. Future improvements include increasing the level of training, using MyFood throughout the patient course and involving the patient's next-of-kin. TRIAL REGISTRATION: The study was acknowledged by The Norwegian Centre for Research Data (NSD), ref. number 135175.

Short-Term Findings From Testing EPIO, a Digital Self-Management Program for People Living With Chronic Pain: Randomized Controlled Trial.

BACKGROUND: Chronic pain conditions involve numerous physical and psychological challenges, and while psychosocial self-management interventions can be of benefit for people living with chronic pain, such in-person treatment is not always accessible. Digital self-management approaches could improve this disparity, potentially bolstering outreach and providing easy, relatively low-cost access to pain self-management interventions. OBJECTIVE: This randomized controlled trial aimed to evaluate the short-term efficacy of EPIO (ie, inspired by the Greek goddess for the soothing of pain, Epione), a digital self-management intervention, for people living with chronic pain. METHODS: Patients (N=266) were randomly assigned to either the EPIO intervention (n=132) or a care-as-usual control group (n=134). Outcome measures included pain interference (Brief Pain Inventory; primary outcome measure), anxiety and depression (Hospital Anxiety and Depression Scale), self-regulatory fatigue (Self-Regulatory Fatigue 18 scale), health-related quality of life (SF-36 Short Form Health Survey), pain catastrophizing (Pain Catastrophizing Scale), and pain acceptance (Chronic Pain Acceptance Questionnaire). Linear regression models used change scores as the dependent variables. RESULTS: The participants were primarily female (210/259, 81.1%), with a median age of 49 (range 22-78) years and a variety of pain conditions. Analyses (n=229) after 3 months revealed no statistically significant changes for the primary outcome of pain interference (P=.84), but significant reductions in the secondary outcomes of depression (mean difference -0.90; P=.03) and self-regulatory fatigue (mean difference -2.76; P=.008) in favor of the intervention group. No other statistically significant changes were observed at 3 months (all P>.05). Participants described EPIO as useful (ie, totally agree or agree; 95/109, 87.2%) and easy to use (101/109, 92.7%), with easily understandable exercises (106/109, 97.2%). CONCLUSIONS: Evidence-informed, user-centered digital pain self-management interventions such as EPIO may have the potential to effectively support self-management and improve psychological functioning in the form of reduced symptoms of depression and improved capacity to regulate thoughts, feelings, and behavior for people living with chronic pain. TRIAL REGISTRATION: ClinicalTrials.gov NCT03705104; https://clinicaltrials.gov/ct2/show/NCT03705104.

Engaging with EPIO, a digital pain self-management program: a qualitative study.

BACKGROUND: Chronic pain conditions entail significant personal and societal burdens and improved outreach of evidence-based pain self-management programs are needed. Digital cognitive-behavioral self-management interventions have shown promise. However, evidence is still scarce and several challenges with such interventions for chronic pain exist. Exploring patients' experiences and engagement with digital interventions may be an essential step towards developing meaningful digital self-management interventions for those living with chronic pain. OBJECTIVES: This study aimed to gain insight into the experiences of people with chronic pain when engaging with EPIO, an application (app)-based cognitive-behavioral pain self-management intervention program. METHODS: Participants (N = 50) living with chronic pain received access to the EPIO intervention in a feasibility pilot-study for 3 months. During this time, all participants received a follow-up phone call at 2-3 weeks, and a subsample (n = 15) also participated in individual semi-structured interviews after 3 months. A qualitative design was used and thematic analysis was employed aiming to capture participants' experiences when engaging with the EPIO intervention program. RESULTS: Findings identifying program-related experiences and engagement were organized into three main topics, each with three sub-themes: (1) Engaging with EPIO; motivation to learn, fostering joy and enthusiasm, and helpful reminders and personalization, (2) Coping with pain in everyday life; awareness, practice and using EPIO in everyday life, and (3) The value of engaging with the EPIO program; EPIO - a friend, making peace with the presence of pain, and fostering communication and social support. CONCLUSIONS: This qualitative study explored participants' experiences and engagement with EPIO, a digital self-management intervention program for people living with chronic pain. Findings identified valued aspects related to motivation for engagement, and showed how such a program may be incorporated into daily life, and encourage a sense of acceptance, social support and relatedness. The findings highlight vital components for facilitating digital program engagement and use in support of self-management for people living with chronic pain. TRIAL REGISTRATION: ClinicalTrials.gov NCT03705104 .

The Public and Patient Engagement Evaluation Tool: forward-backwards translation and cultural adaption to Norwegian.

BACKGROUND: Patient engagement is recommended for improving health care services, and to evaluate its organisation and impact appropriate, and rigorously evaluated outcome measures are needed. METHODS: Interviews (N = 12) were conducted to assess relevance of the Canadian Public and Patient Engagement Evaluation Tool (PPEET) in a Norwegian setting were performed. The tool was translated, back translated, and assessed following cognitive interviews (N = 13), according to the COSMIN checklist. Data quality was assessed in a cross-sectional survey of patient advisory board members from different rehabilitation institutions (N = 47). RESULTS: Interviews with patient board representatives confirmed the relevance of the PPEET Organisational questionnaire in a Norwegian setting and contributed five additional items. Translation and back translation of the original PPEET showed no major content differences. Differences in vocabulary and sentence structure were solved by discussion among the translators. Comments from cognitive interviews mainly related to the use of different synonyms, layout, and minor differences in semantic structure. Results of the cross-sectional survey support the data quality and construct validity of PPEET items, including 95 score comparisons where 76 (80%) were as hypothesized. CONCLUSIONS: The PPEET Organisational questionnaire has been thoroughly translated and tested, and the resulting Evalueringsverktøy for Brukermedvirkning (EBNOR) has adequate levels of comprehensibility and content validity. Further testing for measurement properties is recommended, but given these results, the EBNOR should be considered for assessing patient engagement in a Norwegian health care organisational context.

Understanding mechanisms behind unwanted health behaviours in Nordic and South Asian women and how they affect their gestational diabetes follow-ups: A qualitative study.

AIMS: The type 2 diabetes risk following gestational diabetes mellitus (GDM) is high, particularly among South Asian women in Western countries. Our study aimed to advance the knowledge regarding the mechanisms behind suboptimal follow-up in the Nordic and South Asian women with previous GDM by comparing (1) their experiences, (2) health and disease perceptions and (3) barriers to and facilitators of health-promoting behaviours. METHODS: This qualitative study was conducted in three hospital outpatient clinics in Norway, comprising six focus group interviews with 28 women 1-3 years after a pregnancy with GDM. The participants were purposively sampled and grouped according to their ethnicity. The data were analysed using thematic analysis, and a theoretical approach was applied to support the analysis and discuss the study's findings. RESULTS: Five main themes were identified: lack of resilience, emotional distress, 'caught between a rock and a hard place', postpartum abandonment and insufficient guidance. The key determinants of the maintenance of unwanted health behaviours after GDM were consistent across the ethnic groups. Although the importance of a culturally sensitive approach was emphasised, it appeared secondary to the need for a more organised public healthcare during and after GDM. CONCLUSIONS: Women's real-life constraints, combined with the inadequate healthcare-service implementation, could explain the non-adherence to the lifestyle-changes guidelines essential for preventing diabetes post-GDM. We suggest promoting specific coping strategies and changing the healthcare service approach rather than relying on women's capacity to initiate the necessary changes.

Video as an alternative to in-person consultations in outpatient renal transplant recipient follow-up: a qualitative study.

BACKGROUND: Renal transplant recipients have to see a nephrologist for regular follow-up for the rest of their lives. To reduce the burden for the patients, video consultation can be an alternative to traditional in-person hospital consultations. The aim of the current study was, from the perspectives of patients and health care providers, to investigate the perceived benefits and challenges of using video consultations in outpatient renal transplant recipient follow-up. METHODS: Patients (i.e., renal transplant recipients; n = 18) alternated between regular in-person follow-up consultations and video consultations. Patients and health care providers were then invited to participate in semi-structured interviews. The interviews were analyzed using thematic analysis. RESULTS: Patients interviewed (n = 15) were median 53 years old (range 37-64) and 53% female. The video consultation solution used in the study turned out to have major technical deficiencies. Despite the technical challenges, however, the majority of the patients reported appreciating being able to alternate between video and in-person hospital consultations. Main benefits reported included not needing to travel to the hospital and thereby saving time, less focus on being chronically ill and potential economic benefits for patients and society. The health care providers (n = 3) also valued the benefits provided by the use of video consultations, but described the reoccurring technical challenges as disruptive. The fact that patients were in a stable phase of their health condition and already had an established, trusting relationship with their nephrologist, acted as facilitators for success. Possible challenges and harms described included concerns related to security, confidentiality and interruptions, as well as the potential need for physical examinations. CONCLUSIONS: Benefits from using video consultations as an alternative to in-person consultations may outweigh potential technological challenges for patients as well as health care providers. A long-lasting mutually trusting relationship between patient and provider may be an important prerequisite for the experienced benefits of using video consultation. Findings also indicate that starting such care delivery changes in a small-scale, with a few selected patients in a stable phase of their condition, may be an important factor for success.

Process evaluation of the implementation of a decision support system to prevent and treat disease-related malnutrition in a hospital setting.

BACKGROUND: Malnutrition is present in 30% of hospitalized patients and has adverse outcomes for the patient and the healthcare system. The current practice for nutritional care is associated with many barriers. The MyFood decision support system was developed to prevent and treat malnutrition. METHODS: This paper reports on a process evaluation that was completed within an effectiveness trial. MyFood is a digital tool with an interface consisting of an app and a website. MyFood includes functions to record and evaluate dietary intake. It also provides reports to nurses, including tailored recommendations for nutritional treatment. We used an effectiveness-implementation hybrid design in a randomized controlled trial. The RE-AIM (Reach, Efficiency, Adoption, Implementation, Maintenance) framework was used to perform a process evaluation alongside the randomized controlled trial, using a combination of quantitative and qualitative methods. An implementation plan, including implementation strategies, was developed to plan and guide the study. RESULTS: Reach: In total, 88% of eligible patients consented to participate (n = 100). Adoption: Approximately 75% of the nurses signed up to use MyFood and 50% used the reports. IMPLEMENTATION: MyFood empowered the patients in their nutritional situation and acted as a motivation to eat to reach their nutritional target. The compliance of using MyFood was higher among the patients than the nurses. A barrier for use of MyFood among the nurses was different digital systems which were not integrated and the log-in procedure to the MyFood website. Despite limited use by some nurses, the majority of the nurses claimed that MyFood was useful, better than the current practice, and should be implemented in the healthcare system. CONCLUSIONS: This study used a process evaluation to interpret the results of a randomized controlled trial more in-depth. The patients were highly compliant, however, the compliance was lower among the nurses. MyFood empowered the patients in their nutritional situation, the usability was considered as high, and the experiences and attitudes towards MyFood were primarily positive. Focus on strategies to improve the nurses' compliance may in the future improve the MyFood system's potential. TRIAL REGISTRATION: The trial was registered in ClinicalTrials.gov 26/01/2018 ( NCT03412695 ).

Health care providers' experiences of pain management and attitudes towards digitally supported self-management interventions for chronic pain: a qualitative study.

BACKGROUND: Chronic pain constitutes a significant burden for the individuals affected, and is a frequent reason why patients seek health care services. While in-person psychosocial interventions can be of support to people living with chronic pain, such interventions are not always accessible. eHealth interventions may provide greater accessibility, but the evidence and use of digital self-management solutions for chronic pain are still limited and the lack of health care provider input in the development process of such solutions a concern. Therefore, the aim of the current study was to investigate health care providers' experiences of treating patients with chronic pain, their attitudes towards, and use of, digital solutions in pain management, and their suggestions for content and design elements for a potential digital pain self-management intervention. METHODS: Twelve health care providers representing a variety of health care disciplines participated in semi-structured interviews. The interviews were analyzed using thematic analysis. RESULTS: The material was analyzed into three main themes: [1] Patients with chronic pain and their current use of the health care services, [2] Health care providers' own motivation and impression of patient prerequisites for use of digital self-management interventions, and [3] Suggestions for content and design elements in a digital self-management intervention for people living with chronic pain. The challenges faced by patients living with chronic pain were described as numerous. Despite interest and positive attitudes, few of the health care providers had used or recommended eHealth solutions to their patients. A range of potential content and functionality elements were identified, including aspects of motivation and engagement and providers also emphasized the importance of easy access and positive, personal content to support existing treatment. CONCLUSIONS: This study offers insights into health care providers' considerations for the potential of digital self-management interventions supporting patients living with chronic pain. Findings indicate the need for change and a more comprehensive treatment approach to pain management. eHealth solutions may contribute to such change, and providers pointed to a need for health care provider involvement, timely support and follow-up as important factors for integrating digital pain self-management interventions into clinical care. TRIAL REGISTRATION: ClinicalTrials.gov : NCT03705104.

A Digital Patient-Provider Communication Intervention (InvolveMe): Qualitative Study on the Implementation Preparation Based on Identified Facilitators and Barriers.

BACKGROUND: Chronic health conditions are affecting an increasing number of individuals, who experience various symptoms that decrease their quality of life. Digital communication interventions that enable patients to report their symptoms have been shown to positively impact chronic disease management by improving access to care, patient-provider communication, clinical outcomes, and health-related quality of life. These interventions have the potential to prepare patients and health care providers (HCPs) before visits and improve patient-provider communication. Despite the recent rapid development and increasing number of digital communication interventions that have shown positive research results, barriers to realizing the benefits offered through these types of interventions still exist. OBJECTIVE: The aim of this study is to prepare for the implementation of a digital patient-provider communication intervention in the daily workflow at 2 outpatient clinics by identifying potential determinants of implementation using the Consolidated Framework for Implementation Research (CFIR) to tailor the use of digital communication intervention to the intended context and identify key aspects for an implementation plan. METHODS: A combination of focus groups, workshops, and project steering committee meetings was conducted with HCPs (n=14) and patients (n=2) from 2 outpatient clinics at a university hospital. The CFIR was used to guide data collection and analysis. Transcripts, written minutes, and notes were analyzed and coded into 5 CFIR domains using thematic analysis. RESULTS: Data were examined and analyzed into 18 CFIR constructs relevant to the study purpose. On the basis of the identified determinants, important intervention tailoring includes adjustments to the digital features and adjustments to fit the clinical workflow and a decision to conduct a future pilot study. Furthermore, it was decided to provide the intervention to patients as early as possible in their disease trajectory, with tailored information about its use. Key aspects for the implementation plan encompassed maintaining the identified engagement and positive attitude, involving key stakeholders in the implementation process, and providing the needed support and training. CONCLUSIONS: This study offers insight into the involvement of stakeholders in the tailoring and implementation planning of a digital communication intervention in clinical practice. Stakeholder involvement in the identification of implementation facilitators and barriers can contribute to the tailoring of digital communication interventions and how they are used and can also inform systematic and targeted implementation planning.

A User-Centered Approach to an Evidence-Based Electronic Health Pain Management Intervention for People With Chronic Pain: Design and Development of EPIO.

BACKGROUND: Chronic pain conditions are complicated and challenging to live with. Electronic health (eHealth) interventions show promise in helping people cope with chronic illness, including pain. The success of these interventions depends not only on the technology and intervention content but also on the users' acceptance and adherence. Involving all stakeholders (eg, patients, spouses, health care providers, designers, software developers, and researchers) and exploring their input and preferences in the design and development process is an important step toward developing meaningful interventions and possibly strengthening treatment outcomes. OBJECTIVE: The aim of this study was to design and develop a user-centered, evidence-based eHealth self-management intervention for people with chronic pain. METHODS: The study employed a multidisciplinary and user-centered design approach. Overall, 20 stakeholders from the project team (ie, 7 researchers, 5 editors, 7 software developers, and 1 user representative), together with 33 external stakeholders (ie, 12 health care providers, 1 health care manger, 1 eHealth research psychologist, and 17 patients with chronic pain and 2 of their spouses) participated in a user-centered development process that included workshops, intervention content development, and usability testing. Intervention content was developed and finalized based on existing evidence, stakeholder input, and user testing. Stakeholder input was examined through qualitative analyses with rapid and in-depth analysis approaches. RESULTS: Analyses from stakeholder input identified themes including a need for reliable, trustworthy, and evidence-based content, personalization, options for feedback, behavioral tracking, and self-assessment/registration as factors to include in the intervention. Evidence-based intervention content development resulted in one face-to-face introduction session and 9 app-based educational and exercise-based modules. Usability testing provided further insight into how to optimize the design of the intervention to the user group, identifying accessibility and a simple design to be essential. CONCLUSIONS: The design and development process of eHealth interventions should strive to combine well-known evidence-based concepts with stakeholder input. This study, designing and developing the pain management intervention EPIO, illustrates how a stakeholder-centered design approach can provide essential input in the development of an eHealth self-management intervention for people with chronic pain. TRIAL REGISTRATION: ClinicalTrials.gov NCT03705104; https://clinicaltrials.gov/ct2/show/NCT03705104.

Content and system development of a digital patient-provider communication tool to support shared decision making in chronic health care: InvolveMe.

BACKGROUND: Chronic conditions present major health problems, affecting an increasing number of individuals who experience a variety of symptoms that impact their health related quality of life. Digital tools can be of support in chronic conditions, potentially improving patient-provider communication, promoting shared decision making for treatment and care, and possibly even improving patient outcomes. This study aimed to develop a digital tool for patient-provider communication in chronic health care settings and describes the data collection and subsequent content and software development of the InvolveMe tool. InvolveMe will provide patients with the opportunity to report symptoms and preferences to their health care providers (HCP), and to use secure messaging to interact with the HCPs. METHOD: The study employed a combination of interviews with patients with chronic conditions and focus groups with HCPs, examining experiences with chronic conditions and the potential use of a digital tool for support. Participants were recruited from two outpatient clinics at a university hospital. Data collected from interviews and focus groups were analysed using thematic analysis. Content and software development was informed by the data collection and by tool development workshops. RESULTS: Analyses from interviews with patients (n = 14) and focus groups with HCPs (n = 11) generated three main themes: 1) Making symptoms and challenges visible, 2) Mastering a new life, and 3) Digital opportunities for follow-up. Each main theme generated separate subthemes. Theme 1 and 2 gave input for content development of the symptom and needs assessment part of the tool, while theme 3 provided ideas for the software development of the InvolveMe tool. Tool development workshops with patients (n = 6) and HCPs (n = 6) supplemented the development. CONCLUSIONS: A digital tool such as InvolveMe has the potential to support shared decision making for patients with chronic health conditions. Through integration with an existing patient portal such a tool can provide opportunities for meaningful interactions and communication between patients and HCP's, particularly with regards to symptoms, needs and preferences for care.

Persuasive System Design Principles and Behavior Change Techniques to Stimulate Motivation and Adherence in Electronic Health Interventions to Support Weight Loss Maintenance: Scoping Review.

BACKGROUND: Maintaining weight after weight loss is a major health challenge, and eHealth (electronic health) solutions may be a way to meet this challenge. Application of behavior change techniques (BCTs) and persuasive system design (PSD) principles in eHealth development may contribute to the design of technologies that positively influence behavior and motivation to support the sustainable health behavior change needed. OBJECTIVE: This review aimed to identify BCTs and PSD principles applied in eHealth interventions to support weight loss and weight loss maintenance, as well as techniques and principles applied to stimulate motivation and adherence for long-term weight loss maintenance. METHODS: A systematic literature search was conducted in PsycINFO, Ovid MEDLINE (including PubMed), EMBASE, Scopus, Web of Science, and AMED, from January 1, 2007 to June 30, 2018. Arksey and O'Malley's scoping review methodology was applied. Publications on eHealth interventions were included if focusing on weight loss or weight loss maintenance, in combination with motivation or adherence and behavior change. RESULTS: The search identified 317 publications, of which 45 met the inclusion criteria. Of the 45 publications, 11 (24%) focused on weight loss maintenance, and 34 (76%) focused on weight loss. Mobile phones were the most frequently used technology (28/45, 62%). Frequently used wearables were activity trackers (14/45, 31%), as well as other monitoring technologies such as wireless or digital scales (8/45, 18%). All included publications were anchored in behavior change theories. Feedback and monitoring and goals and planning were core behavior change technique clusters applied in the majority of included publications. Social support and associations through prompts and cues to support and maintain new habits were more frequently used in weight loss maintenance than weight loss interventions. In both types of interventions, frequently applied persuasive principles were self-monitoring, goal setting, and feedback. Tailoring, reminders, personalization, and rewards were additional principles frequently applied in weight loss maintenance interventions. Results did not reveal an ideal combination of techniques or principles to stimulate motivation, adherence, and weight loss maintenance. However, the most frequently mentioned individual techniques and principles applied to stimulate motivation were, personalization, simulation, praise, and feedback, whereas associations were frequently mentioned to stimulate adherence. eHealth interventions that found significant effects for weight loss maintenance all applied self-monitoring, feedback, goal setting, and shaping knowledge, combined with a human social support component to support healthy behaviors. CONCLUSIONS: To our knowledge, this is the first review examining key BCTs and PSD principles applied in weight loss maintenance interventions compared with those of weight loss interventions. This review identified several techniques and principles applied to stimulate motivation and adherence. Future research should aim to examine which eHealth design combinations can be the most effective in support of long-term behavior change and weight loss maintenance.

Patients' Needs and Requirements for eHealth Pain Management Interventions: Qualitative Study.

BACKGROUND: A growing body of evidence supports the potential effectiveness of electronic health (eHealth) interventions in managing chronic pain. However, research on the needs and preferences of patients with chronic pain in relation to eHealth interventions is scarce. Eliciting user input in the development of eHealth interventions may be a crucial step toward developing meaningful interventions for patients for potentially improving treatment outcomes. OBJECTIVE: This study aimed to explore the experiences of patients with chronic pain with regard to information and communication technology, understand how an eHealth intervention can support the everyday needs and challenges of patients with chronic pain, and identify possible facilitators and barriers for patients' use of an eHealth pain management intervention. METHODS: Twenty patients living with chronic pain and five spouses participated in individual interviews. Semistructured interview guides were used to explore participants' needs, experiences, and challenges in daily life as well as their information and communication technology experiences and preferences for eHealth support interventions. Spouses were recruited and interviewed to gain additional insight into the patients' needs. The study used qualitative thematic analysis. RESULTS: The participants were generally experienced technology users and reported using apps regularly. They were mainly in favor of using an eHealth self-management intervention for chronic pain and considered it a potentially acceptable way of gathering knowledge and support for pain management. The participants expressed the need for obtaining more information and knowledge, establishing a better balance in everyday life, and receiving support for improving communication and social participation. They provided suggestions for the eHealth intervention content and functionality to address these needs. Accessibility, personalization, and usability were emphasized as important elements for an eHealth support tool. The participants described an ideal eHealth intervention as one that could be used for support and distraction from pain, at any time or in any situation, regardless of varying pain intensity and concentration capacity. CONCLUSIONS: This study provides insight into user preferences for eHealth interventions aiming to address self-management for chronic pain. Participants highlighted important factors to be considered when designing and developing eHealth interventions for self-management of chronic pain, illustrating the importance and benefit of including users in the development of eHealth interventions. TRIAL REGISTRATION: ClinicalTrials.gov NCT03705104; https://clinicaltrials.gov/ct2/show/NCT03705104.

Implementation Strategies to Enhance the Implementation of eHealth Programs for Patients With Chronic Illnesses: Realist Systematic Review.

BACKGROUND: There is growing evidence of the positive effects of electronic health (eHealth) interventions for patients with chronic illness, but implementation of such interventions into practice is challenging. Implementation strategies that potentially impact implementation outcomes and implementation success have been identified. Which strategies are actually used in the implementation of eHealth interventions for patients with chronic illness and which ones are the most effective is unclear. OBJECTIVE: This systematic realist review aimed to summarize evidence from empirical studies regarding (1) which implementation strategies are used when implementing eHealth interventions for patients with chronic illnesses living at home, (2) implementation outcomes, and (3) the relationship between implementation strategies, implementation outcomes, and degree of implementation success. METHODS: A systematic literature search was performed in the electronic databases MEDLINE, Embase, PsycINFO, Scopus, Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library. Studies were included if they described implementation strategies used to support the integration of eHealth interventions into practice. Implementation strategies were categorized according to 9 categories defined by the Expert Recommendations for Implementing Change project: (1) engage consumers, (2) use evaluative and iterative strategies, (3) change infrastructure, (4) adapt and tailor to the context, (5) develop stakeholder interrelationships, (6) use financial strategies, (7) support clinicians, (8) provide interactive assistance, and (9) train and educate stakeholders. Implementation outcomes were extracted according to the implementation outcome framework by Proctor and colleagues: (1) acceptability, (2) adoption, (3) appropriateness, (4) cost, (5) feasibility, (6) fidelity, (7) penetration, and (8) sustainability. Implementation success was extracted according to the study authors' own evaluation of implementation success in relation to the used implementation strategies. RESULTS: The implementation strategies management support and engagement, internal and external facilitation, training, and audit and feedback were directly related to implementation success in several studies. No clear relationship was found between the number of implementation strategies used and implementation success. CONCLUSIONS: This is the first review examining implementation strategies, implementation outcomes, and implementation success of studies reporting the implementation of eHealth programs for patients with chronic illnesses living at home. The review indicates that internal and external facilitation, audit and feedback, management support, and training of clinicians are of importance for eHealth implementation. The review also points to the lack of eHealth studies that report implementation strategies in a comprehensive way and highlights the need to design robust studies focusing on implementation strategies in the future. TRIAL REGISTRATION: PROSPERO CRD42018085539; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=85539.

Shifting Practices Toward Recovery-Oriented Care Through an E-Recovery Portal in Community Mental Health Care: A Mixed-Methods Exploratory Study.

BACKGROUND: Mental health care is shifting from a primary focus on symptom reduction toward personal recovery-oriented care, especially for persons with long-term mental health care needs. Web-based portals may facilitate this shift, but little is known about how such tools are used or the role they may play in personal recovery. OBJECTIVE: The aim was to illustrate uses and experiences with the secure e-recovery portal "ReConnect" as an adjunct to ongoing community mental health care and explore its potential role in shifting practices toward recovery. METHODS: ReConnect was introduced into two Norwegian mental health care communities and used for 6 months. The aim was to support personal recovery and collaboration between service users and health care providers. Among inclusion criteria for participation were long-term care needs and at least one provider willing to interact with service users through ReConnect. The portal was designed to support ongoing collaboration as each service user-provider dyad/team found appropriate and consisted of (1) a toolbox of resources for articulating and working with recovery processes, such as status/goals/activities relative to life domains (eg, employment, social network, health), medications, network map, and exercises (eg, sleep hygiene, mindfulness); (2) messaging with providers who had partial access to toolbox content; and (3) a peer support forum. Quantitative data (ie, system log, questionnaires) were analyzed using descriptive statistics. Qualitative data (eg, focus groups, forum postings) are presented relative to four recovery-oriented practice domains: personally defined recovery, promoting citizenship, working relationships, and organizational commitment. RESULTS: Fifty-six participants (29 service users and 27 providers) made up 29 service user-provider dyads. Service users reported having 11 different mental health diagnoses, with a median 2 (range 1-7) diagnoses each. The 27 providers represented nine different professional backgrounds. The forum was the most frequently used module with 1870 visits and 542 postings. Service users' control over toolbox resources (eg, defining and working toward personal goals), coupled with peer support, activated service users in their personal recovery processes and in community engagement. Some providers (30%, 8/27) did not interact with service users through ReConnect. Dyads that used the portal resources did so in highly diverse ways, and participants reported needing more than 6 months to discover and adapt optimal uses relative to their individual and collaborative needs. CONCLUSIONS: Regardless of providers' portal use, service users' control over toolbox resources, coupled with peer support, offered an empowering common frame of reference that represented a shift toward recovery-oriented practices within communities. Although service users' autonomous use of the portal can eventually influence providers in the direction of recovery practices, a fundamental shift is unlikely without broader organizational commitments aligned with recovery principles (eg, quantified goals for service user involvement in care plans).

Using the Consolidated Framework for Implementation Research to Identify Barriers and Facilitators for the Implementation of an Internet-Based Patient-Provider Communication Service in Five Settings: A Qualitative Study.

BACKGROUND: Although there is growing evidence of the positive effects of Internet-based patient-provider communication (IPPC) services for both patients and health care providers, their implementation into clinical practice continues to be a challenge. OBJECTIVE: The 3 aims of this study were to (1) identify and compare barriers and facilitators influencing the implementation of an IPPC service in 5 hospital units using the Consolidated Framework for Implementation Research (CFIR), (2) assess the ability of the different constructs of CFIR to distinguish between high and low implementation success, and (3) compare our findings with those from other studies that used the CFIR to discriminate between high and low implementation success. METHODS: This study was based on individual interviews with 10 nurses, 6 physicians, and 1 nutritionist who had used the IPPC to answer messages from patients. RESULTS: Of the 36 CFIR constructs, 28 were addressed in the interviews, of which 12 distinguished between high and low implementation units. Most of the distinguishing constructs were related to the inner setting domain of CFIR, indicating that institutional factors were particularly important for successful implementation. Health care providers' beliefs in the intervention as useful for themselves and their patients as well as the implementation process itself were also important. A comparison of constructs across ours and 2 other studies that also used the CFIR to discriminate between high and low implementation success showed that 24 CFIR constructs distinguished between high and low implementation units in at least 1 study; 11 constructs distinguished in 2 studies. However, only 2 constructs (patient need and resources and available resources) distinguished consistently between high and low implementation units in all 3 studies. CONCLUSIONS: The CFIR is a helpful framework for illuminating barriers and facilitators influencing IPPC implementation. However, CFIR's strength of being broad and comprehensive also limits its usefulness as an implementation framework because it does not discriminate between the relative importance of its many constructs for implementation success. This is the first study to identify which CFIR constructs are the most promising to distinguish between high and low implementation success across settings and interventions. Findings from this study can contribute to the refinement of CFIR toward a more succinct and parsimonious framework for planning and evaluation of the implementation of clinical interventions. CLINICALTRIAL: Clinicaltrials.gov NCT00971139; http://clinicaltrial.gov/ct2/show/NCT00971139 (Archived by WebCite at http://www.webcitation.org/6cWeqN1uY).

Middle Managers' Experiences and Role in Implementing an Interactive Tailored Patient Assessment eHealth Intervention in Clinical Practice.

The role of nurse and physician managers is considered crucial for implementing eHealth interventions in clinical practice, but few studies have explored this. The aim of the current study was to examine the perceptions of nurse and physician managers regarding facilitators, barriers, management role, responsibility, and action taken in the implementation of an eHealth intervention called Choice into clinical practice. Individual qualitative interviews were conducted with six nurses and three physicians in management positions at five hospital units. The findings revealed that nurse managers reported conscientiously supporting the implementation, but workloads prevented them from participating in the process as closely as they wanted. Physician managers reported less contribution. The implementation process was influenced by facilitating factors such as perceptions of benefits from Choice and use of implementation strategies, along with barriers such as physician resistance, contextual factors and difficulties for front-line providers in learning a new way of communicating with the patients. The findings suggest that role descriptions for both nurse and physician managers should include implementation knowledge and implementation skills. Managers could benefit from an implementation toolkit. Implementation management should be included in management education for healthcare managers to prepare them for the constant need for implementation and improvement in clinical practice.

Living well with chronic pain: a 12-month randomized controlled trial revealing impact from the digital pain self-management program EPIO.

Introduction: Chronic pain affects a wide range of physical and psychological aspects of life for those impacted. Psychosocial treatment approaches may be of support, but outreach is still limited. Objectives: To evaluate the efficacy of EPIO, an evidence-informed, user-centered digital self-management intervention for people with chronic pain, in a 12-month randomized controlled trial. Methods: People living with chronic pain (N = 266) were randomized to the EPIO intervention (n = 132) or a usual-care control group (n = 134). The intervention was delivered in a simple blended care model, and outcome measures collected at baseline, 6 months, and 12 months. Generalized linear models for repeated measures were fitted to compare groups over time. Results: Participants were primarily female (81%), median age 49 years (range 22-78), with heterogeneous pain conditions, and had lived with pain >5 years (77.6%). A mixed linear model with all timepoints included revealed no statistically significant group differences for the primary outcome of pain interference. Significant psychological benefits in favor of the intervention group were however detected for depression (P = 0.022), self-regulatory fatigue (P = 0.024), vitality (P = 0.016), and mental health (P = 0.047). Baseline to 12-month changes showed additional favorable effects for anxiety (between-group mean differences [MDs] = 0.79, P = 0.047), depression (MD = 1.08, P = 0.004), self-regulatory fatigue (MD = 2.42, P = 0.021), pain catastrophizing (MD = 2.62, P = 0.009), and health-related quality of life. Conclusions: The EPIO program aims to improve outreach of evidence-based pain self-management interventions. Findings demonstrate how using EPIO can lead to sustainable psychological change, enhancing mental health and health-related quality of life for people suffering from pain, providing a chance to live well with the pain.

Patients' reported reasons for non-use of an internet-based patient-provider communication service: qualitative interview study.

BACKGROUND: The adoption of Internet-based patient-provider communication services (IPPC) in health care has been slow. Patients want electronic communication, and the quality of health care can be improved by offering such IPPCs. However, the rate of enrollment in such services remains low, and the reasons for this are unclear. Knowledge about the barriers to use is valuable during implementation of IPPCs in the health care services, and it can help timing, targeting, and tailoring IPPCs to different groups of patients. OBJECTIVE: The goal of our study was to investigate patients' views of an IPPC that they could use from home to pose questions to nurses and physicians at their treatment facility, and their reported reasons for non-use of the service. METHODS: This qualitative study was based on individual interviews with 22 patients who signed up for, but did not use, the IPPC. RESULTS: Patients appreciated the availability and the possibility of using the IPPC as needed, even if they did not use it. Their reported reasons for not using the IPPC fell into three main categories: (1) they felt that they did not need the IPPC and had sufficient access to information elsewhere, (2) they preferred other types of communication such as telephone or face-to-face contact, or (3) they were hindered by IPPC attributes such as login problems. CONCLUSIONS: Patients were satisfied with having the opportunity to send messages to health care providers through an IPPC, even if they did not use the service. IPPCs should be offered to the patients at an appropriate time in the illness trajectory, both when they need the service and when they are receptive to information about the service. A live demonstration of the IPPC at the point of enrollment might have increased its use. TRIAL REGISTRATION: ClinicalTrials.gov NCT00971139; http://clinicaltrial.gov/ct2/show/NCT00971139 (Archived by WebCite at http://www.webcitation.org/6KlOiYJrW).

A mobile application for early labour support -feasibility pilot study.

BACKGROUND: Use of mobile applications (apps) are increasing during pregnancy but few of these are evidence-based or evaluated in research. AIM: To examine the feasibility, including perceived usefulness and usability, and the preliminary effects of an app based on the Confident birth method. METHODS: A mixed-method approach, including 48 women, was used to evaluate acceptability, usability and to test study design and procedures. iPhone-users (n = 24) tested the app during pregnancy while the remaining (n = 24) formed a control group. Background characteristics and outcome measurements were collected from all women at baseline. Women in the app group received two follow-up phone calls from a midwife concerning usefulness and ease of use of the app. A follow-up questionnaire after birth were used to measure preliminary effects of the intervention as well as system usability of the app. RESULTS: Women using the app found the app exercises simple, understandable, and useful. System usability score showed a mean score of 85.3 indicating excellent system usability. Notes from phone calls resulted in four categories: positive feedback about the app, negative feedback about the app, partners involvement, and knowledge. Preliminary effects of labour experience showed no significant differences between the two groups, in terms of early labour or childbirth experience. CONCLUSION: The app tested in this feasibility study, was perceived as useful and appreciated by women. Areas for improvement of the app were identified. The result shows promise for further efficacy testing in a forthcoming randomised controlled trial.