Mapping Theories, Models, and Frameworks to Evaluate Digital Health Interventions: Scoping Review.

BACKGROUND: Digital health interventions (DHIs) are a central focus of health care transformation efforts, yet their uptake in practice continues to fall short of their potential. In order to achieve their desired outcomes and impact, DHIs need to reach their target population and need to be used. Many factors can rapidly intersect between this dynamic of users and interventions. The application of theories, models, and frameworks (TMFs) can facilitate the systematic understanding and explanation of the complex interactions between users, practices, technology, and health system factors that underpin research questions. There remains a gap in our understanding of how TMFs have been applied to guide the evaluation of DHIs with real-world health system operations. OBJECTIVE: This study aims to map TMFs used in studies to guide the evaluation of DHIs. The objectives are to (1) describe the TMFs and the constructs they target, (2) identify how TMFs have been prospectively used (ie, their roles) in primary studies to evaluate DHIs, and (3) to reflect on the relevance and utility of our findings for knowledge users. METHODS: This scoping review was conducted in partnership with knowledge users using an integrated knowledge translation approach. We included papers (eg, reports; empirical quantitative, qualitative, and mixed methods studies; conference proceedings; and dissertations) if primary insights resulting from the application of TMFs were presented. Any type of DHI was eligible. Papers published from 2000 and onward were mainly identified from the following databases: MEDLINE (Ovid), CINAHL Complete (EBSCOhost), PsycINFO (Ovid), EBM Reviews (Ovid), and Embase (Ovid). RESULTS: A total of 156 studies published between 2000 and 2022 were included. A total of 68 distinct TMFs were identified across 85 individual studies. In more than half (85/156, 55%) of the included studies, 1 of following 6 prevailing TMFs were reported: Consolidated Framework for Implementation Research (n=39); the Reach, Effectiveness, Adoption, Implementation, and Maintenance Framework (n=17); the Technology of Acceptance Model (n=16); the Unified Theory on Acceptance and Use of Technology (n=12); the Diffusion of Innovation Theory (n=10); and Normalization Process Theory (n=9). The most common intended roles of the 6 TMFs were to inform data collection (n=86), to inform data analysis (n=69), and to identify key constructs that may serve as barriers and facilitators (n=52). CONCLUSIONS: As TMFs are most often reported to be applied to support data collection and analysis, researchers should consider more clearly synthesizing key insights as practical use cases to both increase the relevance and digestibility of their findings. There is also a need to adapt or develop guidelines for better reporting DHIs and the use of TMFs to guide evaluation. Hence, it would contribute to ensuring ongoing technology transformation efforts are evidence and theory informed rather than anecdotally driven.

Information and Communications Technologies Enabling Integrated Primary Care for Patients With Complex Care Needs: Scoping Review.

BACKGROUND: Information and communications technologies (ICTs) are recognized as critical enablers of integrated primary care to support patients with multiple chronic conditions. Although ICT-enabled integrated primary care holds promise in supporting patients with complex care needs through team-based and continued care, critical implementation factors regarding what ICTs are available and how they enable this model are yet to be mapped in the literature. OBJECTIVE: This scoping review addressed the current knowledge gap by answering the following research question: What ICTs are used in delivering integrated primary care to patients with complex care needs? METHODS: The Arksey and O'Malley method enhanced by the work by Levac et al was used to guide this scoping review. In total, 4 electronic medical databases were accessed-MEDLINE, Embase, CINAHL, and PsycINFO-collecting studies published between January 2000 and December 2021. Identified peer-reviewed articles were screened. Relevant studies were charted, collated, and analyzed using the Rainbow Model of Integrated Care and the eHealth Enhanced Chronic Care Model. RESULTS: A total of 52,216 articles were identified, of which 31 (0.06%) met the review's eligibility criteria. In the current literature, ICTs are used to serve the following functions in the integrated primary care setting: information sharing, self-management support, clinical decision-making, and remote service delivery. Integration efforts are supported by ICTs by promoting teamwork and coordinating clinical services across teams and organizations. Patient, provider, organizational, and technological implementation factors are considered important for ICT-based interventions in the integrated primary care setting. CONCLUSIONS: ICTs play a critical role in enabling clinical and professional integration in the primary care setting to meet the health system-related needs of patients with complex care needs. Future research is needed to explore how to integrate technologies at an organizational and system level to create a health system that is well prepared to optimize technologies to support patients with complex care needs.

On the same page? A qualitative study of shared mental models in an interprofessional, inter-organizational team implementing goal-oriented care.

Goal-oriented care is an approach to care delivery that uses patient-identified goals to drive care planning. Implementing goal-oriented care requires team members to cognitively shift the focus from "what is the matter" to "what matters to patients," and align their mental models of what it means to care for patients. Yet, no empirical studies of goal-oriented care apply evidence from the cognitive sciences, such as Shared Mental Model (SMM) theory. We conducted a qualitative case study of an interprofessional team that adopted goal-oriented care in Vermont, US (n = 18). Guided by SMM theory, we distinguished between task-related and team-related mental models. We used framework analysis and qualitative content analysis to determine mental model content and similarity. The most shared content areas were operationalizing goal-oriented care, engaging in formal and informal communication, taking a "whole-person" approach, taking a team approach, and building trusting relationships with patients and with other team members. Trust was the only construct that spanned both task and team mental model categories, highlighting the importance of both intra-team trust and provider-patient trust to the implementation of goal-oriented care. Team members developed SMMs through training, regular meetings, and interactions during care delivery. This study provides insight into the cognitive mechanisms that underlie team-based goal-oriented care delivery, which can be used to inform implementation, training content, and future research.

Supporting goal-oriented care using mobile technology: Findings from the mixed-methods trial of the ePRO tool.

Context: Goal-oriented models of care are becoming more widely used as part of primary care delivery for older adults with multimorbidity and complex care needs. While these models hold promise, implementation remains challenging. Digital health solutions may improve adoption however, they require evaluation to determine feasibility and impact. Objective: This study evaluates the implementation and effectiveness of the electronic Patient Reported Outcome (ePRO) mobile application and portal system, designed to enable goal-oriented care delivery in inter-professional primary care practices. Study design: Multi-method pragmatic randomized control trial using a stepped-wedge design and ethnographic case studies over a 15-month period. Setting: 6 comprehensive primary care practices across Ontario. Population studied: Older adults with complex care needs; target sample 176 patients. Intervention: Patient and provider participants used the ePRO tool in addition to usual care. The 6 practices randomized into either early (3-month control; 12-month intervention) or late (6-month control; 9-month intervention) groups. Outcome measures: The Assessment of Quality of Life-4D collected at baseline and 3-month intervals. Ethnographic data (observations and interviews) collected at mid-point and end of the intervention. Outcome data were analyzed using linear models. Ethnographic data was analyzed using qualitative description and framework analysis methods, guided by Normalization Process Theory. Results: The trial experienced recruitment challenges resulting in fewer sites (n=6) and participants (n=45) than expected. As such the impact of ePRO on quality of life could not be definitively assessed; analysis trends suggest decreased quality of life for patients over both the control and intervention periods. Ethnographic data reveals a complex implementation process, in which the meaningfulness (or coherence) of the technology to individuals lives, relationships and approach chronic disease management drove adoption and perceived value or irrelevance of ePRO. Conclusions: Implementation challenges were broad and largely unexpected. The difficultly in aligning meaningfulness of a complex intervention across diverse user groups over time, suggests the intervention may not be sufficiently adaptable, or that more dynamic trial methods may be required. Including ethnographic data collection reveals critical underlying mechanisms driving digital health innovations.

Continuity of care for older adults in a Canadian long-term care setting: a qualitative study.

BACKGROUND: Continuity of care has been shown to improve health outcomes and increase patient satisfaction. Goal-oriented care, a person-centered approach to care, has the potential to positively impact continuity of care. This study sought to examine how a goal-oriented approach impacts continuity of care in a long-term care setting. METHODS: Using a case study approach, we examined what aspects of goal-oriented care facilitate or inhibit continuity of care from the perspectives of administrators, care providers, and residents in a long-term care centre in Ontario, Canada. Data was collected through documentary evidence and semi-structured interviews. RESULTS: We analyzed six internal documents (e.g., strategic plan, client information package, staff presentations, evaluation framework, program logic model), and conducted 13 interviews. The findings indicated that the care provided through the goal-oriented approach program had elements that both facilitated and inhibited continuity of care. These factors are outlined according to the three types of continuity, including aspects of the program that influence informational, relational, and management continuity. CONCLUSIONS: Aspects of the goal-oriented care approach that facilitate continuity can be targeted when designing person-centered care approaches. More research is needed on goal-oriented care approaches that have been implemented in other long-term care settings to determine if the factors identified here as influencing continuity are confirmed.

Assessing the Implementation and Effectiveness of the Electronic Patient-Reported Outcome Tool for Older Adults With Complex Care Needs: Mixed Methods Study.

BACKGROUND: Goal-oriented care is being adopted to deliver person-centered primary care to older adults with multimorbidity and complex care needs. Although this model holds promise, its implementation remains a challenge. Digital health solutions may enable processes to improve adoption; however, they require evaluation to determine feasibility and impact. OBJECTIVE: This study aims to evaluate the implementation and effectiveness of the electronic Patient-Reported Outcome (ePRO) mobile app and portal system, designed to enable goal-oriented care delivery in interprofessional primary care practices. The research questions driving this study are as follows: Does ePRO improve quality of life and self-management in older adults with complex needs? What mechanisms are likely driving observed outcomes? METHODS: A multimethod, pragmatic randomized controlled trial using a stepped-wedge design and ethnographic case studies was conducted over a 15-month period in 6 comprehensive primary care practices across Ontario with a target enrollment of 176 patients. The 6 practices were randomized into either early (3-month control period; 12-month intervention) or late (6-month control period; 9-month intervention) groups. The primary outcome measure of interest was the Assessment of Quality of Life-4D (AQoL-4D). Data were collected at baseline and at 3 monthly intervals for the duration of the trial. Ethnographic data included observations and interviews with patients and providers at the midpoint and end of the intervention. Outcome data were analyzed using linear models conducted at the individual level, accounting for cluster effects at the practice level, and ethnographic data were analyzed using qualitative description and framework analysis methods. RESULTS: Recruitment challenges resulted in fewer sites and participants than expected; of the 176 target, only 142 (80.6%) patients were identified as eligible to participate because of lower-than-expected provider participation and fewer-than-expected patients willing to participate or perceived as ready to engage in goal-setting. Of the 142 patients approached, 45 (32%) participated. Patients set a variety of goals related to self-management, mental health, social health, and overall well-being. Owing to underpowering, the impact of ePRO on quality of life could not be definitively assessed; however, the intervention group, ePRO plus usual care (mean 15.28, SD 18.60) demonstrated a nonsignificant decrease in quality of life (t24=-1.20; P=.24) when compared with usual care only (mean 21.76, SD 2.17). The ethnographic data reveal a complex implementation process in which the meaningfulness (or coherence) of the technology to individuals' lives and work acted as a key driver of adoption and tool appraisal. CONCLUSIONS: This trial experienced many unexpected and significant implementation challenges related to recruitment and engagement. Future studies could be improved through better alignment of the research methods and intervention to the complex and diverse clinical settings, dynamic goal-oriented care process, and readiness of provider and patient participants. TRIAL REGISTRATION: ClinicalTrials.gov NCT02917954; https://clinicaltrials.gov/ct2/show/NCT02917954.

Seeking Meaningful Innovation: Lessons Learned Developing, Evaluating, and Implementing the Electronic Patient-Reported Outcome Tool.

Digital health solutions, in particular information communication technologies, often experience implementation failures leading to slower adoption than expected. This implementation challenge has spurred the development of frameworks to help navigate this uncertain and messy process. These frameworks point to environmental, organizational, individual, and technological factors that can drive or hinder implementation, with some in the field suggesting that perceived value may play a pivotal role. However, the concept of value can have varying meanings and be challenging to operationalize as a means to support implementation. Attending to philosophical and psychological meaningfulness for users and organizations in which technologies are adopted may offer a useful lens, by linking perceived value to individual behavior changes often required as part of implementing digital health technologies. Lessons learned from developing, evaluating, and implementing the electronic Patient-Reported Outcome (ePRO) tool demonstrate how qualitative methods can be used to uncover meaningfulness. By drawing from this example and other similar studies, this viewpoint offers suggestions on how future inquiry could deepen an understanding of meaningful innovation to help drive the implementation of digital health technologies.

Scaling up eConsult for access to specialists in primary healthcare across four Canadian provinces: study protocol of a multiple case study.

BACKGROUND: Canada has been referred to as the land of 'perpetual pilot projects'. Effective innovations often remain small in scale, with limited impact on health systems. Several innovations have been developed in Canada to tackle important challenges such as poor access to services and excessive wait times - one of the most promising innovations that has been piloted is eConsult, which is a model of asynchronous communication that allows primary care providers to electronically consult with specialists regarding their patients' medical issues. eConsult pilot projects have been shown to reduce wait times for specialist care, prevent unnecessary referrals and reduce health system costs. eConsult has been spread throughout Ontario as well as to certain regions in Manitoba, Quebec, and Newfoundland and Labrador. Our aim is to understand and support the scale-up process of eConsult in Ontario, Quebec, Manitoba, and Newfoundland and Labrador. Our specific objectives are to (1) describe the main components of eConsult relevant to the scale-up process in each province; (2) understand the eConsult scale-up process in each province and compare across provinces; (3) identify policy issues and strategies to scaling up eConsult in each province; and (4) foster cross-level and cross-jurisdictional learning on scaling up eConsult. METHODS: We will conduct a qualitative multiple case study to investigate the scaling up of eConsult in four Canadian provinces using a grey literature review, key stakeholder interviews (10 interviews/province), non-participant observations, focus groups and deliberative dialogues. We will identify the main components of eConsult to be scaled up using logic models (obj. 1). Scaling up processes will be analysed using strategies adapted from process research (obj. 2). Policy issues and strategies to scale-up eConsult will be analysed thematically (obj. 3). Finally, a symposium will foster pan-Canadian learning on the process of scaling up eConsult (obj. 4). DISCUSSION: This study will likely increase learning and support evidence-based policy-making across participating provinces and may improve the capacity for a pan-Canadian scale-up of eConsult, including in provinces where eConsult has not yet been implemented. This work is essential to inform how similar innovations can reshape our health systems in the evolving information age.

Patterns of community follow-up, subsequent health service use and survival among young and mid-life adults discharged from chronic care hospitals: a retrospective cohort study.

BACKGROUND: Despite the demand for rehabilitation and chronic care services across the life course, policy and care strategies tend to focus on older adults and overlook medically complex younger adult populations. This study examined young and mid-life adults discharged from tertiary chronic care hospitals in order to describe their health service use and to examine the association between patterns of timely community follow-up, and subsequent health outcomes. METHODS: This population-based retrospective cohort study used linked administrative data to identify 1,906 individuals aged 18-64 years and discharged alive from tertiary chronic care hospitals in Ontario, Canada between April 1, 2005 and March 31, 2006. Multivariate Cox proportional hazard models were used to examine the effect of community follow-up within 7 days of discharge (home care and/or a primary care physician visit or neither) on time to first hospitalization and emergency department (ED) visit. Five-year survival was examined using Kaplan-Meier survival curves. RESULTS: The cohort had a high prevalence of multi-morbidity and use of hospital, emergency services and physician services was high in the year following discharge. Most individuals received follow-up care from a primary care physician and/or home care within 7 days of discharge while 30 % received neither. Within 1 year of discharge, 18 % of individuals died. Among those who survived, time to acute care hospitalization in the year following discharge was significantly longer among those who received both a home care and a physician follow-up visit compared to those who received neither. No significant associations were found between community follow-up and ED visits within 1 year. CONCLUSIONS: Immediate community follow-up may reduce subsequent use of acute care services. Future research should determine why some individuals, who would likely benefit from services, are not receiving them including barriers to access.

Digitally mediated relationships: How social representation in technology influences the therapeutic relationship in primary care.

Relationships, built on trust, knowledge, regard, and loyalty, have been demonstrated to be fundamental to health care delivery. Strong relationships between patients and providers have been linked to more compassionate care delivery, and better patient experience and outcomes, and may be particularly important in primary care. The rapid adoption of digital technologies since the onset of COVID-19 has led health care systems to seriously consider a "digital-first" primary care delivery model. Questions remain regarding what impact this transformation will have on the therapeutic relationship. Using a rapid ethnographic approach this study explores how patient and provider understandings of therapeutic relationships and digital health technologies may influence relationship-building or maintenance between patients with complex care needs and their care providers. Three team-based primary care sites in Toronto, Ontario, Canada were included in the study. Across the three sites 9 patients with chronic health conditions, 1 caregiver, and 10 healthcare providers (including family physicians, family medicine residents, social workers, and nurse practitioners) participated. Interviews were conducted with all participants and 8 observations of virtual clinical encounters (phone and video visits) were conducted. Using social representation theory as a lens, analysis revealed that participants' constructions of therapeutic relationships and digital technologies were informed by their identities, experiences, and expectations. For participants to see technologies as enabling to the therapeutic relationship, there needed to be alignment between how participants viewed the role of technology in care and in their lives, and how they recognized (or constructed) a good therapeutic relationship. This exploratory work suggests the need to think about how both patients' and providers' views of technology may determine whether digital technologies can be leveraged to meet patient needs while maintaining, or building, strong therapeutic relationships.

Understanding the connection between hospital goals and patient and family engagement: A scoping review.

The person-centered care movement has influenced hospitals to make patient and family engagement (PE) an explicit commitment in their strategic plans. This is often reflected in mission, vision, and value (MVV) statements, which are organizational artifacts intended to influence the attitudes, beliefs, and actions of hospital teams and employees because of their saliency in organizational documents and communications. Previous research has found that organizational goals for PE, like those articulated in MVV statements, can lead to effective and meaningful PE. However, a deeper understanding of how and under which circumstances MVV statements encourage and promote PE practices is needed. A scoping review was conducted to understand the connection between hospital PE goals (such as MVV statements) and PE processes and practices. The research question was: what is known about how hospital MVV statements relate to PE processes and activities? Following Arksey and O'Malley's scoping review approach, 27 articles were identified as relevant to the research question. These articles revealed five strategies that help realize hospital PE goals: communicating organizational goals; aligning documents that convey organizational goals; aligning organizational processes to support PE; providing employees with resources and support; and motivating and empowering employees to integrate PE into their work. We discuss the implications of misalignment between hospital goals and practices, which reduce team and individual motivation toward hospital PE goals.

Use of eco-mapping in health services research: a scoping review protocol.

INTRODUCTION: People with complex health and social needs often require care from different providers and services. Identifying their existing sources of support could assist with addressing potential gaps and opportunities for enhanced service delivery. Eco-mapping is an approach used to visually capture people's social relationships and their linkages to the larger social systems. As it is an emerging and promising approach in the health services field, a scoping review on eco-mapping is warranted. This scoping review aims to synthesise the empirical literature that has focused on the application of eco-mapping by describing characteristics, populations, methodological approaches and other features of eco-mapping in health services research. METHODS AND ANALYSIS: This scoping review will follow the Joanna Briggs Institute methodology. From the date of database construction to 16 January 2023, the following databases in English will be searched: Ovid Medline, Ovid Embase, CINAHL Ultimate (EBSCOhost), Emcare (Ovid), Cochrane Central Register of Controlled Trials (Ovid) and Cochrane Database of Systematic Reviews (Ovid) Study/Source of Evidence selection. The inclusion criteria consist of empirical literature that uses eco-mapping or a related tool in the context of health services research. Two researchers will independently screen references against inclusion and exclusion criteria using Covidence software. Once screened, the data will be extracted and organised according to the following research questions: (1) What research questions and phenomena of interest do researchers address when using eco-mapping? (2) What are the characteristics of studies that use eco-mapping in health services research? (3) What are the methodological considerations for eco-mapping in health services research? ETHICS AND DISSEMINATION: This scoping review does not require ethical approval. The findings will be disseminated through publications, conference presentations and stakeholder meetings. TRIAL REGISTRATION NUMBER: https://doi.org/10.17605/OSF.IO/GAWYN.

Addendum to the Acknowledgements: Experiences of Complex Patients with Telemonitoring in a Nurse-Led Model of Care: Multi-Method Feasibility Study.

[This corrects the article DOI: 10.2196/22118.].

Correction: Exploring an Innovative Care Model and Telemonitoring for the Management of Patients with Complex Chronic Needs: Qualitative Description Study.

[This corrects the article DOI: 10.2196/15691.].

Correction: Normalizing Telemonitoring in Nurse-Led Care Models for Complex Chronic Patient Populations: Case Study.

[This corrects the article DOI: 10.2196/36346.].

Implementing artificial intelligence in Canadian primary care: Barriers and strategies identified through a national deliberative dialogue.

BACKGROUND: With large volumes of longitudinal data in electronic medical records from diverse patients, primary care is primed for disruption by artificial intelligence (AI) technology. With AI applications in primary care still at an early stage in Canada and most countries, there is a unique opportunity to engage key stakeholders in exploring how AI would be used and what implementation would look like. OBJECTIVE: To identify the barriers that patients, providers, and health leaders perceive in relation to implementing AI in primary care and strategies to overcome them. DESIGN: 12 virtual deliberative dialogues. Dialogue data were thematically analyzed using a combination of rapid ethnographic assessment and interpretive description techniques. SETTING: Virtual sessions. PARTICIPANTS: Participants from eight provinces in Canada, including 22 primary care service users, 21 interprofessional providers, and 5 health system leaders. RESULTS: The barriers that emerged from the deliberative dialogue sessions were grouped into four themes: (1) system and data readiness, (2) the potential for bias and inequity, (3) the regulation of AI and big data, and (4) the importance of people as technology enablers. Strategies to overcome the barriers in each of these themes were highlighted, where participatory co-design and iterative implementation were voiced most strongly by participants. LIMITATIONS: Only five health system leaders were included in the study and no self-identifying Indigenous people. This is a limitation as both groups may have provided unique perspectives to the study objective. CONCLUSIONS: These findings provide insight into the barriers and facilitators associated with implementing AI in primary care settings from different perspectives. This will be vital as decisions regarding the future of AI in this space is shaped.

Exploring readiness for implementing goal-oriented care in primary care using normalization process theory.

AIM: To use normalization process theory (NPT) to build a strategy for the implementation of goal-oriented care (GOC) in primary care in Flanders, Belgium. BACKGROUND: GOC is a possible approach to more coordinated and integrated care and tailors care to patients' personal life goals. The concept has gained interest among policy makers and researchers, but the main drivers for successful implementation are the primary healthcare professionals (PHCPs) who need to see added value of GOC in order to embed it into their daily practice. NPT, developed to understand the processes of implementing new ways of organizing care, offers a useful lens to understand adoption of GOC in primary care practice. METHOD: PHCPs (n = 131) who participated in a 2-hour community meeting on GOC were asked to complete the Normalization MeAsure Development survey. This 23-item survey is based on NPT and describes participants' views about how an intervention would impact their work, their expectations about it, and whether it could become a routine part of their work. FINDINGS: The NPT constructs coherence (sense-making work) and cognitive participation (relational work) showed positive tendency toward implementation of GOC. The participants had an initial understanding on GOC and there was much interest in supporting and start working with this approach. The other constructs collective action (operational work) and reflexive monitoring (appraisal work) will need further efforts to trigger implementation. A common ground is needed to integrate GOC as a common practice which can be achieved by intensive interprofessional collaboration.

Pioneering family physicians and the mechanisms for strengthening primary health care in India-A qualitative descriptive study.

India has one of the most unequal healthcare systems globally, lagging behind its economic development. Improved primary care and primary health care play an integral role in overcoming health disparities. Family medicine is a subset of primary care-delivered by family physicians, characterized by comprehensive, continuous, coordinated, collaborative, personal, family and community-oriented services-and may be able to fill these gaps. This research aims to understand the potential mechanisms by which family physicians can strengthen primary health care. In this qualitative descriptive study, we interviewed twenty family physicians, identified by purposeful and snowball sampling, who are among the first family physicians in India who received accredited certification in FM and were identified as pioneers of family medicine. We used the Contribution of Family Medicine to Strengthening Primary Health Care Framework to understand the potential mechanisms by which family medicine strengthens primary health care. Iterative inductive techniques were used for analysis. This research identifies multiple ways family physicians can strengthen primary health care in India. They are skilled primary care providers and support mid and low-level health care providers' ongoing training and capacity building. They develop relationships with specialists, ensure appropriate referral systems are in place, and, when necessary, work with governments and organizations to access the essential resources needed to deliver care. They motivate the workforce and change how care is delivered by ensuring providers' skills match the needs of communities and engage communities as partners in healthcare delivery. These findings highlight multiple mechanisms by which family physicians strengthen primary health care. Investments in postgraduate training in family medicine and integrating family physicians into the primary care sector, particularly the public sector, could address health disparities.

Building Compassionate Experience Through Compassionate Action: Qualitative Behavioral Analysis.

BACKGROUND: The acceleration of technology-based primary care during the COVID-19 pandemic outpaced the ability to understand whether and how it impacts care delivery and outcomes. As technology-based care continues to evolve, focusing on the core construct of compassion in a primary care context will help ensure high-quality patient care and increased patient autonomy and satisfaction. The ability to successfully operationalize the use of technology in patient-clinician interactions hinges on understanding not only how compassionate care is experienced in this context but also how clinicians can create it. OBJECTIVE: The objectives of this study were to understand whether and how compassionate behaviors are experienced in technology-based primary care interactions and identify the individual and contextual drivers that influence whether and how these behaviors occur. METHODS: We conducted a series of qualitative one-on-one interviews with primary care physicians, nurses, and patients. Qualitative data were initially analyzed using an inductive thematic analysis approach to identify preliminary themes for each participant group independently. We then looked across participant groups to identify areas of alignment and distinction. Descriptions of key behaviors that participants identified as elements of a compassionate interaction and descriptions of key drivers of these behaviors were inductively coded and defined at this stage. RESULTS: A total of 74 interviews were conducted with 40 patients, 20 nurses, and 14 primary care physicians. Key behaviors that amplified the experience of compassion included asking the patient's modality preference, using video to establish technology-based presence, sharing the screen, and practicing effective communication. Participants' knowledge or skills as well as their beliefs and emotions influenced whether or not these behaviors occurred. Contextual elements beyond participants' control influenced technology-based interactions, including resource access, funding structures, culture, regulatory standards, work structure, societal influence, and patient characteristics and needs. A high-yield, evidence-based approach to address the identified drivers of compassion-focused clinician behavior includes a combination of education, training, and enablement. CONCLUSIONS: Much of the patient experience is influenced by clinician behavior; however, clinicians need a supportive system and adequate supports to evolve new ways of working to create the experience of compassionate care. The current state of technology-based care operationalization has led to widespread burnout, societal pressure, and shifting expectations of both clinicians and the health system more broadly, threatening the ability to deliver compassionate care. For clinicians to exhibit compassionate behaviors, they need more than just adequate supports; they also need to receive compassion from and experience the humanity of their patients.

Exploring the Poststroke Experiences and Needs of South Asian Communities Living in High-Income Countries: Findings from a Scoping Review.

Despite the high prevalence of stroke among South Asian communities in high-income countries, a comprehensive understanding of their unique experiences and needs after stroke is lacking. This study aimed to synthesize the literature examining the experiences and needs of South Asian community members impacted by stroke and their family caregivers residing in high-income countries. A scoping review methodology was utilized. Data for this review were identified from seven databases and hand-searching reference lists of included studies. Study characteristics, purpose, methods, participant characteristics, results, limitations, recommendations, and conclusions were extracted. Data were analyzed using descriptive qualitative analysis. In addition, a consultative focus group exercise with six South Asian community members who had experienced a stroke and a program facilitator was conducted to inform the review interpretations. A total of 26 articles met the inclusion criteria and were analyzed. Qualitative analysis identified four descriptive categories: (1) rationale for studying the South Asian stroke population (e.g., increasing South Asian population and stroke prevalence), (2) stroke-related experiences (e.g., managing community support versus stigma and caregiving expectations), (3) stroke service challenges (e.g., language barriers), and (4) stroke service recommendations to address stroke service needs (e.g., continuity of care). Several cultural factors impacted participant experiences, including cultural beliefs about illness and caregiving. Focus group participants from our consultation activity agreed with our review findings. The clinical and research recommendations identified in this review support the need for culturally appropriate services for South Asian communities across the stroke care continuum; however, more research is necessary to inform the design and structure of culturally appropriate stroke service delivery models.