Identifying actionable strategies: using Consolidated Framework for Implementation Research (CFIR)-informed interviews to evaluate the implementation of a multilevel intervention to improve colorectal cancer screening

Abstract Background Many evidence-based interventions (EBIs) found to be effective in research studies often fail to translate into meaningful patient outcomes in practice. The purpose of this study was to identify facilitators and barriers that affect the implementation of three EBIs to improve colorectal cancer (CRC) screening in an urban federally qualified health center (FQHC) and offer actionable recommendations to improve future implementation efforts. Methods We conducted 16 semi-structured interviews guided by the Consolidation Framework for Implementation Research (CFIR) to describe diverse stakeholders’ implementation experience. The interviews were conducted in the participant’s clinic, audio-taped, and professionally transcribed for analysis. Results We used the five CFIR domains and 39 constructs and subconstructs as a coding template to conduct a template analysis. Based on experiences with the implementation of three EBIs, stakeholders described barriers and facilitators related to the intervention characteristics, outer setting, and inner setting. Implementation barriers included (1) perceived burden and provider fatigue with EHR (Electronic Health Record) provider reminders, (2) unreliable and ineffectual EHR provider reminders, (3) challenges to providing health care services to diverse patient populations, (4) lack of awareness about CRC screening among patients, (5) absence of CRC screening goals, (6) poor communication on goals and performance, and (7) absence of printed materials for frontline implementers to educate patients. Implementation facilitators included (1) quarterly provider assessment and feedback reports provided real-time data to motivate change, (2) integration with workflow processes, (3) pressure from funding requirement to report quality measures, (4) peer pressure to achieve high performance, and (5) a culture of teamwork and patient-centered mentality. Conclusions The CFIR can be used to conduct a post-implementation formative evaluation to identify barriers and facilitators that influenced the implementation. Furthermore, the CFIR can provide a template to organize research data and synthesize findings. With its clear terminology and meta-theoretical framework, the CFIR has the potential to promote knowledge-building for implementation. By identifying the contextual determinants, we can then determine implementation strategies to facilitate adoption and move EBIs to daily practice.

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Barriers and Facilitators to Colorectal Cancer Screening Within a Hispanic Population

Hispanic Health Care International ◽

10.1177/1540415318818982 ◽

2018 ◽

Vol 17 (1) ◽

pp. 23-29 ◽

Cited By ~ 9

Author(s):

Theresa L. Byrd ◽

Jessica Calderón-Mora ◽

Rebekah Salaiz ◽

Navkiran K. Shokar

Keyword(s):

Colorectal Cancer ◽

Focus Groups ◽

Screening Program ◽

El Paso ◽

Barriers And Facilitators ◽

Hispanic Population ◽

Community Based ◽

Crc Screening ◽

Predominantly Hispanic ◽

9Th Grade

Introduction: Colorectal cancer (CRC) is the third leading cancer cause of death among US Hispanics. CRC screening among the Hispanic population is lower compared with non-Hispanic Whites. Method: The purpose of this qualitative, exploratory study was to better understand the barriers and facilitators of CRC screening and preference for stool-based testing collection methods among the predominantly Hispanic population of El Paso, Texas. Nine focus groups were conducted by a trained bilingual facilitator with a moderator guide informed by the literature. Transcripts of the focus groups were entered into qualitative analysis software and a thematic network was developed. Results: Fifty-six participants were recruited: average age was 68.5 years, 58.9% were female, 98.2% were Hispanic, 87.5% had an annual income of less than $20,000, 58.9% had 9th grade education or less, 12.5% had a discount program, and 5.4% had no insurance. Barriers to CRC screening included cost, fear, and embarrassment. Facilitators to screening included in-person health education and physician recommendation. Participants preferred the hygienic nature of a stool test collected with a brush and bottle. Conclusion: Overall, there was a lack of knowledge regarding CRC and significant barriers to CRC screening. A community-based CRC screening program was subsequently developed from our findings.

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Shared Decision-Making and Colorectal Cancer Screening Behaviors Among Older Adults With Low Health Literacy

Innovation in Aging ◽

10.1093/geroni/igab046.1154 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. 299-299

Author(s):

Rebekah Halmo ◽

Siobhan McDonold ◽

Mara Schonberg ◽

Tamara Cadet

Keyword(s):

Colorectal Cancer ◽

Decision Making ◽

Health Literacy ◽

Shared Decision Making ◽

Shared Decision ◽

Structured Interviews ◽

National Guidelines ◽

Crc Screening ◽

High School Degree ◽

Low Health Literacy

Abstract National guidelines recommend adults >75 engage in shared decision making (SDM) around colorectal cancer (CRC) screening because of the uncertain benefit to risk ratio. There are no decision tools to support CRC decision making for adults >75 years with low health literacy (LHL). The purpose of this mixed-methods study was to better understand the perspectives of adults >75 with LHL on SDM around CRC screening and to obtain their feedback on an existing higher literacy CRC decision aid. Utilizing the Brief Health Literacy Screening Tool to identify participants with LHL, semi-structured interviews were conducted with 30 adults. Findings indicate that 80% of participants were non-Hispanic Black and 42% had < high school degree. 76% felt they would benefit from CRC screening despite their age. Themes related to CRC screening included lack of knowledge of options and harms, but a desire to understand more to better take care of their health.

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Tracking the Randomized Rollout of a Veterans Affairs Opioid Risk Management Tool: A Multi-method Implementation Evaluation Using the Consolidated Framework for Implementation Research

10.21203/rs.3.rs-826458/v1 ◽

2021 ◽

Author(s):

Sharon McCarthy ◽

Matthew Chinman ◽

Shari Rogal ◽

Gloria Klima ◽

Leslie Hausmann ◽

...

Keyword(s):

Implementation Research ◽

Structured Interview ◽

Barriers And Facilitators ◽

Management Tool ◽

Opioid Overdose ◽

Veterans Health ◽

Health Administration ◽

Implementation Barriers ◽

Implementation Climate ◽

The Mean

Abstract BackgroundThe Veterans Health Administration (VHA) developed the Stratification Tool for Opioid Risk Mitigation (STORM) dashboard to assist VHA clinicians in identifying Veterans at risk for adverse opioid overdose or suicide-related events. In 2018, a national policy was implemented requiring providers at all VHA facilities to complete case reviews of Veterans identified by STORM as very high risk for adverse events. Nationally, facilities were randomized by the type of oversight required when sufficient case reviews were not completed and also by the timing of an increase in the number of required case reviews. As part of a comprehensive assessment of this policy intervention, we aimed to 1) identify barriers and facilitators to implementing case reviews as required in the policy; 2) assess variation across the four arms of the study; and 3) evaluate associations between facility characteristics and implementation barriers and facilitators.MethodsUsing the Consolidated Framework for Implementation Research (CFIR), we developed a semi-structured interview guide to examine barriers to and facilitators of implementing the STORM policy. Staff from 40 purposefully selected facilities who were involved in implementation were invited to participate in telephone interviews. Interview transcripts were coded and then organized into memos, which were numerically rated using the -2 to +2 CFIR rating system for each construct. Descriptive statistics were used to evaluate the mean ratings on each CFIR construct, the associations between ratings and study arm, and three facility characteristics (size, rurality, and level of academic detailing) associated with CFIR ratings. We used the mean CFIR rating for each site to determine which constructs differed between the sites with highest and lowest overall CFIR scores, and these constructs were described in detail. ResultsInterviews with 78 staff at 39 VHA facilities identified a slightly positive (+0.2) overall mean CFIR rating. CFIR ratings were not significantly different between the four study arms, nor associated with facility characteristics. Overall, two important barriers to implementation were CFIR constructs Access to knowledge and information and Evaluating and reflecting. Having time to complete the reviews was a pervasive barrier. Sites with higher overall CFIR scores showed three important facilitators: Leadership engagement, Engaging, and Implementation climate. ConclusionAlthough there was variability in implementation barriers and facilitators across facilities, these were unrelated to study arms and facility characteristics. Leadership, resources, and overall implementation climate were the strongest facilitators of policy implementation.

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Barriers and facilitators for colorectal cancer screening in a low-income urban community in Mexico City

10.21203/rs.3.rs-17322/v2 ◽

2020 ◽

Author(s):

Karla Unger-Saldaña ◽

Minerva Saldaña-Tellez ◽

Michael B. Potter ◽

Katherine Van Loon ◽

Betania Allen-Leigh ◽

...

Keyword(s):

Colorectal Cancer ◽

Health Care ◽

Barriers And Facilitators ◽

Health Care Personnel ◽

Middle Income ◽

Crc Screening ◽

Middle Income Countries ◽

Lay Beliefs ◽

Incidence And Mortality ◽

The Social

Abstract Background. Colorectal cancer (CRC) incidence and mortality are increasing in many low- and middle-income countries (LMICs), possibly due to a combination of changing lifestyles and improved healthcare infrastructure to facilitate diagnosis. Unfortunately, a large proportion of CRC cases in these countries remain undiagnosed or are diagnosed at advanced stages, resulting in poor outcomes. Decreasing mortality trends in HICs are likely due to evidence-based screening and treatment approaches that are not widely available in LMICs. Formative research to identify emerging opportunities to implement appropriate screening and treatment programs in LMICs is, therefore, of growing importance. We sought to identify potential barriers and facilitators for future implementation of fecal immunochemical test (FIT)-based CRC screening in a public healthcare system in a middle-income country with increasing CRC incidence and mortality. Methods. We performed a qualitative study with semi-structured individual and focus group interviews with different CRC screening stakeholders, including: 30 lay people at average risk for CRC; 13 health care personnel from a local public clinic; and 7 endoscopy personnel from a cancer referral hospital. All interviews were transcribed verbatim for analysis. Data were analyzed using the constant comparison method, under the theoretical perspectives of the Social Ecological Model (SEM), the PRECEDE-PROCEED Model, and the Health Belief Model. Results. We identified barriers and facilitators for implementation of a FIT-based CRC screening program at several levels of the SEM. The main barriers in each of the SEM levels, were: 1) at the social context level: poverty, health literacy and lay beliefs related to gender, cancer, allopathic medicine, and religion; 2) at the health services organization level: a lack of CRC knowledge among health care personnel and the community perception of poor quality of health care; 3) at the individual level: a lack of CRC awareness and therefore lack of risk perception, together with fear of participating in screening activities and finding out about a serious disease. The main facilitators perceived by the participants were CRC screening information and the free provision of screening tests.Conclusions. This study’s findings suggest that multi-level CRC screening programs in middle income countries such as Mexico should incorporate complementary strategies to address barriers and facilitators, such as: 1) provision of free screening tests, 2) education of primary healthcare personnel, and 3) promotion of non fear-based CRC screening messages to the target population, tailored to address common lay beliefs.

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Barriers and facilitators for colorectal cancer screening in a low-income urban community in Mexico City

10.21203/rs.3.rs-17322/v1 ◽

2020 ◽

Author(s):

Karla Unger-Saldaña ◽

Minerva Saldaña-Tellez ◽

Michael B. Potter ◽

Katherine Van Loon ◽

Betania Allen-Leigh ◽

...

Keyword(s):

Colorectal Cancer ◽

Health Care ◽

Cancer Screening ◽

Screening Program ◽

Barriers And Facilitators ◽

Health Care Personnel ◽

Crc Screening ◽

Lay Beliefs ◽

Incidence And Mortality ◽

The Social

Abstract Background Colorectal cancer (CRC) incidence and mortality are increasing in many middle- and lower-income countries, possibly due to a combination of changing lifestyles and improved healthcare infrastructure that facilitates diagnosis. Unfortunately, a large proportion of cases may be diagnosed at advanced stages, resulting in poor outcomes. Decreasing trends in higher income countries are likely due to improved early detection combined with best practices in CRC treatment and management. More data on implementation of better quality CRC screening programs are needed for contexts where incidence is increasing. Therefore, we sought to identify potential barriers and facilitators for future implementation of fecal immunochemical test (FIT)-based CRC screening in a public healthcare system in a middle-income country with increasing CRC incidence and mortality. Methods. Qualitative study including semi-structured individual and focus group interviews with different stakeholders of colorectal cancer screening: 30 average-risk lay people, 13 health care personnel from a local public clinic, and 7 endoscopy unit personnel from a cancer referral hospital. All interviews were transcribed verbatim for analysis. Data was analyzed using the constant comparison method, under the theoretical perspectives of the Social Ecological Model (SEM), the PRECEDE-PROCEED Model, and the Health Belief Model. Results. We found multiple barriers and facilitators for implementation of a FIT-based CRC screening program at different levels of the SEM. The main barriers in each of the SEM levels, were: 1) at the social context level: poverty, health literacy and lay beliefs related to gender, cancer, allopathic medicine, and religion; 2) at the health services organization level: the lack of CRC knowledge among health care personnel and the community perception of poor quality of health care; 3) at the individual level: a lack of CRC awareness and therefore lack of risk perception, together with fear of participating in screening activities and finding out about a serious disease. The main facilitators perceived by the participants were CRC screening information and the free provision of screening tests.Conclusions. This study’s findings suggest the need for a multi-level CRC screening program that includes complementary strategies aimed at reducing perceived barriers and enhancing facilitators, starting with: 1) free provision of screening tests, 2) education of primary health care personnel, and 3) promotion of non fear-based CRC screening awareness among the target population, taking into account their lay beliefs.

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GPs’ perspectives on colorectal cancer screening and their potential influence on FIT-positive patients: an exploratory qualitative study from a Dutch context

BJGP Open ◽

10.3399/bjgpopen18x101631 ◽

2019 ◽

Vol 3 (1) ◽

pp. bjgpopen18X101631 ◽

Cited By ~ 1

Author(s):

Lucinda Bertels ◽

Sientje van der Heijden ◽

Maartje Hoogsteyns ◽

Evelien Dekker ◽

Kristel van Asselt ◽

...

Keyword(s):

Colorectal Cancer ◽

Cancer Screening ◽

Screening Programme ◽

Potential Influence ◽

Structured Interviews ◽

Crc Screening ◽

Open Coding ◽

Immunochemical Test ◽

Advanced Adenomas

BackgroundIn the Dutch colorectal cancer (CRC) screening programme, individuals receive a faecal immunochemical test (FIT) to do at home. After a positive FIT result, a follow-up colonoscopy is recommended to identify CRC or advanced adenomas (AA). GPs may influence their patients’ decisions on adherence to follow-up by colonoscopy.AimTo explore GPs’ perspectives on the CRC screening programme and their potential influence on FIT-positive patients to follow up with the recommended colonoscopy.Design & settingSemi-structured interviews among GPs in Amsterdam, the Netherlands.MethodGPs were approached using purposive sampling. Analysis was performed on 11 interviews using open coding and constant comparison.ResultsAll interviewed GPs would recommend FIT-positive patients without obvious contraindications to adhere to a follow-up colonoscopy. If patients were likely to be distressed by a positive FIT result, most GPs described using reassurance strategies emphasising a low cancer probability. Most GPs stressed the probability of false-positive FIT results. Some described taking a positive screening result in CRC screening less seriously than one in breast cancer screening. Most GPs underestimated CRC and AA probabilities after a positive FIT result. When told the actual probabilities, some stated that this knowledge might change the way they would inform patients.ConclusionThese results imply that some of the interviewed GPs have too low a perception of the risk associated with a positive FIT result, which might influence their patients’ decision-making. Simply informing GPs about the actual rates of CRC and AA found in the screening programme might improve this risk perception.

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Implementation Challenges With Evidence-Based Practice Within Inpatient Rehabilitation to Incorporate Task-Specific Training

American Journal of Occupational Therapy ◽

10.5014/ajot.2021.75s2-rp266 ◽

2021 ◽

Vol 75 (Supplement_2) ◽

pp. 7512510266p1-7512510266p1

Author(s):

Eron Bozec ◽

Namrata Grampurohit ◽

Jaime Gorska

Keyword(s):

Implementation Research ◽

Inpatient Rehabilitation ◽

Barriers And Facilitators ◽

Training Manual ◽

Evidence Based ◽

Specific Training ◽

Implementation Barriers ◽

Study Objective ◽

Implementation Challenges ◽

Primary Author

Abstract Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations. The study objective was to examine the implementation barriers and facilitators after a year of training and use of a task-specific training manual in inpatient rehabilitation. The Consolidated Framework for Implementation Research provided structure for the survey of OTs. Stakeholders reported confidence in evidence incorporation, and the barriers related to ease of selection and use of this intervention need to be addressed. Primary Author and Speaker: Eron Bozec Additional Authors and Speakers: Namrata Grampurohit Contributing Authors: Namrata Grampurohit, Jaime Gorska

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Implementation of social needs screening in primary care: a qualitative study using the health equity implementation framework

BMC Health Services Research ◽

10.1186/s12913-021-06991-3 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Connor Drake ◽

Heather Batchelder ◽

Tyler Lian ◽

Meagan Cannady ◽

Morris Weinberger ◽

...

Keyword(s):

Primary Care ◽

Health Outcomes ◽

Health Equity ◽

Social Needs ◽

Barriers And Facilitators ◽

Future Research ◽

Structured Interviews ◽

Implementation Barriers ◽

Patient Acceptability ◽

Implementation Framework

Abstract Background Screening in primary care for unmet individual social needs (e.g., housing instability, food insecurity, unemployment, social isolation) is critical to addressing their deleterious effects on patients’ health outcomes. To our knowledge, this is the first study to apply an implementation science framework to identify implementation factors and best practices for social needs screening and response. Methods Guided by the Health Equity Implementation Framework (HEIF), we collected qualitative data from clinicians and patients to evaluate barriers and facilitators to implementing the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE), a standardized social needs screening and response protocol, in a federally qualified health center. Eligible patients who received the PRAPARE as a standard of care were invited to participate in semi-structured interviews. We also obtained front-line clinician perspectives in a semi-structured focus group. HEIF domains informed a directed content analysis. Results Patients and clinicians (i.e., case managers) reported implementation barriers and facilitators across multiple domains (e.g., clinical encounters, patient and provider factors, inner context, outer context, and societal influence). Implementation barriers included structural and policy level determinants related to resource availability, discrimination, and administrative burden. Facilitators included evidence-based clinical techniques for shared decision making (e.g., motivational interviewing), team-based staffing models, and beliefs related to alignment of the PRAPARE with patient-centered care. We found high levels of patient acceptability and opportunities for adaptation to increase equitable adoption and reach. Conclusion Our results provide practical insight into the implementation of the PRAPARE or similar social needs screening and response protocols in primary care at the individual encounter, organizational, community, and societal levels. Future research should focus on developing discrete implementation strategies to promote social needs screening and response, and associated multisector care coordination to improve health outcomes and equity for vulnerable and marginalized patient populations.

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Differences in Colorectal Cancer (CRC) patients who did and did not undergo screening

European Journal of Public Health ◽

10.1093/eurpub/ckaa165.1343 ◽

2020 ◽

Vol 30 (Supplement_5) ◽

Author(s):

J Thompson ◽

J Ng ◽

B Armstrong ◽

E Feletto ◽

T Ha

Keyword(s):

Physical Activity ◽

Colorectal Cancer ◽

Cohort Study ◽

Screening Program ◽

Barriers And Facilitators ◽

Average Risk ◽

Physical Activity Guidelines ◽

Crc Screening ◽

Female Patients ◽

Screening Participation

Abstract Background The Australian National Bowel Cancer Screening Program (NBSCP) is a free population-based screening program which aims to identify precancerous lesions and early colorectal cancer (CRC) using an immunochemical faecal occult blood test in average risk Australians. Formally commencing in 2006, NBCSP participation rate in eligible 50-74-year-old people was 42% in 2018. The barriers and facilitators of participation in the NBCSP have been explored for the general, at-risk population but not in a population of CRC patients. This is the first study to assess a population of CRC patients, post diagnosis, who would have been eligible for CRC screening to determine the barriers and facilitators to screening. Methods A cross sectional study nested within a cohort study. Data from CRC patients who participated in the 45 and Up Study; the largest cohort study in Australia and southern hemisphere, were analysed to compare those who had and had not participated in CRC screening. Logistic regression analyses were conducted using RStudio (version 3.5.2, Boston, Massachusetts, USA.). Multiple Imputation (MI), was used to handle missing values assumed to be missing at random. Results A total of 339 CRC patients were included. Patients who were female, overweight (≥25kg/m2), consumed less than the recommended five servings of vegetables per day, consumed less than or equal to fourteen standard drinks per week (compared to non-drinkers) or did not meet physical activity guidelines were significantly less likely to have participated in screening. Conclusions Our study has taken a unique approach to identifying a high-risk group by exploring factors to screening participation in CRC patients. CRC patients with less healthy lifestyles were less likely to participate in screening. In contrast to previous studies, female patients were less likely to participate in screening than males were. This was an unexpected finding and should be replicated. Key messages Not surprising that those with less healthy lifestyle practices also reflected less than ideal screening practices. Surprising that female patients participated less in screening than males. Future interventions to improve CRC screening participation rates should consider specialised messaging for average-risk females who are overweight not meeting dietary or physical activity guidelines.

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Barriers and facilitators for colorectal cancer screening in a low-income urban community in Mexico City

10.21203/rs.2.24822/v1 ◽

2020 ◽

Author(s):

Karla Unger-Saldaña ◽

Minerva Saldaña-Tellez ◽

Michael B. Potter ◽

Katherine Van Loon ◽

Betania Allen-Leigh ◽

...

Keyword(s):

Colorectal Cancer ◽

Health Care ◽

Cancer Screening ◽

Colorectal Cancer Screening ◽

Screening Program ◽

Barriers And Facilitators ◽

Health Care Personnel ◽

Crc Screening ◽

Lay Beliefs ◽

The Social

Abstract Background. Colorectal cancer (CRC) incidence and mortality are increasing in many middle- and lower-income countries, possibly due to a combination of changing lifestyles and improved healthcare infrastructure that facilitates diagnosis. Unfortunately, a large proportion of cases may be diagnosed at advanced stages, resulting in poor outcomes. Decreasing trends in higher income countries are likely due to improved early detection combined with best practices in CRC treatment and management. More data on implementation of better quality CRC screening programs are needed for contexts where incidence is increasing. Therefore, we sought to identify potential barriers and facilitators for future implementation of fecal immunochemical test (FIT)-based CRC screening in a public healthcare system in a middle-income country with increasing CRC incidence and mortality.Methods. Qualitative study including semi-structured individual and focus group interviews with different stakeholders of colorectal cancer screening: 30 average-risk lay people, 13 health care personnel from a local public clinic, and 7 endoscopy unit personnel from a cancer referral hospital. All interviews were transcribed verbatim for analysis. Data was analyzed using the constant comparison method, under the theoretical perspectives of the Social Ecological Model (SEM), the PRECEDE-PROCEED Model, and the Health Belief Model. Results. We found multiple barriers and facilitators for implementation of a FIT-based CRC screening program at different levels of the SEM. The main barriers in each of the SEM levels, were: 1) at the social context level: poverty, health literacy and lay beliefs related to gender, cancer, allopathic medicine, and religion; 2) at the health services organization level: the lack of CRC knowledge among health care personnel and the community perception of poor quality of health care; 3) at the individual level: a lack of CRC awareness and therefore lack of risk perception, together with fear of participating in screening activities and finding out about a serious disease. The main facilitators perceived by the participants were CRC screening information and the free provision of screening tests.Conclusions. This study’s findings suggest the need for a multi-level CRC screening program that includes complementary strategies aimed at reducing perceived barriers and enhancing facilitators, starting with: 1) free provision of screening tests, 2) education of primary health care personnel, and 3) promotion of non fear-based CRC screening awareness among the target population, taking into account their lay beliefs.

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