Assessing the implementation of a clinical decision support tool in primary care for diabetes prevention: a qualitative interview study using the Consolidated Framework for Implementation Science

Background In this paper we describe the use of the Consolidated Framework for Implementation Research (CFIR) to study implementation of a web-based, point-of-care, EHR-linked clinical decision support (CDS) tool designed to identify and provide care recommendations for adults with prediabetes (Pre-D CDS). Methods As part of a large NIH-funded clinic-randomized trial, we identified a convenience sample of interview participants from 22 primary care clinics in Minnesota, North Dakota, and Wisconsin that were randomly allocated to receive or not receive a web-based EHR-integrated prediabetes CDS intervention. Participants included 11 clinicians, 6 rooming staff, and 7 nurse or clinic managers recruited by study staff to participate in telephone interviews conducted by an expert in qualitative methods. Interviews were recorded and transcribed, and data analysis was conducted using a constructivist version of grounded theory. Results Implementing a prediabetes CDS tool into primary care clinics was useful and well received. The intervention was integrated with clinic workflows, supported primary care clinicians in clearly communicating prediabetes risk and management options with patients, and in identifying actionable care opportunities. The main barriers to CDS use were time and competing priorities. Finally, while the implementation process worked well, opportunities remain in engaging the care team more broadly in CDS use. Conclusions The use of CDS tools for engaging patients and providers in care improvement opportunities for prediabetes is a promising and potentially effective strategy in primary care settings. A workflow that incorporates the whole care team in the use of such tools may optimize the implementation of CDS tools like these in primary care settings. Trial registration Name of the registry: Clinicaltrial.gov. Trial registration number: NCT02759055. Date of registration: 05/03/2016. URL of trial registry record: https://clinicaltrials.gov/ct2/show/NCT02759055 Prospectively registered.

Prevention and Control of African Swine Fever in the Smallholder Pig Value Chain in Northern Uganda: Thematic Analysis of Stakeholders' Perceptions

African swine fever (ASF) is endemic in Uganda and considered a major constraint to pig production. In the absence of a vaccine, biosecurity is key for ASF prevention and control. To improve prevention and control on farm and community level there is need for more knowledge on current application of biosecurity practises, and better understanding of how pig value chain actors perceive prevention and control. To achieve this, a qualitative interview study involving focus group discussions (FGD) was conducted with actors from the smallholder pig value chain in northern Uganda. Six villages were purposively selected based on previous outbreaks of ASF, preliminary perceived willingness to control ASF, and the representation of several different value chain actors in the village. Results indicated that biosecurity practises such as basic hygiene routines including safe carcass handling, minimising direct and indirect contacts between pigs or between pigs and people, trade restrictions and sharing of disease information were implemented in some of the villages. Thematic analysis based on grounded theory revealed six categories of data relating to ASF prevention and control. Together these categories form a logical framework including both enablers and hindrances for ASF prevention and control. In summary participants mostly had positive perceptions of ASF biosecurity, describing measures as effective. Participants further possessed knowledge of ASF and its transmission, some of which was in line with known scientific knowledge and some not. Nevertheless, participants were hindered from preventing and controlling ASF due to biosecurity costs and a need to prioritise family livelihood over disease transmission risks, incompatibility of current biosecurity practises with local culture, traditions and social contexts and finally lack of access to veterinarians or, occasionally, low-quality veterinary services. The constraints could be addressed by applying participatory processes in designing biosecurity measures to ensure better adaptation to local cultural and social contexts.

The Experience of Participating in an Internet-Based Cognitive Behavioral Therapy Program Among Patients with Cardiovascular Disease and Depression: A Qualitative Interview Study

Background Depression in cardiovascular disease (CVD) is associated with poor outcomes and there is a treatment gap of depression in CVD patients. Recently we found that an Internet-based cognitive behavioral therapy (iCBT) tailored for CVD patients led to reduced symptoms of depression. However, we still have little knowledge about CVD patients’ experiences of working with iCBT. The aim of this study was therefore to explore CVD patients experience of engaging with a tailored iCBT program. Methods A qualitative interview study using inductive thematic analysis. Data was obtained from 20 patients with CVD and depressive symptoms who had participated in a randomized controlled trial (RCT) evaluating the impact of a nine-week iCBT program on depression. Results Three main themes emerged: (1) Taking control of the disease, (2) Not just a walk in the park, and (3) Feeling a personal engagement with the iCBT program. The first theme included comments that the tailored program gave the patients a feeling of being active in the treatment process and helped them achieve changes in thoughts and behaviors necessary to take control of their CVD. The second theme showed that patients also experienced the program as demanding and emotionally challenging. However, it was viewed as helpful to challenge negative thinking about living with CVD and to change depressive thoughts. In the third theme patients reported that the structure inherent in the program, in the form of organizing their own health and the scheduled feedback from the therapist created a feeling of being seen as an individual. The feeling of being acknowledged as a person also made it easier to continuously work with the changes necessary to improve their health. Conclusions Engaging in an iCBT program tailored for patients with CVD and depression was by the patients perceived as helpful in the treatment of depression. They experienced positive changes in emotions, thoughts, and behaviors which a result of learning to take control of their CVD, being confirmed and getting support. The patients considered working with the iCBT program as demanding and emotionally challenging, but necessary to achieve changes in emotions, thoughts, and behaviors.

Customer Experience in Circular Economy: Experiential Dimensions among Consumers of Reused and Recycled Clothes

The textile and clothing industry is undergoing a sustainability transition, pushing related businesses to adapt to circular economy (CE) models, such as recycling and reuse. This shift has been extensively studied from industry and business model perspectives, but we lack an understanding of the customer perspective, i.e., how circulated products, such as reused and recycled clothes are experienced among consumers. This understanding is crucial, as customer experience plays a significant role in the adoption of CE products. Therefore, we conducted a qualitative interview study to explore how consumer-customers experience recycled textiles and reused clothes. We used an established experience dimension model and mapped how the five dimensions of customer experience—sensory, affective, behavioral, cognitive, and social—present themselves in the sustainable clothing industry. The data comprised 16 qualitative semi-structured interviews analyzed with a coding framework built on the basis of customer experiences, customer values, and the CE business model literature. The results revealed that diverse sensory (e.g., scent), affective (e.g., pride and shame), behavioral (e.g., developing new decision-making rules), cognitive (e.g., learning and unlearning), and social (e.g., getting feedback from others and manifesting own values) aspects shape how consumers experience reused and recycled clothes. We also compared and analyzed the results of the reuse and redistribute model and the recycle model. Our study contributes to the literature of CE business models and customer experience by providing a structured map of diverse experiential triggers and outcomes from the five experiential dimensions, which together reveal how consumers experience circulated products of the clothing industry. These findings enhance our understanding of customers’ motivation to use recycled and reused products and adoption of CE products.

Influences on Pregnant Women’s and Health Care Professionals’ Behaviour Regarding Maternal Vaccinations: A Qualitative Interview Study

The uptake of maternal influenza and pertussis vaccinations is often suboptimal. This study explores the factors influencing pregnant women’s and health care professionals’ (HCPs) behaviour regarding maternal vaccinations (MVs). Pregnant/recently pregnant women, midwives, pharmacists and general practice staff in Waikato, New Zealand, were interviewed. The analysis used the behaviour change wheel model. Interviews of 18 women and 35 HCPs revealed knowledge about MVs varied with knowledge deficiencies hindering the uptake, particularly for influenza vaccination. HCPs, especially midwives, were key in raising women’s awareness of MVs. Experience with vaccinating, hospital work (for midwives) and training increased HCPs’ knowledge and proactivity about MVs. A “woman’s choice” philosophy saw midwives typically encouraging women to seek information and make their own decision. Women’s decisions were generally based on knowledge, beliefs, HCPs’ emphasis and their perceived risk, with little apparent influence from friends, family, or online or promotional material. General practice’s concentration on children’s vaccination and minimal antenatal contact limited proactivity with MVs. Busyness and prioritisation appeared to affect HCPs’ proactivity. Multi-pronged interventions targeting HCPs and pregnant women and increasing MV access are needed. All HCPs seeing pregnant women should be well-informed about MVs, including how to identify and address women’s questions or concerns about MVs to optimise uptake.

Verbalizing spiritual needs in palliative care: a qualitative interview study on verbal and non-verbal communication in two Danish hospices

Denmark is considered one of the World’s most secular societies, and spiritual matters are rarely verbalized in public. Patients report that their spiritual needs are not cared for sufficiently. For studying spiritual care and communication, twelve patients admitted to two Danish hospices were interviewed. Verbal and non-verbal communication between patients and healthcare professionals were identified and analysed. Methodically, the Interpretative Phenomenological Analysis was used, and the findings were discussed through the lenses of existential psychology as well as philosophy and theory of caring sciences. Three themes were identified: 1. When death becomes present, 2. Direction of the initiative, and 3. Bodily presence and non-verbal communication. The encounter between patient and healthcare professional is greatly influenced by sensing, decoding, and interpretation. A perceived connection between the patient and the healthcare professional is of great importance as to how the patient experiences the relationship with the healthcare professional.The patient’s perception and the patient’s bodily experience of the healthcare professional are crucial to whether the patient opens up to the healthcare professional about thoughts and needs of a spiritual nature and initiates a conversation hereabout. In this way we found three dynamically connected movements toward spiritual care: 1. From secular to spiritual aspects of care 2. From bodily, sensory to verbal aspects of spiritual care and 3. From biomedical to spiritual communication and care. Thus, the non-verbal dimension becomes a prerequisite for the verbal dimension of spiritual communication to develop and unfold. The behaviour of the healthcare professionals, characterised by the way they move physically and the way they touch the patient, was found to be just as important as verbal conversation when it comes to spiritual care. The healthcare professional can create a connection to the patient through bodily and relational presence. Furthermore, the healthcare professionals should let their sensing and impressions guide them when meeting the patient in dialog about matters of a spiritual nature. Their perception of the patient and non-verbal communication are a prerequisite for being able to meet patient’s spiritual needs with care and verbal communication.

Ten years of NIHR research training: perceptions of the programmes: a qualitative interview study

ObjectivesThe UK National Institute for Health Research (NIHR) training programmes were created to build and sustain research capacity in healthcare. Following the training programme 10-year strategic review, this qualitative study aimed to deepen understanding of facilitators and barriers for those progressing through NIHR-supported research careers.DesignSemistructured qualitative study.Data collection and analysisTelephone interviews conducted between May and August 2017 were digitally recorded, transcribed and analysed using Framework Approach.SettingUK National Health Service (NHS) Trusts, university medical schools, District General Hospitals, Integrated Academic Training Programme centres and Research Design Services across the North East, North West, South East and South West of England, London and the Midlands.ParticipantsFourteen women and eight men, of whom, 14 were previous or current NIHR personal awardees (seven doctors and seven allied health professionals (AHPs) or nurses) and eight were managers (staff within clinical or university training-related roles).Results(1) NIHR awards were viewed as transformative for research careers; (2) however, there were perceptions of a biased ‘playing field’. (3) Inequalities were perceived for AHPs and nurses, those outside of established research institutes and those in ‘unfashionable’ specialisms. (4) While support for NIHR awards contributed to a healthy research culture, (5) short-term awards were perceived as a barrier to continuing an independent research career.ConclusionsParticipants perceived many strengths of the NIHR training programmes in terms of developing individual careers and research capacity. Areas in which improvement could enhance the ability to attract, develop and retain researcher were identified. Our findings are of relevance to schemes in other countries, where healthcare researchers experience similar challenges. Further work is needed to overcome barriers and ensure equity of access to, and success within, clinical research training schemes to sustain the research workforce needed to address future global health challenges.