Verbesserung allgemeiner ambulanter Palliativversorgung in Hausarztpraxen – Evaluation der Interventionsstudie ALLPRAX

Zusammenfassung Hintergrund Trotz eines hohen Bedarfs an allgemeiner ambulanter Palliativversorgung (AAPV) fehlt es an konkreten Lösungsansätzen für eine zielgerichtete Integration in Hausarztpraxen. Ziel dieser Arbeit ist die Evaluation von Maßnahmen zur Verbesserung der AAPV aus Sicht hausärztlicher Praxisteams. Methoden Qualitative Evaluation der Implementierungsstudie ALLPRAX mit sieben Praxisteams mittels der Normalization Process Theory. Ergebnisse Bedürfnisse von Palliativpatient*innen und ihren Angehörigen konnten mittels eines palliativmedizinischen Erstassessments und Krisenbogens besser identifiziert werden. Zu ihrer Beratung und Informationen wurde die Bereitstellung von Flyern als hilfreich bewertet. Demgegenüber gelang die Integration von Maßnahmen mit hohem Arbeitsaufwand selten. Schlussfolgerungen Maßnahmen zur Verbesserung der AAPV sollten leicht integrierbar sein und neben den Bedürfnissen von Palliativpatient*innen gezielt die Belastungen von Angehörigen berücksichtigen.

Evaluation of normalization after implementation of the digital Dutch Obstetric Telephone Triage System: Mixed methods design (questionnaire and focus group discussion) (Preprint)

BACKGROUND The Dutch Obstetric Telephone Triage System (DOTTS) was developed to improve the quality of acute obstetric care. To achieve optimal effect, DOTTS should be adopted in the daily care process by triage staff. The outcome of implementation was evaluated in nine hospitals. OBJECTIVE The aim of this study was to gain insight into the degree of implementation (normalization) and to evaluate which lessons can be learned from the implementation of DOTTS that can help optimize current and new implementations. METHODS An evaluation study with a mixed methods design was performed. All triage staff in hospitals who implemented DOTTS before 1 September 2019 were invited to complete the Normalization MeAsure Development (NoMAD) questionnaire between December 2019 and July 2020. The questionnaire is based on the Normalization Process Theory. This self-report questionnaire gives insight into the work people do in order to integrate and embed new practice in routine care. Normalization Process Theory is based on four constructs: coherence, cognitive participation, collective action and reflexive monitoring. Within the questionnaire each construct is represented by 4-7 questions. Questions could be scored on a 5-point Likert scale. Descriptive statistics were used for analysis of questionnaire scores. Subsequently, analysis of questionnaires were discussed during a focus group. Template analysis following the four constructs of NPT was used for analyzing the results of the focus group. RESULTS In total 173 triage-staff members completed the NoMAD questionnaire. Ninety percent of the participants had used DOTTS for over six months. The digital application was used as much as possible or always by 79.1% of the participants (n=137). The overall Normalization Process Score was 3.77 (SD=0.36). The constructs Coherence and Cognitive Participation scored 4.01 (SD=0.47) and 4.05 (SD=0.45) respectively. Collective Action scored 3.5 (SD=0.45) and Reflexive Monitoring scored 3.72 (SD=0.47). Analysis of the focus group discussion showed that the added value of DOTTS was seen as a quality improvement for pregnant women. Dedication of the complete multidisciplinary implementation team, with specific support from the medical staff, as well as proper use by all disciplines involved in the triage is important for facilitating normalization. Participants appreciated training and evaluation and indicated a need for ongoing training and evaluation in relation to goal achievement. CONCLUSIONS The DOTTS has been integrated into normal care in daily practice. Evaluation by NoMAD-questionnaires gave a positive overall score. These results are in line or, in some aspects better, when compared to other evaluation studies. Key factors in the normalization process of the DOTTS in obstetric triage are the shared added value for stakeholders, the dedication of the complete multidisciplinary implementation team and implementation plans that are tailor made in the practical context of the hospital.

Impact of a health literacy intervention combining general practitioner training and a consumer facing intervention to improve colorectal cancer screening in underserved areas: protocol for a multicentric cluster randomized controlled trial

Background Colorectal cancer (CRC) is a leading cause of cancer burden worldwide. In France, it is the second most common cause of cancer death after lung cancer. Systematic uptake of CRC screening can improve survival rates. However, people with limited health literacy (HL) and lower socioeconomic position rarely participate. Our aim is to assess the impact of an intervention combining HL and CRC screening training for general practitioners (GPs) with a pictorial brochure and video targeting eligible patients, to increase CRC screening and other secondary outcomes, after 1 year, in several underserved geographic areas in France. Methods We will use a two-arm multicentric randomized controlled cluster trial with 32 GPs primarily serving underserved populations across four regions in France with 1024 patients recruited. GPs practicing in underserved areas (identified using the European Deprivation Index) will be block-randomized to: 1) a combined intervention (HL and CRC training + brochure and video for eligible patients), or 2) usual care. Patients will be included if they are between 50 and 74 years old, eligible for CRC screening, and present to recruited GPs. The primary outcome is CRC screening uptake after 1 year. Secondary outcomes include increasing knowledge and patient activation. After trial recruitment, we will conduct semi-structured interviews with up to 24 GPs (up to 8 in each region) and up to 48 patients (6 to 12 per region) based on data saturation. We will explore strategies that promote the intervention’s sustained use and rapid implementation using Normalization Process Theory. We will follow a community-based participatory research approach throughout the trial. For the analyses, we will adopt a regression framework for all quantitative data. We will also use exploratory mediation analyses. We will analyze all qualitative data using a framework analysis guided by Normalization Process Theory. Discussion Limited HL and its impact on the general population is a growing public health and policy challenge worldwide. It has received limited attention in France. A combined HL intervention could reduce disparities in CRC screening, increase screening rates among the most vulnerable populations, and increase knowledge and activation (beneficial in the context of repeated screening). Trial registration Registry: ClinicalTrials.gov. Trial registration number: 2020-A01687-32. Date of registration: 17th November 2020.

Evaluating Implementation Contexts, Mechanisms, and Outcomes: A Normalization Process Theory Coding Manual for Qualitative Research and Instrument Development

Background. Qualitative studies, especially those conducted by teams of researchers, may benefit from clearly structured, parsimonious, coding manuals. The process of creating rigorous and robust coding manuals for individual studies is rarely described, and generalizable coding manuals are rare. Normalization Process Theory (NPT) provides conceptual tools to facilitate understanding of the dynamics of adoption, implementation, and sustainment of socio-technical and organizational innovations. As a widely used theory, a generalizable coding manual would be of utility to implementation researchersObjectives. To make the application of NPT simple for the user, to describe the development of a coding manual for qualitative content analytic studies using NPT, and present this for wider use.Method. Concept Selection and Structuring. Qualitative Content Analysis of selected published papers and interview transcripts. Results. All identifiable theoretical concepts (n=149) embedded in papers and chapters that developed NPT between 2006 and 2020 were identified and extracted from their texts. Overlapping, ambiguous, and duplicate versions of concepts were eliminated, as were concepts derived from other theories. This left 38 core concept definitions. These were piloted in coding of qualitative transcripts collected in two implementation studies, and by collaboratively coding papers collected for a systematic review of implementation studies. At the end of this process, a further process of elimination of overlapping or ambiguous concepts was undertaken leaving 12 primary NPT concepts. Conclusion. The process of coding manual resulted in the presentation of NPT concepts according to the Context-Mechanism-Outcomes configuration of realist evaluation research. A coding manual for NPT that is in accordance with realistic evaluation research was successfully produced and is now freely available to researchers who wish to use NPT in primary and secondary research that employs qualitative methods.

Combining Realist approaches and Normalization Process Theory to understand implementation: a systematic review

Background Realist approaches and Normalization Process Theory (NPT) have both gained significant traction in implementation research over the past 10 years. The aim of this study was therefore to explore how the approaches are combined to understand problems of implementation, to determine the degree of complementarity of the two approaches and to provide practical approaches for using them together. Methods Systematic review of research studies combining Realist and NPT approaches. Realist methodology is concerned with understanding and explaining causation, that is, how and why policies, programmes and interventions achieve their effects. NPT is a theory of implementation that explains how practices become normalised. Databases searched (January 2020) were ASSIA, CINAHL, Health Research Premium Collection via Proquest (Family Health Database, Health & Medical Collection, Health Management Database, MEDLINE, Nursing & Allied Health Database, Psychology Database, Public Health Database) and PsycARTICLES. Studies were included if the author(s) stated they used both approaches: a scientific Realist perspective applying the principles of Pawson and Tilley’s Realist Evaluation or Pawson’s Realist Synthesis and Normalization Process Theory either solely or in addition to other theories. Two authors screened records; discrepancies were reviewed by a third screener. Data was extracted by three members of the team and a narrative synthesis was undertaken. Results Of 245 total records identified, 223 unique records were screened and 39 full-text papers were reviewed, identifying twelve papers for inclusion in the review. These papers represented eight different studies. Extent and methods of integration of the approaches varied. In most studies (6/8), Realist approaches were the main driver. NPT was mostly used to enhance the explanatory power of Realist analyses, informing development of elements of Contexts, Mechanisms and Outcomes (a common heuristic in realist work). Authors’ reflections on the integration of NPT and Realist approaches were limited. Conclusions Using Realist and NPT approaches in combination can add explanatory power for understanding the implementation of interventions and programmes. Attention to detailed reporting on methods and analytical process when combining approaches, and appraisal of theoretical and practical utility is advised for advancing knowledge of applying these approaches in research. Systematic review registration Not registered.

‘If relevant, yes; if not, no’: General practitioner (GP) users and GP perceptions about asking ethnicity questions in Irish general practice: A qualitative analysis using Normalization Process Theory

Context The use of ethnic identifiers in health systems is recommended in several European countries as a means to identify and address heath inequities. There are barriers to implementation that have not been researched. Objective This study examines whether and how ethnicity data can be collected in Irish general practices in a meaningful and acceptable way. Methods Qualitative case study data generation was informed by Normalization Process Theory (NPT) constructs about ‘sense’ making and ‘engagement’. It consisted of individual interviews and focus group discussions based on visual participatory techniques. There were 70 informants, including 62 general practitioner (GP) users of diverse ethnic backgrounds recruited through community organisations and eight GPs identified through an inter-agency steering group. Data were analysed according to principles of thematic analysis using NPT. Results The link between ethnicity and health was often considered relevant because GP users grasped connections with genetic (skin colour, lactose intolerance), geographic (prevalence of disease, early years exposure), behavioural (culture/food) and social determinant (housing) factors. The link was less clear with religion. There was some scepticism and questions about how the collection of data would benefit GP consultations and concerns regarding confidentiality and the actual uses of these data (e.g. risk of discrimination, social control). For GPs, the main theme discussed was relevance: what added value would it bring to their consultations and was it was their role to collect these data? Their biggest concern was about data protection issues in light of the European Union (EU) General Data Protection Regulation (GDPR). The difficulty in explaining a complex concept such as ‘ethnicity’ in the limited time available in consultations was also worrying. Conclusions Implementation of an ethnicity identifier in Irish general practices will require a strong rationale that makes sense to GP users, and specific measures to ensure that its benefits outweigh any potential harm. This is in line with both our participants’ views and the EU GDPR.