Multiple health behaviour change primary care intervention for smoking cessation, physical activity and healthy diet in adults 45 to 75 years old (EIRA study): a hybrid effectiveness-implementation cluster randomised trial

Background This study aimed to evaluate the effectiveness of a) a Multiple Health Behaviour Change (MHBC) intervention on reducing smoking, increasing physical activity and adherence to a Mediterranean dietary pattern in people aged 45–75 years compared to usual care; and b) an implementation strategy. Methods A cluster randomised effectiveness-implementation hybrid trial-type 2 with two parallel groups was conducted in 25 Spanish Primary Health Care (PHC) centres (3062 participants): 12 centres (1481 participants) were randomised to the intervention and 13 (1581 participants) to the control group (usual care). The intervention was based on the Transtheoretical Model and focused on all target behaviours using individual, group and community approaches. PHC professionals made it during routine care. The implementation strategy was based on the Consolidated Framework for Implementation Research (CFIR). Data were analysed using generalised linear mixed models, accounting for clustering. A mixed-methods data analysis was used to evaluate implementation outcomes (adoption, acceptability, appropriateness, feasibility and fidelity) and determinants of implementation success. Results 14.5% of participants in the intervention group and 8.9% in the usual care group showed a positive change in two or all the target behaviours. Intervention was more effective in promoting dietary behaviour change (31.9% vs 21.4%). The overall adoption rate by professionals was 48.7%. Early and final appropriateness were perceived by professionals as moderate. Early acceptability was high, whereas final acceptability was only moderate. Initial and final acceptability as perceived by the participants was high, and appropriateness moderate. Consent and recruitment rates were 82.0% and 65.5%, respectively, intervention uptake was 89.5% and completion rate 74.7%. The global value of the percentage of approaches with fidelity ≥50% was 16.7%. Eight CFIR constructs distinguished between high and low implementation, five corresponding to the Inner Setting domain. Conclusions Compared to usual care, the EIRA intervention was more effective in promoting MHBC and dietary behaviour change. Implementation outcomes were satisfactory except for the fidelity to the planned intervention, which was low. The organisational and structural contexts of the centres proved to be significant determinants of implementation effectiveness. Trial registration ClinicalTrials.gov, NCT03136211. Registered 2 May 2017, “retrospectively registered”.

Development of the Cancer Exercise Toolkit: a website for exercise professionals using a co-design approach (Preprint)

BACKGROUND Access to exercise therapy for cancer survivors is poor. Professional development to support exercise professionals to deliver these interventions is needed. Few online resources exist for exercise professionals to address this issue. OBJECTIVE To develop and evaluate a freely available online toolkit to support exercise professionals working with cancer survivors. METHODS A two-phase, experience-based co-design approach was completed to develop and evaluate the online toolkit. The two phases were: 1) needs identification and co-design of resources and platform and 2) pilot evaluation. Four co-design workshops were conducted, transcribed and thematically analysed to identify key elements for the toolkit. For the pilot evaluation, a customised survey was distributed to exercise professionals at baseline and 3-months following launch of the online toolkit to determine its usability, utility and effectiveness on exercise professional’s knowledge, confidence and behaviour (Determinants of Implementation Behaviour Questionnaire). Results were described using medians and interquartile range and changes calculated using non-parametric tests. Website analytics described site usage after initial evaluation. RESULTS Twenty-five exercise professionals participated in co-designing eight key elements of the online Cancer Exercise Toolkit: Homepage, Getting Started, Screening and Safety, Assessment, Exercise Prescription, Education, Locations and Resources. For the pilot evaluation, 320 respondents (87% physiotherapists) from 26 countries completed the survey at baseline, with 58 exercise professionals completing follow-up surveys at 3-months. Exercise professional’s knowledge, skills and confidence in delivering exercise therapy for cancer survivors increased at 3-months from baseline (follow-up median 6 points on a 1 to 7 Likert scale, IQR 4 to 6). Most participants (76%) agreed or strongly agreed they would recommend the toolkit to colleagues. In the 6-months following the pilot evaluation, the toolkit received an average of 866 views per month. CONCLUSIONS The co-designed online Cancer Exercise Toolkit was a useful resource for exercise professionals that may increase their knowledge, skills and confidence to provide exercise therapy to cancer survivors. CLINICALTRIAL not applicable

Considering the role of context when implementing government policies in hospitals: introduction of a prospective payment system for psychiatry

PurposeThe context in which an innovation is implemented is an important and often neglected mediator of change. A prospective payment system (PPS) for psychiatric and psychosomatic facilities with major implications for inpatient psychiatric care in Germany was implemented from 2013 to 2017. This study aims to examine the determinants of implementation of this government policy using the Diffusion of Innovations theory and consider the role of context.Design/methodology/approachAn exploratory case study was conducted in two wards of a psychiatric hospital in Germany: geriatric psychiatry (GerP) and general psychiatry (GenP). Fifteen interviews were conducted with different occupational groups and analyzed in-depths. Routine hospital data were analyzed for delimiting the two contexts.FindingsRoutine hospital data show a higher day-mix index (1.08 vs. 0.94) in the GerP context and a very different structure regarding PPS groups, indicating a higher patient complexity. Two types of factors influencing implementation were identified: Context-independent factors included social separation between nurses and doctors, poor communication behavior between the groups and a lack of conveying information about the underlying principles of the PPS. Context-dependent factors included compatibility of the new requirements with existing routines and the relative advantage of the PPS, which were both perceived to be lower in the GerP context.Practical implicationsDepending on the patient characteristics in the specific context, compatibility with existing routines should be ensured when implementing. Clear communication of the underlying principles and reduction of organizational and communicative barriers between professional groups are crucial success factors for implementing such innovations.Originality/valueThis study shows how a diffusion process takes place in an organization even after the organization adopts an innovation. The authors could show how contextual differences in terms of patient characteristics result in different determinants of implementation from the views of the employees affected by the innovation.

Using the Theoretical Domains Framework to investigate clinicians’ behavioural determinants of antimicrobial prescribing in Qatar

Introduction A recent systematic review by Talkhan et al demonstrated the need for theoretically based behaviour change interventions in this area. [1] For development of such complex interventions, emphasis should be placed on using theory to systematically identify behavioural determinants of antimicrobial prescribing. Aim To identify and quantify clinicians’ behavioural determinants of antimicrobial prescribing in Qatar. Methods This cross-sectional survey is part of a multi-phase explanatory, sequential mixed methods PhD project in Qatar. Questionnaires were distributed (online and paper based) to all doctors (~4,000) and pharmacists (~400) within Hamad Medical Corporation (HMC, the main healthcare provider). The questionnaire was developed with reference to the Determinants of Implementation Behaviour Questionnaire (a generic questionnaire derived from the 14 theoretical domains of the Theoretical Domains Framework, TDF). [2] Each item was presented as a 5-point Likert scale (scored 5=Strongly agree to 1=Strongly disagree). Personal and practice demographics were also collected for data contextualisation. The draft questionnaire was reviewed for face/content validity by an expert panel of six researchers in Qatar and the UK with experience in the use of the TDF, followed by ‘Think aloud’ testing and piloting. Analysis investigated the behavioural determinants and influential factors through descriptive, principal component analysis (PCA) and inferential analysis. Ethics approval was granted from a UK university and HMC. Results In total, 535 responses were received, 339 (63.4%) from doctors and 196 (36.6%) from pharmacists. Respondents were predominantly male, 346 (64.7%). Just over half (n=285, 53.3%) had ≤ 5 years’ experience as health professionals. PCA showed a three component (C) solution with components incorporating a number of questionnaire items labelled: ‘Guidelines compliance’ (C1 with 8 items), ‘Influences on prescribing’ (C2 with 7 items) and ‘Self-efficacy’ (C3 with 5 items) in prescribing/recommendation activity. A scale score for each respondent was calculated through summation of Likert scores for the relevant questionnaire items within each component. These scales had high internal reliability (Cronbach’s alpha all >0.7) showing consistency in response between component items indicating statistical appropriateness for developing scales. The median score (possible scale range, midpoint) for each scale was C1, 32 (8 to 40, 24), C2, 26 (7 to 35, 21) and C3, 20, (5 to 25, 15). By way of example Table 1 shows levels of agreement for items in C2. This shows lower levels of agreement than C1 scale with the median scale score (26) closer to the midpoint (21) indicating that respondents had less positive views. Inferential analysis using these scale scores and free text analysis is in progress. Conclusion A theoretical basis was used throughout providing insights to behavioural determinants for the development of a theory-based behaviour change intervention. Preliminary results suggest that social influences, staff development and quality monitoring may be useful targets for behaviour change interventions to improve antimicrobial prescribing practice. Limitations include potential social desirability bias and focus on one healthcare organisation/country in the Middle East which may limit generalisability of findings. More in-depth exploration is required to select and test appropriate linked theory-based behaviour change techniques. References 1. Talkhan H, Stewart D, McIntosh T, Ziglam H Palli Valapila, A; Moza Sulaiman H, Diab M, Cunningham S. The use of theory in the development and evalu​ation of behaviour change interventions to improve antimicrobial prescribing: a systematic review. J Antimicrob Chemother. 2020;75(9):2394–2410, Available from https://doi.org/10.1093/jac/dkaa154 [Accessed 12 Oct 2020]. 2. Huijg JM, Gebhardt WA, Dusseldorp E, Verheijden MW, van der Zouwe N, Middelkoop BJ, Crone MR. Measuring determinants of implementation behaviour: psychometric properties of a questionnaire based on the Theoretical Domains Framework. Implement. Sci. 2014;9(1):33.

School Management Attitudes as Determinants of Implementation of Guidance and Counselling Services in Secondary Schools in Baringo Central Sub-County, Kenya

Guidance and counselling constitute the best approach to help children and their families deal with life’s frustrating issues. In the school context, guidance and counselling services assist the school to manage discipline and deal with the influence of social evils on learners and the learning environment. However, for guidance and counselling services to be effective in schools, several factors must be put in place. Among these factors, the key is school management support for guidance and counselling services. In recognition of this fact, the study examined the influence of the schools’ management attitudes towards guidance and counselling on the implementation of guidance and counselling programmes in secondary schools in Baringo Central Sub-County. The study used the descriptive survey research method. It relied on a sample of 36 secondary schools with 36 principals and 72 teacher-counsellors. The research employed a questionnaire to collect the data. The collected data was then analysed using SPSS, version 22. The results of the study revealed that although most schools’ managers had embraced and recognised the role of guidance and counselling in their schools, little time and resources were availed to sustain these important services. This situation had negatively affected the implementation of guidance and counselling in schools. Therefore, it was recommended that guidance should be conceptualised in a broader and more comprehensive and holistic view, incorporating vocational and other aspects of development

Determinants of Implementation of County Bursary Regulations in Kirinyaga County, Kenya

Kirinyaga County bursary scheme was introduced in the 2013/14 financial year. Bursary for secondary schools and higher level institutions being a National government function, the county sought advice from the then cabinet to offer state support to enhance access, ensure retention and reduce corruption in the provision of school education. Poor vetting criterion and compliance of guidelines have resulted in cronyism and nepotism which have plagued the bursary award process for decades. Poor monitoring & evaluation has piled up grievances with no follow up system. Lack of clear regulations on funding allocation has allowed political interference on budget cycles. The County bursary targets were students from poor households and the vulnerable. This study sought to examine the determinants of implementation of county bursary regulations in Kirinyaga County, Kenya. The study was guided by the following objectives; To establish the extent to which compliance of guidelines determines the implementation of County Bursary in Kirinyaga County, to explore the extent to which vetting criteria determines the implementation of County Bursary in Kirinyaga County, to examine the extent to which funding allocation determines the implementation of County Bursary in Kirinyaga County and to examine the extent to which monitoring of utilization of the bursary fund determines the implementation of County Bursary in Kirinyaga County. The new public administration theory that captures the concept of equity and fairness was adopted to explore the gaps during implementation of county bursary regulations in Kirinyaga County. The study sourced requisite data from 70 parents whose students benefited from bursary and 31 principals, both samples having been picked from the PTAs membership. The respondents were drawn using a combination of random and purposive sampling procedures. The study adopted descriptive design which was used to analyze primary data. Data was presented, interpreted and analyzed using frequency & percentage distributions, cross tabulations with STATA. Qualitative data in form of first hand experiences, informed opinions and suggestions, were analyzed using qualitative procedures and were used to strengthen quantitative findings. The results of the study indicated that majority of beneficiaries allocation by need were from poor households 51% followed by bright students at 29%. Similarly, orphans and special needs students both received 9.7%.