A realist process evaluation within the Facilitating Implementation of Research Evidence (FIRE) cluster randomised controlled international trial: An exemplar

Trial Registration: Current Controlled Trials ISRCTN11598502Background Facilitation is a promising implementation intervention, which requires theory informed evaluation. This paper presents an exemplar of a multi-country realist process evaluation that was embedded in the first international randomised controlled trial evaluating two types of facilitation for implementing urinary continence care recommendations. We aimed to uncover what worked (and did not work), for whom, how, why and in what circumstances during the process of implementing the facilitation interventions in practice. Methods This realist process evaluation included theory formulation, theory testing and refining. Data were collected in 24 care home sites across four European countries. Data were collected over four time-points using multiple qualitative methods: observation (372 hours), interviews with staff (n=357), residents (n=152), next of kin (n=109) other stakeholders (n=128), supplemented by facilitator activity logs. A combined inductive and deductive data analysis process focused on realist theory refinement and testing. Results The content and approach of the two facilitation programmes prompted variable opportunities to align and realign support with the needs and expectations of facilitators and homes. This influenced their level of confidence in fulfilling the facilitator role, and ability to deliver the intervention as planned. The success of intervention implementation was largely dependent on whether sites prioritised their involvement in both the study and the facilitation programme. In contexts where the study was prioritised (including release of resources) and where managers and staff support was sustained, this prompted collective engagement (as an attitude and action). Internal facilitators’ (IF) personal characteristics and abilities, including personal and formal authority, in combination with a supportive environment prompted by managers triggered the potential for learning over time. Learning over time resulted in a sense of confidence and personal growth, and enactment of the facilitation role, which resulted in practice changes. Conclusion The scale and multi-country nature of this study provided a novel context to conduct one of the few trial embedded realist informed process evaluations. In addition to providing an explanatory account of implementation processes, a conceptual platform for future facilitation research is presented. Finally a realist informed process evaluation framework is outlined, which could inform future research of this nature.The research leading to these results has received funding from the European Union's Seventh Framework Programme (FP7/2007-2013) under grant agreement n° 223646. The funder had no role in designing, conducting, or interpreting study findings.https://implementationscience.biomedcentral.com/articles13pubpub13

Lack of effective communication between communities and hospitals in Uganda: a qualitative exploration of missing links

<p>Abstract</p> <p>Background</p> <p>Community members are stakeholders in hospitals and have a right to participate in the improvement of quality of services rendered to them. Their views are important because they reflect the perspectives of the general public. This study explored how communities that live around hospitals pass on their views to and receive feedback from the hospitals' management and administration.</p> <p>Methods</p> <p>The study was conducted in eight hospitals and the communities around them. Four of the hospitals were from three districts from eastern Uganda and another four from two districts from western Uganda. Eight key informant interviews (KIIs) were conducted with medical superintendents of the hospitals. A member from each of three hospital management boards was also interviewed. Eight focus group discussions (FGDs) were conducted with health workers from the hospitals. Another eight FGDs (four with men and four with women) were conducted with communities within a five km radius around the hospitals. Four of the FGDs (two with men and two with women) were done in western Uganda and the other four in eastern Uganda. The focus of the KIIs and FGDs was exploring how hospitals communicated with the communities around them. Analysis was by manifest content analysis.</p> <p>Results</p> <p>Whereas health unit management committees were supposed to have community representatives, the representatives never received views from the community nor gave them any feed back from the hospitals. Messages through the mass media like radio were seen to be non specific for action. Views sent through suggestion boxes were seen as individual needs rather than community concerns. Some community members perceived they would be harassed if they complained and had reached a state of resignation preferring instead to endure the problems quietly.</p> <p>Conclusion</p> <p>There is still lack of effective communication between the communities and the hospitals that serve them in Uganda. This deprives the communities of the right to participate in the improvement of the services they receive, to assume their position as stakeholders. Various avenues could be instituted including using associations in communities, rapid appraisal methods and community meetings.</p

The accessibility and acceptability of self-management support interventions for men with long term conditions: a systematic review and meta-synthesis of qualitative studies

Background: Self-management support interventions can improve health outcomes, but their impact is limited by the numbers of people able or willing to access them. Men’s attendance at existing self-management support services appears suboptimal despite their increased risk of developing many of the most serious long term conditions. The aim of this review was to determine whether current self-management support interventions are acceptable and accessible to men with long term conditions, and explore what may act as facilitators and barriers to access of interventions and support activities. Methods: A systematic search for qualitative research was undertaken on CINAHL, EMBASE, MEDLINE, PsycINFO and Social Science Citation Index, in July 2013. Reference lists of relevant articles were also examined. Studies that used a qualitative design to explore men’s experiences of, or perceptions towards, self-management support for one or more long term condition were included. Studies which focused on experiences of living with a long term condition without consideration of self-management support were excluded. Thirty-eight studies met the inclusion criteria. A meta-ethnography approach was employed to synthesise the findings. Results: Four constructs associated with men’s experience of, and perceptions towards, self management support were identified: 1) need for purpose; 2) trusted environments; 3) value of peers; and 4) becoming an expert. The synthesis showed that men may feel less comfortable participating in self-management support if it is viewed as incongruous with valued aspects of their identity, particularly when activities are perceived to challenge masculine ideals associated with independence, stoicism, and control. Men may find self-management support more attractive when it is perceived as action-oriented, having a clear purpose, and offering personally meaningful information and practical strategies that can be integrated into daily life. Conclusions: Self-management support is most likely to be successful in engaging men when it is congruent with key aspects of their masculine identity. In order to overcome barriers to access and fully engage with interventions, some men may need self-management support interventions to be delivered in an environment that offers a sense of shared understanding, connectedness, and normality, and involves and/or is facilitated by men with a shared illness experience

A digital intake approach in specialized mental health care : study protocol of a cluster randomised controlled trial

Background: Enhancing patient participation is becoming increasingly important in mental health care as patients use to have a dependent, inactive role and nonadherence to treatment is a regular problem. Research shows promising results of initiatives stimulating patient participation in partnership with their clinicians. However, few initiatives targeting both patients’ and clinicians’ behaviour have been evaluated in randomised trials (RCT). Therefore, in GGz Breburg, a specialized mental health institution, a digital intake approach was developed aimed at exploring treatment needs, expectations and preferences of patients intended to prepare patients for the intake consultations. Subsequently, patients and clinicians discuss this information during intake consultations and make shared decisions about options in treatment. The aim of this trial is to test the efficacy of this new digital intake approach facilitated by Routine Outcome Monitoring (ROM), peer support and training of clinicians as compared to the intake as usual. The primary outcome is decisional conflict about choices in treatment. Secondary outcomes focus on patient participation, shared decision making, working alliance, adherence to treatment and clinical outcomes. Methods: This article presents the study protocol of a cluster-randomised controlled trial in four outpatient departments for adults with depression, anxiety and personality disorders, working in two different regions. Randomisation is done between two similar intake-teams within each department. In the four intervention teams the new intake approach is implemented. The four control teams apply the intake as usual and will implement the new approach after the completion of the study. In total 176 patients are projected to participate in the study. Data collection will be at baseline, and at two weeks and two months after the intake. Discussion: This study will potentially demonstrate the efficacy of the new digital intake approach in mental health care in terms of the primary outcome the degree of decisional conflict about choices in treatment. The findings of this study may contribute to the roll out of such eHealth initiatives fostering patient involvement in decision making about their treatment