Investigating innovations in outpatient services: a mixed-methods rapid evaluation.

Background: Within outpatient services, a broad range of innovations are being pursued to better manage care and reduce unnecessary appointments. One of the least-studied innovations is Patient-Initiated Follow-Up, which allows patients to book appointments if and when they need them, rather than follow a standard schedule. Objectives: To use routine national hospital data to identify innovations in outpatient services implemented, in recent years, within the National Health Service in England. To carry out a rapid mixed-methods evaluation of the implementation and impact of Patient-Initiated Follow-Up. Methods: The project was carried out in four sequential workstreams: (1) a rapid scoping review of outpatient innovations; (2) the application of indicator saturation methodology for scanning national patient-level data to identify potentially successful local interventions; (3) interviews with hospitals identified in workstream 2; and (4) a rapid mixed-methods evaluation of Patient-Initiated Follow-Up. The evaluation of Patient-Initiated Follow-Up comprised an evidence review, interviews with 36 clinical and operational staff at 5 National Health Service acute trusts, a workshop with staff from 13 National Health Service acute trusts, interviews with four patients, analysis of national and local data, and development of an evaluation guide. Results: Using indicator saturation, we identified nine services with notable changes in follow-up to first attendance ratios. Of three sites interviewed, two queried the data findings and one attributed the change to a clinical assessment service. Models of Patient-Initiated Follow-Up varied widely between hospital and clinical specialty, with a significant degree of variation in the approach to patient selection, patient monitoring and discharge. The success of implementation was dependent on several factors, for example, clinical condition, staff capacity and information technology systems. From the analysis of national data, we found evidence of an association between greater use of Patient-Initiated Follow-Up and a lower frequency of outpatient attendance within 15 out of 29 specialties and higher frequency of outpatient attendance within 7 specialties. Four specialties had less frequent emergency department visits associated with increasing Patient-Initiated Follow-Up rates. Patient-Initiated Follow-Up was viewed by staff and the few patients we interviewed as a positive intervention, although there was varied impact on individual staff roles and workload. It is important that sites and services undertake their own evaluations of Patient-Initiated Follow-Up. To this end we have developed an evaluation guide to support trusts with data collection and methods. Limitations: The Patient-Initiated Follow-Up evaluation was affected by a lack of patient-level data showing who is on a Patient-Initiated Follow-Up pathway. Engagement with local services was also challenging, given the pressures facing sites and staff. Patient recruitment was low, which affected the ability to understand experiences of patients directly. Conclusions: The study provides useful insights into the evolving national outpatient transformation policy and for local practice. Patient-Initiated Follow-Up is often perceived as a positive intervention for staff and patients, but the impact on individual outcomes, health inequalities, wider patient experience, workload and capacity is still uncertain. Future research: Further research should include patient-level analysis to determine clinical outcomes for individual patients on Patient-Initiated Follow-Up and health inequalities, and more extensive investigation of patient experiences. Study registration: This study is registered with the Research Registry (UIN: researchregistry8864). Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 16/138/17) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 38. See the NIHR Funding and Awards website for further award information.

When someone visits hospital for an operation or an ongoing condition, they are given follow-up appointments at clinics, often after 6 months. The National Health Service thinks that many of these appointments are not necessary because they are not useful to patients. Also, outside fixed appointments, patients are not always being seen when they are most in need. Hospitals have been testing new ways to improve services. We looked at hospital data and discussed interesting findings with hospitals themselves to see if we could find approaches that worked. We then looked at one new approach called Patient-Initiated Follow-Up. Patients using Patient-Initiated Follow-Up can book appointments when they are needed, rather than at a pre-planned time. We explored how Patient-Initiated Follow-Up was being used in hospitals, what effect it was having and what patients and National Health Service staff thought about it. We studied hospital data and interviewed patients and National Health Service staff. We found that Patient-Initiated Follow-Up works differently depending on the hospital and the patient's condition. Patient-Initiated Follow-Up is most frequently used for patients needing short-term follow-up, such as after an operation. It is also starting to be used for patients with long-term chronic conditions. National Health Service staff think that Patient-Initiated Follow-Up can benefit patients, although some may find it easier to use than others. Patients appear to like Patient-Initiated Follow-Up, but some still prefer to let the hospital schedule appointments. From data it appears that for some conditions, where more patients use Patient-Initiated Follow-Up, fewer follow-up visits are required. For a few conditions, there is evidence of fewer emergency department visits, but the overall impact is small. We interviewed staff from a small number of hospitals and four patients, so what we found may not apply across the National Health Service. We also developed a guide to help hospitals evaluate the success of their own Patient-Initiated Follow-Up services.

Digital Interventions for Reducing Loneliness and Depression in Korean College Students: Mixed Methods Evaluation.

BACKGROUND: The COVID-19 pandemic has exacerbated the prevalence of loneliness and depression among college students. Digital interventions, such as Woebot (Woebot Health, Inc) and Happify (Twill Inc), have shown promise in alleviating these symptoms. OBJECTIVE: This study aims to investigate the effectiveness and acceptability of Woebot and Happify in reducing loneliness and depression among college students after the COVID-19 pandemic. METHODS: A mixed methods approach was used over 4 months. A total of 63 participants aged 18 to 27 years from Sungkyunkwan University in Seoul, South Korea, were initially recruited, with an inclusion criterion of University of California, Los Angeles (UCLA) Loneliness Scale score ≥34. The final sample consisted of 27 participants due to attrition. Participants were randomly assigned to Woebot (15/27, 55%); Happify (9/27, 33%); or a control group using Bondee (Metadream), a metaverse social network messenger app (3/27, 11%). Quantitative measures (UCLA Loneliness Scale and Patient Health Questionnaire-9) and qualitative assessments (user feedback and focused interviews) were used. RESULTS: Although mean decreases in loneliness and depression were observed in the control and intervention groups after the intervention, the differences between the control and intervention groups were not statistically significant (UCLA Loneliness: P=.67; Patient Health Questionnaire-9: P=.35). Qualitative data indicated user satisfaction, with suggestions for improved app effectiveness and personalization. CONCLUSIONS: Despite limitations, this study highlights the potential of well-designed digital interventions in alleviating college students' loneliness and depression. The findings contribute to the growing body of research on accessible digital mental health tools and underscore the importance of comprehensive support systems. Further research with larger and more diverse samples is needed to better understand the effectiveness and optimization of such interventions. TRIAL REGISTRATION: Clinical Research Information Service KCT0009449; https://bit.ly/4d2e4Bu.

Veteran Experiences With an mHealth App to Support Measurement-Based Mental Health Care: Results From a Mixed Methods Evaluation.

BACKGROUND: Mental health conditions are highly prevalent among US veterans. The Veterans Health Administration (VHA) is committed to enhancing mental health care through the integration of measurement-based care (MBC) practices, guided by its Collect-Share-Act model. Incorporating the use of remote mobile apps may further support the implementation of MBC for mental health care. OBJECTIVE: This study aims to evaluate veteran experiences with Mental Health Checkup (MHC), a VHA mobile app to support remote MBC for mental health. METHODS: Our mixed methods sequential explanatory evaluation encompassed mailed surveys with veterans who used MHC and follow-up semistructured interviews with a subset of survey respondents. We analyzed survey data using descriptive statistics. We then compared responses between veterans who indicated having used MHC for ≥3 versus <3 months using χ2 tests. We analyzed interview data using thematic analysis. RESULTS: We received 533 surveys (533/2631, for a 20% response rate) and completed 20 interviews. Findings from these data supported one another and highlighted 4 key themes. (1) The MHC app had positive impacts on care processes for veterans: a majority of MHC users overall, and a greater proportion who had used MHC for ≥3 months (versus <3 months), agreed or strongly agreed that using MHC helped them be more engaged in their health and health care (169/262, 65%), make decisions about their treatment (157/262, 60%), and set goals related to their health and health care (156/262, 60%). Similarly, interviewees described that visualizing progress through graphs of their assessment data over time motivated them to continue therapy and increased self-awareness. (2) A majority of respondents overall, and a greater proportion who had used MHC for ≥3 months (versus <3 months), agreed/strongly agreed that using MHC enhanced their communication (112/164, 68% versus 51/98, 52%; P=.009) and rapport (95/164, 58% versus 42/98, 43%; P=.02) with their VHA providers. Likewise, interviewees described how MHC helped focus therapy time and facilitated trust. (3) However, veterans also endorsed some challenges using MHC. Among respondents overall, these included difficulty understanding graphs of their assessment data (102/245, 42%), not receiving enough training on the app (73/259, 28%), and not being able to change responses to assessment questions (72/256, 28%). (4) Interviewees offered suggestions for improving the app (eg, facilitating ease of log-in, offering additional reminder features) and for increasing adoption (eg, marketing the app and its potential advantages for veterans receiving mental health care). CONCLUSIONS: Although experiences with the MHC app varied, veterans were positive overall about its use. Veterans described associations between the use of MHC and engagement in their own care, self-management, and interactions with their VHA mental health providers. Findings support the potential of MHC as a technology capable of supporting the VHA's Collect-Share-Act model of MBC.

"Hypertension is such a difficult disease to manage": federally qualified health center staff- and leadership-perceived readiness to implement a technology-facilitated team-based hypertension model.

BACKGROUND: Despite decades of evidence demonstrating the efficacy of hypertension care delivery in reducing morbidity and mortality, a majority of hypertension cases remain uncontrolled. There is an urgent need to elucidate and address multilevel facilitators and barriers clinical staff face in delivering evidence-based hypertension care, patients face in accessing it, and clinical systems face in sustaining it. Through a rigorous pre-implementation evaluation, we aimed to identify facilitators and barriers bearing the potential to affect the planned implementation of a multilevel technology-facilitated hypertension management trial across six primary care sites in a large federally qualified health center (FQHC) in New York City. METHODS: During a dedicated pre-implementation period (3-9 months/site, 2021-2022), a capacity assessment was conducted by trained practice facilitators, including (1) online anonymous surveys (n = 124; 70.5% of eligible), (2) hypertension training analytics (n = 69; 94.5% of assigned), and (3) audio-recorded semi-structured interviews (n = 67; 48.6% of eligible) with FQHC leadership and staff. Surveys measured staff sociodemographic characteristics, adaptive reserve, evidence-based practice attitudes, and implementation leadership scores via validated scales. Training analytics, derived from end-of-course quizzes, included mean score and number attempts needed to pass. Interviews assessed staff-reported facilitators and barriers to current hypertension care delivery and uptake; following audio transcription, trained qualitative researchers employed a deductive coding approach, informed by the Consolidated Framework for Implementation Research (CFIR). RESULTS: Most survey respondents reported moderate adaptive reserve (mean = 0.7, range = 0-1), evidence-based practice attitudes (mean = 2.7, range = 0-4), and implementation leadership (mean = 2.5, range = 0-4). Most staff passed training courses on first attempt and demonstrated high scores (means > 80%). Findings from interviews identified potential facilitators and barriers to implementation; specifically, staff reported that complex barriers to hypertension care, control, and clinical communication exist; there is a recognized need to improve hypertension care; in-clinic challenges with digital tool access imposes workflow delays; and despite high patient loads, staff are motivated to provide high-quality cares. CONCLUSIONS: This study serves as one of the first to apply the CFIR to a rigorous pre-implementation evaluation within the understudied context of a FQHC and can serve as a model for similar trials seeking to identify and address contextual factors known to impact implementation success. TRIAL REGISTRATION: ClinicalTrials.gov NCT03713515 , date of registration: October 19, 2018.

Family-based education and follow-up program for patients with burns: A mixed assessment study.

BACKGROUND: Burn injuries are a major cause of morbidity and mortality worldwide, affecting not only the patients but also their families. Family-based education and follow-up program are interventions that aim to improve the quality of life and psychosocial outcomes of patients with burns and their families. However, we find a lack of evidence on the effectiveness and feasibility of these programs in different settings and populations. This study aimed to evaluate the features of the family-based education and follow-up program (FBEFP), a pilot project that was developed and implemented at the Tabriz Sina Teaching Hospital in 2020 to improve its burn care system. DESIGN: A mixed-methods approach was used to collect and analyze both quantitative and qualitative data from various sources, such as, questionnaires, medical records, interviews and observation notes, to assess the content, process, and outcome of the program. The study followed the three steps of the CDC's framework for program evaluation: describing the program, measuring its effectiveness, and providing recommendations for improvement. RESULTS: The results of this study revealed the positive impacts of the FBEFP on the patients' physical, psychological, and social outcomes and quality of life. 4.8% of the people in the follow-up group were re-admitted, while this amount was 7.2% in the group without follow-up. Although the number of readmissions was less in the non-follow-up group, statistically no significant difference was observed between the two ratios before and after follow-up. In order to evaluate satisfaction rates, In the follow-up group, 72 patients and in the non-follow-up group, 38 patients were reached. After converting these data to normal distribution, using t-tests, it was determined that the difference between the two studied groups was highly significant. In other words, the follow-up process had favorable results on satisfaction of the studied people. However, the study also identified some challenges and barriers in implementing the program, such as lack of resources, staff training, and family involvement. CONCLUSION: FBEFP is a promising intervention that enhances the well-being of patients with burns and their families. However, more evidence is needed to support its effectiveness and feasibility in different contexts and populations. The study also provided valuable insights into the benefits and challenges of implementing a Family-Based Education and Follow-up Program for patients with burns in a low-resource setting. The study contributed to the development of guidelines and recommendations for future research and practice in this field.

The Implementation of a Virtual Emergency Department: Multimethods Study Guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) Framework.

BACKGROUND: While the COVID-19 pandemic dramatically increased virtual care uptake across many health settings, it remains significantly underused in urgent care. OBJECTIVE: This study evaluated the implementation of a pilot virtual emergency department (VED) at an Ontario hospital that connected patients to emergency physicians through a web-based portal. We sought to (1) assess the acceptability of the VED model, (2) evaluate whether the VED was implemented as intended, and (3) explore the impact on quality of care, access to care, and continuity of care. METHODS: This evaluation used a multimethods approach informed by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. Data included semistructured interviews with patients and physicians as well as postvisit surveys from patients. Interviews were transcribed and analyzed using thematic analysis. Data from the surveys were described using summary statistics. RESULTS: From December 2020 to December 2021, the VED had a mean of 153 (SD 25) visits per month. Among them, 67% (n=677) were female, and 75% (n=758) had a family physician. Patients reported that the VED provided high-quality, timely access to care and praised the convenience, shorter appointments, and benefit of the calm, safe space afforded through virtual appointments. In instances where patients were directed to come into the emergency department (ED), physicians were able to provide a "warm handoff" to improve efficiency. This helped manage patient expectations, and the direct advice of the ED physician reassured them that the visit was warranted. There was broad initial uptake of VED shifts among ED physicians with 60% (n=22) completing shifts in the first 2 months and 42% (n=15) completing 1 or more shifts per month over the course of the pilot. There were no difficulties finding sufficient ED physicians for shifts. Most physicians enjoyed working in the VED, saw value for patients, and were motivated by patient satisfaction. However, some physicians were hesitant as they felt their expertise and skills as ED physicians were underused. The VED was implemented using an iterative staged approach with increased service capabilities over time, including access to ultrasounds, virtual follow-ups after a recent ED visit, and access to blood work, urine tests, and x-rays (at the hospital or a local community laboratory). Physicians recognized the value in supporting patients by advising on the need for an in-person visit, booking a diagnostic test, or referring them to a specialist. CONCLUSIONS: The VED had the support of physicians and facilitated care for low-acuity presentations with immediate benefits for patients. It has the potential to benefit the health care system by seeing patients through the web and guiding patients to in-person care only when necessary. Long-term sustainability requires a focus on understanding digital equity and enhanced access to rapid testing or investigations.

Investigating health and social outcomes of the Big Local community empowerment initiative in England: a mixed method evaluation.

Background: Most research on community empowerment provides evidence on engaging communities for health promotion purposes rather than attempts to create empowering conditions. This study addresses this gap. Intervention: Big Local started in 2010 with £271M from the National Lottery. Ending in 2026, it gives 150 relatively disadvantaged communities in England control over £1M to improve their neighbourhoods. Objective: To investigate health and social outcomes, at the population level and among engaged residents, of the community engagement approach adopted in a place-based empowerment initiative. Study design, data sources and outcome variables: This study reports on the third wave of a longitudinal mixed-methods evaluation. Work package 1 used a difference-in-differences design to investigate the impact of Big Local on population outcomes in all 150 Big Local areas compared to matched comparator areas using secondary data. The primary outcome was anxiety; secondary outcomes included a population mental health measure and crime in the neighbourhood. Work package 2 assessed active engagement in Big Local using cross-sectional data and nested cohort data from a biannual survey of Big Local partnership members. The primary outcome was mental well-being and the secondary outcome was self-rated health. Work package 3 conducted qualitative research in 14 Big Local neighbourhoods and nationally to understand pathways to impact. Work package 4 undertook a cost-benefit analysis using the life satisfaction approach to value the benefits of Big Local, which used the work package 1 estimate of Big Local impact on life satisfaction. Results: At a population level, the impacts on 'reporting high anxiety' (-0.8 percentage points, 95% confidence interval -2.4 to 0.7) and secondary outcomes were not statistically significant, except burglary (-0.054 change in z-score, 95% confidence interval -0.100 to -0.009). There was some effect on reduced anxiety after 2017. Areas progressing fastest had a statistically significant reduction in population mental health measure (-0.053 change in z-score, 95% confidence interval -0.103 to -0.002). Mixed results were found among engaged residents, including a significant increase in mental well-being in Big Local residents in the nested cohort in 2018, but not by 2020; this is likely to be COVID-19. More highly educated residents, and males, were more likely to report a significant improvement in mental well-being. Qualitative accounts of positive impacts on mental well-being are often related to improved social connectivity and physical/material environments. Qualitative data revealed increasing capabilities for residents' collective control. Some negative impacts were reported, with local factors sometimes undermining residents' ability to exercise collective control. Finally, on the most conservative estimate, the cost-benefit calculations generate a net benefit estimate of £64M. Main limitations: COVID-19 impacted fieldwork and interpretation of survey data. There was a short 4-year follow-up (2016/20), no comparators in work package 2 and a lack of power to look at variations across areas. Conclusions: Our findings suggest the need for investment to support community organisations to emerge from and work with communities. Residents should lead the prioritisation of issues and design of solutions but not necessarily lead action; rather, agencies should work as equal partners with communities to deliver change. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research Programme (16/09/13) and will be published in full in Public Health Research; Vol. 11, No. 9. See the NIHR Journals Library website for further project information.

The Communities in Control study is looking at the health impacts of the Big Local community empowerment programme, funded by the National Lottery Community Fund and managed by Local Trust (a national charitable organisation). Residents of 150 English areas have at least £1M and other support to improve the neighbourhoods. There have been three phases of the research. This report shares findings from their third phase, which began in 2018. First, we used data from a national survey and data from national health and welfare services to compare changes in mental health between people living in Big Local areas and those in similar areas that did not have a Big Local partnership. Furthermore, we also used publicly available data on crime in the neighbourhoods. We found weak evidence that Big Local was linked with improved mental health and a reduction in burglaries. Second, we used data from a survey conducted by Local Trust to look at health and social impacts on the most active residents. We found an increase in mental well-being in 2018 but this was not maintained in 2020, probably due to the COVID-19 pandemic. Third, we did interviews and observations in 14 Big Local areas to understand what helps and what does not help residents to improve their neighbourhoods. We found that partnerships need to have legitimacy, the right balance of support, and learning opportunities. Residents suggested that creating social connections and welcoming social spaces, improving how people view the area and tackling poverty contributed to health improvements. Direct involvement in Big Local was both stressful and rewarding. Finally, we did a cost­benefit analysis by putting a monetary value on residents' increase in life satisfaction due to Big Local and comparing it with the costs of Big Local. We found that the benefits exceed the costs by at least £60M, suggesting that Big Local provides good value for money.

Parental Intervention Program for Preschool children with Rare Diseases - a mixed methods evaluation of parents' experiences and utility.

BACKGROUND: The purpose of this study was twofold: (i) To assess the parents' experiences and perception of participating in a "Parental Intervention Program for Preschool children with Rare Diseases" (PIPP-RDs). (ii) To evaluate which elements of the PIPP-RDs that the parents emphasized as important for improving their health literacy related to facilitating the transition of their children from kindergarten to school. METHOD: A mixed methods evaluation study was conducted ten and eleven months post-intervention, integrating an online quantitative survey combined with individual semi-structured interviews. Twenty-two parents participated in individual interviews, of these 18 also responded to the online questionnaire survey. RESULTS: All parents that participated in this study reported that the information conveyed at the program was of great value and utility, 88% reported significantly alleviated stress associated to their child`s school-start, 84% indicated had improved the school-home collaboration and 84% reported that it had encouraged them to establish contact with the school prior to school commencement. From the qualitative data five main themes emerged: (i) Competence and Knowledge Acquisition, (ii) Becoming more Prepared and Relaxed, (iii) Achieved Realistic Expectations, (iv) Enhanced Communication Skills, (v) Increased Health Literacy and Self-Efficacy. The evaluative findings suggest that this invention program has notably improved the parents' aptitude for school interaction, enhanced the adaptions according to children`s needs for accommodations, and has provided reassurance in the school-home collaboration. Parents also described increased self-confidence and self-efficacy in managing the school start for children with RDs. CONCLUSION: The highly positive response of participating in PIPP-RDs may not only reflect the merits of the program`s content, but also underscore the significant needs for such support during the transition to school for parents of children with RDs. Comparable initiatives, oriented towards enhancing the health literacy and empowering the parents, are anticipated to yield similarly favourable results. We argue that intervention program amalgamate pertinent information, group discourse, and workshops on school-related issues, alongside opportunities for parents to meet other parents in similar situations.

The Cystic Fibrosis Learning Network: A mixed methods evaluation of program goals, attributes, and impact.

Introduction: The Cystic Fibrosis (CF) Foundation sponsored the design, pilot testing, and implementation of the CF Learning Network (CFLN) to explore how the Foundation's Care Center Network (CCN) could become a learning health system. Six years after the design, the Foundation commissioned a formative mixed methods evaluation of the CFLN to assess: CFLN participants' understanding of program goals, attributes, and perceptions of current and future impact. Methods: We performed semi-structured interviews with CFLN participants to identify perceived goals, attributes, and impact of the network. Following thematic analyses, we developed and distributed a survey to CFLN members and a matched sample of CCN programs to understand whether the themes were unique to the CFLN. Results: Interviews with 24 CFLN participants were conducted. Interviewees identified the primary CFLN goal as improving outcomes for people living with CF, with secondary goals of providing training in quality improvement (QI), creating a learning community, engaging all stakeholders in improvement, and spreading best practices to the CCN. Project management, use of data, common QI methods, and the learning community were seen as critical to success. Survey responses were collected from 103 CFLN members and 25 CCN members. The data revealed that CFLN respondents were more likely than CCN respondents to connect with other CF programs, routinely use data for QI, and engage patient and family partners in QI. Conclusions: Our study suggests that the CFLN provides value beyond that achieved by the CCN. Key questions remain about whether spread of the CFLN could improve outcomes for more people living with CF.

Uptake and Use of Care Companion, a Web-Based Information Resource for Supporting Informal Carers of Older People: Mixed Methods Study.

BACKGROUND: Informal carers play a major role in supporting relatives and friends who are sick, disabled, or frail. Access to information, guidance, and support that are relevant to the lives and circumstances of carers is critical to carers feeling supported in their role. When unmet, this need is known to adversely affect carer resilience and well-being. To address this problem, Care Companion was co-designed with current and former carers and stakeholders as a free-to-use, web-based resource to provide access to a broad range of tailored information, including links to local and national resources. OBJECTIVE: This study aimed to investigate the real-world uptake and use of Care Companion in 1 region of England (with known carer population of approximately 100,000), with local health, community, and social care teams being asked to actively promote its use. METHODS: The study had a convergent parallel, mixed methods design and drew on the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. Data included metrics from carers' use of Care Companion, surveys completed by users recruited through general practice, and interviews with carers and health and social care providers regarding their views about Care Companion and their response to it. Quantitative data were analyzed using descriptive statistics. Interview data were analyzed thematically and synthesized to create overarching themes. The qualitative findings were used for in-depth exploration and interpretation of quantitative results. RESULTS: Despite awareness-raising activities by relevant health, social care, and community organizations, there was limited uptake with only 556 carers (0.87% of the known carer population of 100,000) registering to use Care Companion in total, with median of 2 (mean 7.2; mode 2) visits per registered user. Interviews with carers (n=29) and stakeholders (n=12) identified 7 key themes that influenced registration, use, and perceived value: stakeholders' signposting of carers to Care Companion, expectations about Care Companion, activity levels and conflicting priorities, experience of using Care Companion, relevance to personal circumstances, social isolation and networks, and experience with digital technology. Although many interviewed carers felt that it was potentially useful, few considered it as being of direct relevance to their own circumstances. For some, concerns about social isolation and lack of hands-on support were more pressing issues than the need for information. CONCLUSIONS: The gap between the enthusiastic views expressed by carers during Care Companion's co-design and the subsequent low level of uptake and user experience observed in this evaluation suggests that the co-design process may have lacked a sufficiently diverse set of viewpoints. Numerous factors were identified as contributing to Care Companion's level of use, some of which might have been anticipated during its co-design. More emphasis on the development and implementation, including continuing co-design support after deployment, may have supported increased use.

Reducing Premature Coronary Artery Disease in Malaysia by Early Identification of Familial Hypercholesterolemia Using the Familial Hypercholesterolemia Case Ascertainment Tool (FAMCAT): Protocol for a Mixed Methods Evaluation Study.

BACKGROUND: Familial hypercholesterolemia (FH) is predominantly caused by mutations in the 4 FH candidate genes (FHCGs), namely, low-density lipoprotein receptor (LDLR), apolipoprotein B-100 (APOB-100), proprotein convertase subtilisin/kexin type 9 (PCSK9), and the LDL receptor adaptor protein 1 (LDLRAP1). It is characterized by elevated low-density lipoprotein cholesterol (LDL-c) levels leading to premature coronary artery disease. FH can be clinically diagnosed using established clinical criteria, namely, Simon Broome (SB) and Dutch Lipid Clinic Criteria (DLCC), and can be identified using the Familial Hypercholesterolemia Case Ascertainment Tool (FAMCAT), a primary care screening tool. OBJECTIVE: This study aims to (1) compare the detection rate of genetically confirmed FH and diagnostic accuracy between the FAMCAT, SB, and DLCC in the Malaysian primary care setting; (2) identify the genetic mutation profiles, including novel variants, in individuals with suspected FH in primary care; (3) explore the experience, concern, and expectation of individuals with suspected FH who have undergone genetic testing in primary care; and (4) evaluate the clinical utility of a web-based FH Identification Tool that includes the FAMCAT, SB, and DLCC in the Malaysian primary care setting. METHODS: This is a mixed methods evaluation study conducted in 11 Ministry of Health primary care clinics located at the central administrative region of Malaysia. In Work stream 1, the diagnostic accuracy study design is used to compare the detection rate and diagnostic accuracy of the FAMCAT, SB, and DLCC against molecular diagnosis as the gold standard. In Work stream 2, the targeted next-generation sequencing of the 4 FHCGs is used to identify the genetic mutation profiles among individuals with suspected FH. In Work stream 3a, a qualitative semistructured interview methodology is used to explore the experience, concern, and expectation of individuals with suspected FH who have undergone genetic testing. Lastly, in Work stream 3b, a qualitative real-time observation of primary care physicians using the "think-aloud" methodology is applied to evaluate the clinical utility of a web-based FH Identification Tool. RESULTS: The recruitment for Work stream 1, and blood sampling and genetic analysis for Work stream 2 were completed in February 2023. Data collection for Work stream 3 was completed in March 2023. Data analysis for Work streams 1, 2, 3a, and 3b is projected to be completed by June 2023, with the results of this study anticipated to be published by December 2023. CONCLUSIONS: This study will provide evidence on which clinical diagnostic criterion is the best to detect FH in the Malaysian primary care setting. The full spectrum of genetic mutations in the FHCGs including novel pathogenic variants will be identified. Patients' perspectives while undergoing genetic testing and the primary care physicians experience in utilizing the web-based tool will be established. These findings will have tremendous impact on the management of patients with FH in primary care and subsequently reduce their risk of premature coronary artery disease. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/47911.

Time Utilization Among Immunization Clinics Using an Electronic Immunization Registry (Part 2): Time and Motion Study of Modified User Workflows.

BACKGROUND: Digital health interventions have the potential to improve the provision of health care services through digitized data collection and management. Low- and middle-income countries are beginning to introduce electronic immunization registries (EIRs) into their routine immunization services to better capture and store childhood vaccination information. Especially in Africa, where 25% of children remain unimmunized or underimmunized, technologies that can help identify children due for a vaccination are particularly important for improving vaccination coverage. However, an improved understanding of the effectiveness of these systems is needed to develop and deploy sustainable EIRs in low- and middle-income countries. OBJECTIVE: We conducted an interventional pretest-posttest design study that sought to improve time efficiency through workflow modifications in Kenyan immunization clinics. Our aim was to describe how activity times differed after introducing workflow modifications that could potentially reduce the time needed to perform routine data entry activities. Our intent was to demonstrate changes in efficiency when moving from the existing dual-data entry workflow to a future paperless workflow by health facility size and experience length of health care workers (HCWs). METHODS: We tested how 3 workflow modifications would affect time utilization among HCWs using the EIR at the point of care compared with baseline immunization clinic workflows. Our outcome of interest was the time taken to complete individual activities and a patient's total time in the clinic where we compared the time spent during the baseline workflow with that during the modified workflow. We used a standardized tool to observe and document the immunization clinic workflow. To estimate differences in time utilization, we used bivariate analyses and fit multivariate linear mixed-effects models. RESULTS: Our study found that for HCWs using an EIR, the introduction of modified workflows decreased the amount of time needed to provide services to children seen in the immunization clinic. With a baseline mean time of 10 minutes spent per child, this decreased by about 3 minutes when the preparation modification was introduced and almost 5 minutes for the paperless and combined modifications. Results pertaining to the EIR's performance and ability to connect to the internet were particularly insightful about potential causes of delays. CONCLUSIONS: We were able to conduct a concise clinical simulation exercise by introducing modified workflows and estimating their impact on time utilization in immunization clinics using an EIR. We found that the paperless workflow provided the largest time savings when delivering services, although this was threatened by poor EIR performance and internet connectivity. This study demonstrated that not only should digital health interventions be built and adapted for particular use cases but existing user workflows also need to adapt to new technology.

Intervention in Mothers and Newborns to Reduce Maternal and Perinatal Mortality in 3 Provinces in South Africa Using a Quality Improvement Approach: Protocol for a Mixed Method Type 2 Hybrid Evaluation.

BACKGROUND: The COVID-19 pandemic undermined gains in reducing maternal and perinatal mortality in South Africa. The Mphatlalatsane Initiative is a health system intervention to reduce mortality and morbidity in women and newborns to desired levels. OBJECTIVE: Our evaluation aims to determine the effect of various exposures, including the COVID-19 pandemic, and a system-level, complex, patient-centered quality improvement (QI) intervention (the Mphatlalatsane Initiative) on maternal and neonatal health services at 21 selected South African facilities. The objectives are to determine whether Mphatlalatsane reduces the institutional maternal mortality ratio, neonatal mortality rate, and stillbirth rate (objective 1) and improves patients' experiences (objective 2) and quality of care (objective 3). Objective 4 assesses the contextual and implementation process factors, including the COVID-19 pandemic, that shape Mphatlalatsane uptake and variation. METHODS: This study is an implementation science type 2 hybrid effectiveness, controlled before-and-after design with quantitative and qualitative components. The Mphatlalatsane intervention commenced at the end of 2019. For objective 1, intervention and control facility-level data from the District Health Information System are compared for changes in institutional maternal and neonatal mortality and stillbirth rates and associations with QI, the COVID-19 pandemic, and both. This first analysis includes data from 18 facilities, regardless of their allocation to intervention or comparison, to obtain a general idea of the effect of the COVID-19 pandemic. For objectives 2 to 3, data collectors abstract data from maternal and neonatal records, interview participants, and conduct neonatal facility assessments. For objective 4, interviews, program documentation, surveys, and observations are used to assess how contextual factors at the macro-, meso-, and microlevels explain variation in intervention uptake and outcome. The intervention dose is measured at the microlevel only in the intervention facilities. The study assesses the Mphatlalatsane Initiative from 2020 to 2022. RESULTS: From preliminary analysis, across the 3 provinces, maternal and neonatal deaths increased during the COVID-19 pandemic, whereas stillbirths remained unchanged. Maternal satisfaction with quality of care was >90%. The COVID-19 pandemic severely disrupted the QI teams functioning. However, the QI teams regained their pre-COVID-19 momentum by adapting the QI model, with advisers providing mentoring and support. Variation in adoption at the mesolevel was related to stable and motivated leadership (particularly at the facility level), poor integration into routine processes, and buy-in from senior district managers who were affected by competing priorities. Varying referral and specialist outreach systems, staff availability and development, and service delivery infrastructure are plausible factors in variable outcomes. CONCLUSIONS: Few evaluations rigorously evaluated the effect of health system interventions on improving health services and outcomes. Results will inform the scaling up of successful intervention components and strategies to mitigate the effects of the COVID-19 pandemic or similar emerging epidemics on maternal and neonatal mortality. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/42041.

A Web-Based Gaming Approach to Decrease HIV-Related Stigma: Game Development and Mixed Methods Evaluation.

BACKGROUND: The stigma faced by people living with HIV causes difficulties in the treatment of HIV/AIDS. Decreasing this stigma is thus no less urgent than implementing behavioral interventions. Serious games are being increasingly adopted as an intervention mechanism to control HIV/AIDS around the world. However, the development and evaluation of these games in China are far from adequate. OBJECTIVE: This research aimed to help decrease HIV-related stigma in China via the development and evaluation of a serious game, as well as promote a participatory gamification culture for health interventions. METHODS: Initially, a serious game was developed using free resources from a user-generated content website. Then, quantitative and qualitative methods were employed for game evaluation. A randomized controlled trial was conducted to explore the game's effect on HIV-related stigma. The trial included 167 university students, who were randomly allocated to game and control groups. After the experimental evaluation, focus group discussions were held with 64 participants, who were invited to form 16 groups. RESULTS: The game was called The Second Kind of Life with HIV (SKLWH), which is a free online game that can be played on computers and smartphones. This game hopes to publicize that people living with HIV can live a normal life, that is, a second life different from that imagined by the public. Based on the gamification practice of SKLWH, the participatory serious game development model (PSGDM) was proposed, which guided the development of 3 other HIV-themed games. The trial showed that intimacy stigma was much more severe than morality stigma and personal interaction stigma. Females were more tolerant of morality stigma than males (mean score: 1.29 vs 1.50; P=.01). The game intervention showed an advantage in decreasing intimacy stigma (mean score [game vs control]: 2.43 vs 2.73; P=.04). The group discussions validated the quantitative results and provided further in-depth information. The game intervention was largely preferred by participants, and the belief in intimacy impossibility was commonly expressed by participants when considering their relationship with people living with HIV. CONCLUSIONS: HIV/AIDS education should adopt appropriate media interventions to mitigate different dimensions of HIV-related stigma. Serious games should be used to decrease intimacy stigma, which is the hardest form to diminish. It is expected that the PSGDM can promote the development of more health games. Furthermore, HIV/AIDS intervention requires interdisciplinary efforts and cooperation that will allow more people to participate and share the responsibility of promoting health.

A training intervention to enhance self-management support competencies among nurses: A non-randomized trial with mixed-methods evaluation.

AIM: To evaluate the process and outcomes of INTENSS, a training intervention grounded in Self-Determination Theory to enhance nurses' competencies for self-management support. DESIGN: Non-randomized intervention study with mixed-methods evaluation approach (2019-2020). METHODS: The multifaceted training was implemented in six groups. Cluster-assignment to study arm 1 or arm 2. Arm 1 received a basic training module and arm 2 the basic module with additional video-interaction guidance. Focus groups were held to detect what was helpful in competency enhancement. Intervention effectiveness was determined on trainees' attitude, motivation, self-efficacy and skills for self-management support (multiple time-points by self-reports and observations). RESULTS: Trainees (N = 50) indicated the video-interaction guidance, the connectivity within the training group, the constructive feedback from trainers as well as from peers, as helpful for the acquisition of self-management support skills. At 2-month post-training, participants slightly improved in their competencies for the assess (p = .03), agree (p = .02), arrange (p < .01) phase and partnership skills (p < .01). Between the study arms, video-trained participants significantly reduced their use of controlling approaches (p = .03). Observations indicated that trainees mostly used an autonomy-supportive approach, seldom we observed the use of competence supportive, controlling or chaotic approaches. The interviews gave indications that obligatory training in this field needs to be questioned. CONCLUSION: The outcome evaluation of the INTENNS training indicated most improvement in nurses' skills for collaborative goal setting and partnership with patients. The mixed-methods evaluation emerges transferable principles to implement the training amongst nurses and, by extension, other healthcare professions. A training intervention involving patient experts can add value to further pave the way towards a true partnership between patients and healthcare professionals. IMPACT: A training intervention taking into account the complexity of supporting patients towards self-management is available. Important elements for growth are: connectivity within training group, a safe learning climate where 'failure' is allowed and video-interaction guidance. Obligatory training participation can be questioned.

An e-Mental Health Resource for COVID-19-Associated Stress Reduction: Mixed Methods Study of Reach, Usability, and User Perceptions.

BACKGROUND: COVID-19 and its public health response are having a profound effect on people's mental health. To provide support during these times, Canada's largest mental health and addiction teaching hospital (Centre for Addiction and Mental Health [CAMH]) launched the Mental Health and COVID-19 Pandemic website on March 18, 2020. This website was designed to be a nonstigmatizing psychoeducational resource for people experiencing mild to moderate distress due to COVID-19 and the public health response to the pandemic. OBJECTIVE: The aim of this study was to examine the reach, usability, and user perceptions of the CAMH Mental Health and COVID-19 Pandemic website. METHODS: This study used a mixed methods sequential explanatory design approach, which consisted of the following 2 distinct phases: (1) quantitative data collection and analysis and (2) qualitative semistructured interviews. In phase 1, we analyzed Google Analytics data to understand how many people visited the website and which were the most visited pages. We conducted a survey to identify users' sociodemographic backgrounds, and assess the usability of the website using the System Usability Scale and users' subjective stress levels using the Perceived Stress Scale (PSS-10). For phase 2, we conducted semistructured interviews to explore user experiences; user motivation, engagement, satisfaction, and perception of the stress reduction strategies; reflections of the website's functionality, ease of use, navigation, and design; and recommendations for improvement. RESULTS: Google Analytics results showed 146,978 unique users from June 2020 to March 2021. Most users were from Canada (130,066, 88.5%). Between February 20, 2021, and June 4, 2021, 152 users completed the survey. Most users identified as white, female, and having at least a college degree. Based on the PSS-10 scores, most participants were experiencing moderate to high stress when they visited the website. Users rated the usability of the website as acceptable. Ten users completed in-depth interviews between May 2021 and June 2021. Positive feedback related to the content was that the website was a trustworthy source of mental health information with helpful evidence-based stress reduction strategies. Areas for improvement included the text heavy design of the website, wider dissemination/marketing, and greater accessibility of the website to meet the needs of diverse populations. CONCLUSIONS: Adding stress reduction resources to a website from a well-respected institution may be a practical method to increase awareness and access to evidence-based stress reduction resources during times of crisis, where there is severe disruption to usual health care contacts. Efforts to ensure that these resources are more widely accessed, especially by diverse populations, are needed.

Transforming Latinx HIV Care: Mixed-Methods Evaluation of a Patient-Centered HIV Practice Transformation.

We conducted a mixed-method longitudinal evaluation of an HIV primary care practice transformation project in Washington, D.C. The project aimed to enhance organizational capacity to deliver culturally appropriate and patient-centered care for Latinxs living with HIV. Quantitative and qualitative data were simultaneously collected to capture the complex interactions among care providers, staff, and patients as well as to monitor practice changes that occurred as a result of the project implementation. The practice transformation intervention consisted of core competency workforce training, workflow redesign, and data-driven quality improvement strategies utilized to guide the intervention and to gather data from providers and patients. The mixed-methods approach facilitated meaningful change within the clinic that resulted in improved patient outcomes, patient experiences of care, and increases in staff's perceived level of knowledge of patient-centered care and improved efficiencies in HIV health care service delivery.

Still Lost in Transition? Perspectives of Ongoing Cancer Survivorship Care Needs from Comprehensive Cancer Control Programs, Survivors, and Health Care Providers.

Public health agencies have played a critical role in addressing the complex health and mental health needs of cancer survivors. We conducted a mixed-methods evaluation via a Web-based survey (n = 51) and focus groups (n = 11) with National Comprehensive Cancer Control Program (NCCCP) recipients and interviews (n = 9) with survivors, health care providers (HCPs), and patient navigators to explore these audiences' cancer survivorship information needs and strategies to improve resource dissemination. Participants revealed a need for tailored resources and support for survivors on healthy lifestyle, post-treatment survivorship concerns, psychosocial health, and navigating the health system. HCP needs included education on survivorship care plans and care coordination to facilitate the transition between oncology and primary care. HCPs were survivors' most trusted source for information; however, participants noted difficulties engaging HCPs in survivorship care. These findings can help public health practitioners focus their efforts to better meet the needs of cancer survivors and their HCPs.

Building connection and improving health for Indigenous elders: Findings from the Title VI evaluation.

BACKGROUND: As the older Indigenous population in the United States expands, there is a growing demand for programs to address age-related needs. Although Title VI of the OAA provides culturally responsive strategies to support elders through home- and community-based nutrition services, these programs have not been the subject of a national evaluation; our study is the first. METHODS: We conducted a mixed-methods study to assess the impact of the Title VI programs on elders. We used quantitative data from a national survey of Indigenous elders (n = 1175) and qualitative data collected through interviews (n = 36) and focus groups (18, n = 161) with a subgroup of elders receiving services. We compared outcomes for social and cultural connectedness and physical and mental well-being for different subgroups within our sample of elders based on elders' use of Title VI services and the level of services provided to these elders. Results were adjusted for community characteristics. RESULTS: Elders receiving Title VI services had significantly fewer hospitalizations and falls per year (hospitalizations: 0.9 vs. 1.2, p < 0.05; falls: 1.0 versus 1.1, p < 0.05) and significantly more social and cultural engagements per month (social engagements: 92.6% vs. 75.6%, p < 0.05; cultural practices: 78.8% vs. 64.8%, p < 0.05) compared with elders who did not participate in Title VI services. These findings were confirmed by our qualitative data. CONCLUSIONS: Our findings highlight the vital role that the Title VI program plays in promoting elders' overall health and well-being through decreased hospitalizations and falls and increased connectedness.

[Promoting physical activity in women during breast cancer therapy: A mixed methods evaluation of a nursing counselling intervention]. / Bewegungsförderung bei Frauen während der Brustkrebstherapie.

Promoting physical activity in women during breast cancer therapy: A mixed methods evaluation of a nursing counselling intervention Abstract. Background: Physical activity is associated with improved quality of life in women during breast cancer treatment. However, how physical activity behaviour of patients changes in the first months after the start of the treatment and what role nursing counselling can play has not yet been sufficiently investigated. Aim: To observe differences in physical activity behaviour in women with breast cancer at the time of the initiation of the therapy and six months later, and to explore patients' and health professionals' perspective on a nursing counselling intervention on physical activity. Methods: A mixed-methods evaluation was conducted. In the quantitative part, the physical activity behaviour was assessed at two time points (t0 and t1) with the SQUASH instrument (30-2Wendel-Vos, 2003). In the qualitative part, one focus group interview was conducted with patients and health professionals separately. The quantitative data were analyzed using descriptive and inductive statistics. The qualitative data were analyzed thematically. Results: The sample (N = 47) showed a slight, but not significant increase in the extent of physical activity comparing t1 with t0. A statistically significant increase in the amount of exercise between t0 and t1 was only found in the category "work" (p = 0,002). The central theme of the women was that they felt encouraged by the nursing counselling intervention to "do something for themselves". For the health professionals, in the context of counselling it was important that they themselves were convinced of the importance of physical activity. Conclusions: The integration of physical activity into everyday life is a challenge for women with breast cancer during therapy. A counselling intervention is perceived as supportive but could have a more lasting effect through a longer-term physical activity programme.