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Background: Decentralization and task-shifting of hepatitis C virus (HCV) infection testing and management from specialty services to primary care is vital to achieve global and Canadian HCV elimination targets since direct-acting antiviral therapy revolutionized HCV management. Primary care providers are instrumental in enabling more accessible and sustainable community-based HCV management. Understanding primary care providers' experiences and beliefs on provision of HCV treatment in primary care is vital to optimize primary care-directed HCV treatment. Purpose: We aimed to use best practices from implementation science to determine the key factors influencing primary care physicians' provision of HCV treatment and to synthesize the published evidence on the barriers and enablers to optimizing primary care-directed HCV treatment to inform future implementation interventions. Method: In Study 1, we conducted theory-informed interviews with family physicians practicing in Ontario, Canada to identify perceived barriers of and enablers to their provision of HCV treatment. The interviews and data analysis were guided by the Theoretical Domains Framework (TDF), which incorporates 33 theories of behaviour change into 14 domains to systematically identify cognitive, affective, social, and environmental influences on health behaviours. In Study 2, we conducted a systematic review of the barriers and facilitators to optimizing primary care-directed HCV treatment using the TDF as the organising framework. We characterized key determinants of primary care-directed HCV treatment by using the theoretical constructs, generating themes, and mapping themes to relevant TDF domains to identify potential targets for future implementation interventions. Results: We conducted semi-structured TDF-based interviews with 20 family physicians and found 'knowledge gap of HCV treatment guidelines', 'time and resource constraint and competing priorities in primary care', and 'clarity of primary care physicians' professional role in HCV treatment cascade' were the key barriers and enablers to provision of HCV treatment in primary care. The systematic review included 20 studies which suggested 'enabling environment', 'primary care capacity', and 'knowledge deficit in HCV treatment guidelines' were the key factors coded to 'Environmental context and resources', 'Social influences', 'Identity and social professional role', and 'Knowledge' as the most relevant TDF domains to influencing the optimization of primary care-directed HCV treatment. Conclusion: Our results provided practical insights into the barriers and enablers to better primary care-based HCV management. Future research will focus on developing implementation strategies to tackle the barriers and fortify the enablers to optimal HCV treatment in primary care.

Background: Despite the increasing popularity of using social media to disseminate and translate knowledge, there remains a lack of theoretical understanding of how social media can work for healthcare providers’ knowledge use. The purpose of this thesis was to understand how and under what circumstances social media supports healthcare providers’ use of knowledge in clinical practice. Methods: Drawing on the tenets of scientific realism and the context (C) + mechanism (M) = outcome (O) (CMO) heuristic, a three-phase multi-method study was conducted to build a progressive theoretical understanding of how social media supports healthcare providers’ use of knowledge: 1) theory gleaning by a narrative review of five social media initiatives, five theories, and 58 empirical studies; 2) theory refining by a realist review of 32 articles; and 3) theory consolidation by a realist-informed qualitative study with 11 participants. Results: The Social Media for ImpLementing Evidence (SMILE) framework was developed in the theory gleaning phase. In the theory refining phase, two causal explanations were identified: 1) the rationality-driven approach that primarily uses open social media platforms (eight CMOs), and 2) the relationality-driven approach that primarily uses closed social media platforms (six CMOs). In the theory consolidation phase, the program theory developed for open social media platforms from the realist review was refined to ten CMOs, of which four confirmed the original CMOs, four refined the original CMOs, and two were new CMO propositions. The key mechanisms included content developers’ capabilities and capacities, along with healthcare providers’ increased attention; fulfillment of information needs; access to social influence and support; perception of message value and implementability; behaviour capabilities, self-efficacy, intention, and awareness; and ability to exercise professional autonomy. Conclusions: Through a three-phase realist theory development process, a theoretical understanding of how social media supports healthcare providers’ knowledge use in clinical practice was built. Future research is necessary to further develop this framework and investigate the synergistic effects of the rationality and relationality-driven approaches.

BACKGROUND: Chagas disease, a parasitic infection caused by Trypanosoma cruzi, is a neglected disease endemic to Latin America. Currently, approximately 6–7 million people worldwide are infected. Although Chagas disease is not considered endemic to the United States (US), official estimates put the number of cases at about 300,000 people. However, screening for Chagas disease is not common in the US. This project assessed the barriers, challenges, and opportunities to implementing screening for Chagas disease in primary care settings. METHODS: This project consisted of: 1) a literature review comparing and contrasting Chagas disease screening programs in endemic and non-endemic countries, and 2) semi-structured individual and group interviews with 43 healthcare providers (HCPs) who care for patients at-risk for Chagas disease. Interviews included questions around feasibility of implementing Chagas disease screening in their professional settings and probed on preferences for professional education such as format, length, and mode. Interviews were carried out between April 2021 and January 2022. RESULTS: According to the literature review, no single program for Chagas disease screening works perfectly. However, analyzing both endemic and non-endemic country programs revealed successful components that could be applied to the US context. From the interviews, the majority of participants reported knowing little about Chagas disease, matching the current literature. Most HCPs interviewed were interested in incorporating screening for Chagas disease into their practice but had some concerns. For example, HCPs are already required to screen for several diseases so Chagas disease screening would need to be incorporated into existing workflows. Finally, many HCPs reported that official guidelines from the Centers for Disease Control and Prevention or professional organizations would be enough for them to begin screening. The results informed the creation of a handbook for implementing Chagas disease screening. CONCLUSION: There are many barriers and challenges to implementing routine screening for Chagas disease in primary care settings in the US. However, there is also interest among HCPs in learning more and addressing the gap in screening. Advocacy is also needed to address the lack of national and professional guidelines around screening for Chagas disease.

The Land-Grant University Cooperative Extension (herein: Extension) system has been an underutilized resource for physical activity programming. With the recent addition of physical activity as a focus of Extension work, efforts are needed improve dissemination and implementation of evidence-based physical activity interventions. Improving implementation requires overcoming limitations including institutional support and perceptions of Extension health educators who could develop, deliver, and evaluate these programs. A participatory approach that includes input at all delivery levels (program participants, delivery agents, and administrators) can aid implementation through considering program acceptability, appropriateness, and feasibility from the beginning. This dissertation includes three manuscripts that explore the Extension's role in promoting physical activity in older adults, both in the United States and abroad. Manuscript 1 detailed a systematic review of community-based older adult physical activity programs that was conducted in order to determine the characteristics of effective older adult physical activity programs and the extent to which programs implemented in Extension systems nationwide employ these characteristics. The results indicated notable differences between peer-reviewed literature and Extension programs as well as presented an opportunity for Extension programs to more effectively use evidence-based program characteristics, including behavioral theories and group dynamics. The results also suggested that Extension programs could more effectively report their findings through peer-reviewed sources so that effective programs can be disseminated to reach a broader population. Manuscript 2 was an exploratory study conducted as a first step in bringing older adult physical activity programming to Ghana through Extension. Results of the mixed-methods study suggested that older adults in Ghana have mostly positive perceptions of physical activity and would be receptive to an in-person physical activity program. In particular, without specific prompting on principles of group dynamics, across all focus groups, participants mentioned aspects of groupness ranging from the need for accountability to the enjoyment of exercising with others. The results also indicated a need for education on Ministry of Health physical activity recommendations and how to meet them. These findings can be used as the first step to adapting and delivering an evidence-based intervention in Ghana through an integrated research-practice partnership. This approach includes community-level decision making to ensure the resultant program is a good fit in the intended delivery system. Manuscript 3 detailed the translation of an evidence-based older adult physical activity program to an Extension system in a rural state (population 585,501). Results suggested that Extension health educators have overall positive perceptions of physical activity programming, but they experience barriers in delivering these programs. While the program has the potential to reach a representative sample of the population, the adoption rate among Extension health educators was low, and system-wide changes may be needed to improve physical activity program adoption rates among educators. Overall, results of the three manuscripts provided evidence and recommendations for Extension professionals to improve physical activity program implementation through using evidence-based interventions and characteristics, considering perceptions of end users prior to program implementation, and considering system-level changes that promote physical activity program adoption. / Ph. D. / The United States Department of Agriculture funds a national Cooperative Extension system. This system brings Land-Grand University evidence to the people. Physical activity was recently added as a focus of Extension programming, but work is needed improve the dissemination and implementation of evidence-based physical activity interventions. To improve implementation, barriers such as institutional support and perceptions of Extension professionals need to be addressed. A shared decision-making approach that includes input from multiple groups (those who participate in programs, teach or organize programs, and make decisions about programs) can help with implementation. This approach considers program acceptability, appropriateness, and feasibility from the beginning. This dissertation includes three manuscripts about promoting physical activity in older adults through Extension. This work takes place both in the United States and abroad. Manuscript 1 was a review of older adult physical activity programs that are based in communities. It identifies traits of programs that are shown to be effective. This is compared to similar programs done through Extension throughout the U.S. Results demonstrated differences between effective programs with published results and programs done through Extension. Extension could be more effective by using program characteristics that are backed up by evidence. This included using theories that explain how people change their behavior and using group strategies. Results also suggested that Extension programs could do better publishing their results so others can learn about them. Manuscript 2 was a study about perceptions of physical activity among older adults in Ghana. Results of the surveys and group interviews suggested that older adults in Ghana have mostly positive perceptions of physical activity and that they would like an in-person physical activity program. Participants were especially interested in a group-based program. In each focus group, participants shared the need for accountability and that they enjoyed being active with friends and family. The results also showed a need for education on government physical activity guidelines and how to meet them. These findings can be used as the first step to adapting and delivering a physical activity program in Ghana through a partnership between researchers and those who will teach or organize the program. This approach includes community-level decision making to make sure the program is a good fit in the intended delivery system. Manuscript 3 was a study about bringing an effective older adult physical activity program to Extension in a rural state (population 585,501). Results suggested that Extension health educators have positive views of physical activity programs, but they perceive barriers in delivering these programs. The program that was studied reached older adults who needed it, but most Extension health educators did not want to deliver the program. Changes to the Extension system may be needed to help more educators deliver physical activity programs. Overall, results of the three manuscripts provided evidence and suggestions for Extension staff to improve physical activity program implementation through using evidence-based programs and characteristics, thinking about the perceptions of end users prior to starting a program, and making system-level changes that promote physical activity program adoption.

Many health systems are in the midst of transformation. They are slowly moving from the delivery of reactive care focused on individuals to considering proactive ways of supporting the health and well-being of populations. However, the road to what is often called ‘population-health management’ is rife with implementation challenges. One type of implementation support that has been used to navigate these challenges is technical assistance. Though the use of technical assistance is well documented, there is no consensus on a clear definition or understanding of how it can be used to support system transformation. This thesis contributes to the field of technical assistance through three qualitative studies. First, a critical interpretive synthesis develops a definition and logic model for technical assistance. This logic model integrates diverse academic and grey literature. It aims to draw clearer boundaries around technical assistance as a concept and provide a common language for researchers, technical assistance providers, and decision-makers to use. Second, a qualitative descriptive study explores the use of technical assistance in population-health management transformations in England and the U.S., examining what technical assistance has been provided, by whom, and in what areas of application. Finally, a case study unpacks the use of technical assistance for a recent health-system transformation in Ontario. It examines the influence that political factors related to institutions, ideas, interests and external events have on shaping its evolution. Together, these three studies provide greater clarity on the use of technical assistance in health-system transformations and the range of factors that may affect how it is conceptualized and operationalized. / Thesis / Candidate in Philosophy

<p>  </p> <p>Although community pharmacists have further reduced medication errors and improved care with access to patient data through unidirectional health information exchange (HIE), access to routine patient data has not been sustained. Several barriers to sustaining use and access of HIE in community pharmacies have been noted, such as lack of implementation supports and technological restrictions. Further, pharmacists and pharmacy technicians have not been involved in the development of HIE systems for their use previously. My research aims to optimize HIE access for community pharmacists through our co-developed HIE interface prototype specifically for use by community pharmacy teams in collaboration with PioneerRx, a pharmacy dispensing software system and our state HIE, the Indiana Health Information Exchange (IHIE), and provide supports for the sustainability of community pharmacist access to HIE.</p> <p>Therefore, the objectives of my research are to 1) conduct a formative usability evaluation of the HIE interface prototype with community pharmacists and pharmacy technicians to inform strategies to improve the HIE interface design for future implementation in community pharmacies (“<em>Study One”</em>) and 2) identify the potential barriers, facilitators, and recommendations for HIE implementation in community pharmacies through semi-structured interviews to create a curated list of resources to address identified implementation needs to assist with the future implementation of HIE (“<em>Study Two”</em>).</p> <p>The findings from Study One demonstrate the HIE interface prototype was viewed favorably by pharmacists and pharmacy technicians, with the average System Usability Scale (SUS) score 69 (scale 0 – 100, where 100 is the best). Pharmacists reported higher satisfaction than technicians on average (74 vs. 65, respectively). Key problems identified included accessibility of HIE links and placement in the existing workflow and application label name clarifications. The same eight pharmacists and eight pharmacy technicians, with the addition of seven patients, completed interviews in Study Two. Five barriers, four facilitators, and two recommendations were identified. These were further characterized into four key implementation needs: instruction on how to use HIE, guidance on workflow and team roles, and provider and patient facing resources for discussing HIE. Curated draft implementation resource items that are responsive to all four key implementation needs are in development. The combination of findings from Study One and Study Two create the blueprint for pharmacy-team informed implementation of HIE in community pharmacies.</p>

Low-income groups have greater potential to gain from incorporating health promotion into daily living using bike-share to increase physical activity and expand transport options. The potential is unmet because of socioeconomics and access. Disproportionate uptake of bike-share by higher income individuals widens the gaps in health equity and transportation equity as bike-share use over-represents males with more resources, less need, and lower health risk. The Prescribe a Bike (RxBike) program, a key focus of this study, is a partnership between primary care providers (PCPs) at an urban safety net hospital and the city’s existing income-based, subsidized bike-share membership. Three studies using quantitative and qualitative methods were performed to: examine utilization of bike-share by Boston residents among subsidized and non-subsidized members; examine perceived attributes of the RxBike program by Boston Medical Center (BMC) PCPs; and evaluate BMC patient referrals. The overarching conceptual model uses elements of theories from health services and organizational behavior, in a public health framework. Analysis of Boston resident utilization at the trip-level (2012-2015) demonstrated overall ridership was increasingly by males and residents of more advantaged neighborhoods. Subsidized members had significantly higher likelihood of living in neighborhoods with socioeconomic and health disadvantage, and less gender disparity when compared to non-subsidized members. The impact was minimal because subsidized members made only 7.17% of trips. The survey of PCPs revealed mismatch between highly favorable opinion of RxBike appropriateness and lower intent to refer. Female gender and not being an urban biker predicted lower likelihood of intent to refer. Examination of open-ended survey comments mirrored quantitative data and expanded on the range of provider biking safety concerns in Boston. From 2013-2015, 27 BMC providers made only 72 referrals to RxBike. Patients referred had high cardiovascular health risk, resided in neighborhoods with extremely high levels of disadvantage, and in neighborhoods without meaningful access to bike-share kiosks. Overall, the subsidized membership extends reach of bike-share to residents of neighborhoods with more health and socioeconomic risk than the rest of the city; RxBike has strong potential to impact this vulnerable population. The most critical matters for program success are safety and neighborhood access.