Purpose of Review: This review aims to (1) conceptualize the complexity of the opioid use disorder epidemic using a conceptual model grounded in the disease continuum and corresponding levels of prevention and (2) summarize a select set of interventions for the prevention and treatment of opioid use disorder. Recent Findings: Epidemiologic data indicate non-medical prescription and illicit opioid use have reached unprecedented levels, fueling an opioid use disorder epidemic in the USA. A problem of this magnitude is rooted in multiple supply- and demand-side drivers, the combined effect of which outweighs current prevention and treatment efforts. Multiple primary, secondary, and tertiary prevention interventions, both evidence-informed and evidence-based, are available to address each point along the disease continuum—non-use, initiation, dependence, addiction, and death. Summary: If interventions grounded in the best available evidence are disseminated and implemented across the disease continuum in a coordinated and collaborative manner, public health systems could be increasingly effective in responding to the epidemic./p>

The increased prevalence rate of childhood obesity in Saudi Arabia is a nationwide health issue. The doctoral project was instituted in the pediatric out-patient clinic (POPC) of a tertiary university hospital in Riyadh, Saudi Arabia. Child obesity clinic and clinical practice guideline (CPG) for primary prevention were not available in the pediatric outpatient clinic with a high incidence of newly diagnose obese children. The focus of this doctoral project was to improve the clinical nursing practice of POPC nurses through the adoption of CPG on primary prevention of childhood obesity. The knowledge translation into action framework provided a summary of descriptive series of ideal CPG implementation steps in POPC. The search for published CPGs was taken from DynaMed, National Guideline Clearinghouse, Guideline International Network, Pubmed, and Google Scholar. There were 2 tools applied for analysis and synthesis. First, the appraisal of guidelines for research and evaluation II instrument was used to assess the quality of the guidelines. Second, the BARRIERS' scale was used to assess the extent of nurses' perception of barriers in CPG utilization. The 1st findings from this study revealed that RNAO CPG was the best and high-quality CPG over the Endocrine Society and the Institute for Clinical Systems Improvement CPGs. The 2nd findings showed that most of the nurses perceived BARRIERS to utilization towards on the unclear implications of the CPG in their daily nursing practice. Hence, one of the vital recommendations was to have CPG awareness and education before the implementation. Overall, the doctoral project contributed to positive social change through guidelines, policies, and protocol provision for childhood obesity prevention in similar settings.

Healthcare decision-makers need high quality evidence to inform policy and practice decisions. Systematic reviews of randomized controlled trials (RCTs), including meta- analyses of study effects, are considered one of the highest forms of evidence to inform such decisions. Most applications of systematic reviews and meta-analyses are based on a standardized cannon of methods that seek to collect, abstract, assess, and synthesize evidence from primary studies to produce a comprehensive and unbiased summary of the evidence. While useful, standard synthesis methods tend to assume simple data structures (e.g., two-arm comparison of a single intervention vs. a similar control evaluated in a parallel individual randomized design) and some practices (e.g., author contact) may not always be supported by empirical evidence. Complex interventions are of increasing focus in healthcare and public health and pose challenges to the standard methods of systematic review and meta-analysis. While different definitions of complex interventions have been proposed, most definitions assume: i) multiple intervention ‘components’ that may or may not interact with each other to increase or decrease observed intervention effects and ii) effect modification by study-specific characteristics (e.g., healthcare setting, patient population). At least three challenges may result from this complexity. First, reviewers will likely have to contact authors for additional information about intervention components and contextual factors that may operate as effect modifiers. Unfortunately, evidence supporting optimal strategies for achieving response from author contact is lacking. Second, complex interventions are often evaluated using a cluster randomized trial (CRT) design that randomize units of patients to different healthcare/health policy interventions. Analyses from CRTs that are not adjusted for the clustering effect are said to have unit of analysis errors, which if incorporated in meta-analyses could lead to biased summary estimates and overly precise confidence intervals (CIs). Methods for reviewers to appropriately appraise abstract evidence from CRTs are limited. Thirdly, standard meta-analyses estimate an overall effect of a singular ‘complex intervention’. Such analyses answer the question “Do complex interventions as a whole lead to a difference in observed outcomes?” and tend to exhibit high statistical heterogeneity since variation in intervention components and effect modifiers are not accounted for. Hierarchical multivariate meta-regression models have been proposed as an alternative synthesis approach for complex interventions to better account for observed heterogeneity and answer the question decision-makers are really interested in; that is “What component(s) (or combination of components) work and under what conditions?”. Hierarchical multivariate meta-regression models however have yet to be applied in the review of complex healthcare interventions. The overall aim of my doctoral research was to explore the utility of three methodological approaches to address these challenges and optimize the synthesis of complex interventions using a large systematic review of diabetes quality improvement interventions as a case study. The first objective of this thesis was to do an RCT evaluation of the effect of telephone call versus repeated email contact of non-responding authors for additional study information on response rates and research costs. We found authors contacted by telephone call were more likely to complete requests for additional information (response rate 36.7% vs. 20.2%; adjusted odds ratio 2.26 [95% CI 1.10-4.76]) but the intervention took more time to deliver in total (20 vs. 10 hours over several months vs. one month) and was more expensive overall (approximately $505 vs. $253). The second objective of this thesis was to better account for evidence from CRTs and involved a descriptive study and a methodological study. The descriptive study described the proportion of studies with unit of analysis errors and the nature of the error (inappropriate analysis versus unclear or incomplete reporting). The methodological study investigated the utility of building a database of intracluster correlation coefficients (ICCs) and use of an ICC posterior predictive distribution model to correct unit of analysis errors identified in the descriptive study. We found that although trials often adjusted for the cluster effect (67% across outcomes; range 25%-81%), most did not report enough information to extract adjusted effect estimates required for meta-analysis (an average of 77% of studies with remaining unit of analysis errors across outcomes; range 42%-100%). We were able to construct a posterior predictive distribution of the ICC for most outcomes in our review using estimates of the ICC obtained from the descriptive study combined with external estimates and use these distributions to impute missing ICCs to correct unit of analysis errors. Finally, the third objective of this thesis was to illustrate the use of hierarchical multivariate meta-regression for quantitative synthesis when estimating the effects of complex interventions and exploring effect heterogeneity. Using an arm-based analysis of post-treatment means of one continuous outcome, we demonstrated that hierarchical multivariate meta-regression models can be used to estimate a ‘response surface’ that accounts for complex intervention multiple components and study characteristics, and these models can be used to infer estimates of component effects, interactions among components, and effect modification by study covariates. Collectively the results from this thesis suggest three methodological approaches (contacting authors by telephone, imputing missing ICCs using a predictive distribution, estimating complex intervention effects using a hierarchical multivariate meta-regression) can be used to optimize the processes of synthesizing complex interventions. Further work is needed to evaluate the impact of additional study-covariates on explaining residual heterogeneity and testing these methods in other reviews of complex interventions.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES / Introduction. Clinical Pharmacy Services (CPS) have been growing worldwide and have positively impacted health outcomes. However, studies that go deep into the steps of CPS implementation in the healthcare networks of the Brazilian healthcare system (SUS) are incipient. Objective. To analyze the implementation and propose strategies for integrating CPS into healthcare networks. Methods. A study was carried out in the Recife city, in three steps, from July 2015 to October 2017. The first step corresponded to a quasi-experimental study (before and after), carried out through the problematization with the Maguerez Arc in order to implement CPS. The second step gathered two qualitative studies, conducted through focus groups and semi-structured interviews, in order to identify barriers, facilitators and strategies that influenced the implementation. The third step included a methodological development study, conducted through semi-structured interviews and a nominal group, to propose and prioritize CPS integration strategies for SUS. Participants in the study were pharmacists, health managers and decision-makers involved in implementation, patients and panel experts. This study was approved by the Research Ethics Committee. Results. We carried out in the first step: i) initial evaluations (before): identified incipient CPS, deficiencies in the structure and work process of pharmacists; ii) planning: 16 brainstorming meetings and a strategic plan; iii) intervention: 22 political-administrative meetings were held with managers and health staff, 768 hours of theoretical-practical training with Mentoring for pharmacists; iv) preliminary evaluation (after): structure indicators presented a statistically significant difference, differently from the work process, and 1,465 pharmaceutical appointments were performed with 842 patients. It was possible to identify changes in the clinical status of the most prevalent diseases among the patients attended by three pharmaceutical appointments. In the second step, two focus groups were held with pharmacists and five interviews with health managers, which identified 43 barriers and 39 facilitators related to the healthcare networks, pharmacists, health team, implementation process and/or patients. In addition, 21 strategies related to pharmacists were identified as necessary for the implementation of CPS. In the third step, interviews were conducted with five managers and seven decision-makers who identified 21 barriers and 20 facilitators. From these results, specialists who composed the nominal group proposed 41 CPS integration strategies and prioritized the following: formalizing CPS; agreeing on care flows and referral protocols; evaluating and publicizing CPS results/benefits; planning and defining CPS; sensitizing the health managers. Conclusion. The analysis of the process identified factors that may have influenced the implementation of CPS, planning of the interventions and their application to reality, as well as in the prioritization of the strategies of integration of these services to SUS. Thus, the results obtained in this thesis can serve as a guide to help pharmacists, managers and decision-makers to plan, implement and integrate CPS in SUS. / Introdução. Serviços Clínicos Farmacêuticos (SCF) tem se expandido mundialmente e tem impactado positivamente nos resultados em saúde. Entretanto, estudos que se aprofundem nas etapas de implementação de SCF nas redes de atenção à saúde do sistema de saúde brasileiro (SUS) são incipientes. Objetivo. Analisar a implementação e propor estratégias para integração de SCF às redes de atenção à saúde. Métodos. Foi realizado estudo na cidade do Recife-PE, em três etapas, de julho/2015 a outubro/2017. A primeira etapa correspondeu a um estudo quasi-experimental (antes e depois), realizado por meio da metodologia da problematização com Arco de Maguerez, a fim de implementar SCF. A segunda etapa compreendeu dois estudos qualitativos, realizados por meio de grupos focais e entrevistas semiestruturadas, com a finalidade de identificar barreiras, facilitadores e estratégias que influenciaram na implementação dos SCF. A terceira etapa compreendeu estudo de desenvolvimento metodológico, realizado por meio de entrevistas semiestruturadas e grupo nominal, para propor e priorizar estratégias de integração de SCF ao SUS. Os participantes do estudo foram farmacêuticos, gestores e decision-makers envolvidos na implementação dos SCF, pacientes e painel de especialistas. Este estudo foi aprovado pelo Comitê de Ética em Pesquisa. Resultados. Na primeira etapa foram realizados: i) diagnóstico situacional (antes): identificou SCF incipientes, carências na estrutura e no processo de trabalho dos farmacêuticos; ii) planejamento: foram realizadas 16 reuniões de brainstorming com diferentes atores e um cronograma de atividades; iii) intervenção: foram realizadas 22 reuniões político-administrativas com gestores e equipe de saúde, 768 horas de treinamento teórico-prático com Mentoring para os farmacêuticos; iv) avaliação preliminar (depois): indicadores de estrutura apresentaram diferença estatística significativa, diferentemente dos indicadores de processo, e foram realizadas 1.465 consultas farmacêuticas com 842 pacientes, impactando em mudanças na situação clínica das doenças mais prevalentes entre pacientes atendidos por três consultas. Na segunda etapa foram realizados dois grupos focais com farmacêuticos e cinco entrevistas com gestores, o que identificou 43 barreiras e 39 facilitadores relacionados à rede de saúde, farmacêuticos, equipe de saúde, processo de implementação e/ou pacientes. Ademais, 21 estratégias relacionadas aos farmacêuticos foram identificadas como necessárias à implementação de SCF. Na terceira etapa foram realizadas entrevistas com cinco gestores e sete decision-makers que identificaram 21 barreiras e 20 facilitadores. A partir destes resultados, especialistas que compuseram o grupo nominal propuseram 41 estratégias para integração de SCF e priorizaram as seguintes: institucionalizar os SCF; pactuar fluxos assistenciais e protocolos de encaminhamentos; avaliar e divulgar os resultados/benefícios dos SCF; planejar e definir SCF; sensibilizar a gestão. Conclusão. A análise do processo identificou fatores que podem ter influenciado na implementação de SCF, planejamento das intervenções e sua aplicação à realidade, bem como na priorização das estratégias de integração desses serviços ao SUS. Assim, os resultados obtidos nesta tese poderão servir como eixos norteadores para que farmacêuticos, gestores e decision-makers planejem, implementem e integrem SCF no SUS. / Aracaju

There is a higher rate of recidivism for U.S. veterans compared to the general population of offenders. To address the unique needs of veterans, separate housing units for veterans (VSUs) are now operating within correctional facilities in 29 U.S. states. Despite reports that VSUs are having a positive impact on recidivism, little is known of the experiences of correctional administrators who have implemented a VSU. The purpose of this qualitative phenomenological study was to explore the lived experiences of several individuals who have implemented a VSU in their correctional facility. Guided by the quality implementation framework (QIF), data collected through semistructured interviews conducted with 7 U.S. correctional administrators were analyzed by reducing the information to significant statements, when combined into themes provided a descriptive analysis. Results from this study affirm that implementing a VSU is a feasible option for many correctional administrators with the desire to address the needs of veteran offenders. Key findings indicate most steps taken to implement a VSU align with quality implementation. Additional results indicate that presently there may be less consideration for VSU implementation processes associated with quality in the areas of ensuring staff training to work with the veterans, and in conducting process evaluations including outcomes tracking. VSUs have a profound and nearly immediate, effect on veteran inmate behaviors and reducing recidivism. This examination of the phenomenon of VSU implementation may offer implementers with evidenced-based practices to advance understanding of VSU implementation in the future, ultimately to benefit veteran offenders and the communities in which they reintegrate.

As a response to the need for efficiency and innovation that modern society hasplaced over healthcare organizations, they are constantly looking for more efficientand innovative tools that facilitate the daily practices for providers. In this context,the use of digital solutions or eHealth arises as an alternative for healthcare.Despite the potential benefits of eHealth solutions, healthcare leaders experiencedifficulties implementing them. For that reason, health services researchersacknowledge the critical role of implementation science in the sector. Seeking tomotivate organizations to embrace eHealth solutions and their benefits, thisresearch identifies the barriers and facilitators experienced by project managersduring the implementation projects of innovations in healthcare. Moreover, itproposes the clarification of concrete criteria to assess success derived from theoutcomes of an implementation project. Starting with a literature review, followedby qualitative research and a data collection through a total of ten semi-structuredinterviews with project managers. Moreover, the data analysis is made based onthematic analysis. The results identify three main facilitators for innovation: 1)maintaining a balanced level of understanding for all stakeholders, 2) to have opencommunication, and 3) to have a high involvement of the top management with theproject. Moreover, the most relevant barrier faced by managers is the lack of skilledand competent people within the organization. Regarding the success ofimplementation projects, the most relevant criteria are: 1) delivering in the righttime, budget, scope and quality (reach the project goals), 2) maintaining thecustomer and user satisfaction, and 3) increase in work efficiency in the healthcareorganizations. To some extent, the mentioned factors contribute to facilitating theimplementation of innovations in healthcare. The role of managers inimplementation is highly valuable since they represent the bridge between topmanagement and front-line employees. This research summarizes the experienceof the managers -from a consultancy company- while working in theimplementation of digital tools in healthcare. Therefore, the research provides abetter understanding regarding the barriers, facilitators and success criteria forimplementation.

Background: Shared decision-making (SDM) counseling for lung cancer screening is recommended by multiple professional societies and mandated by the Center for Medicare and Medicaid Services since lung cancer screening has both benefits and risks. However, uptake of SDM counseling as well as lung cancer screening itself remain low. We sought to develop educational text messages about lung cancer screening as an innovative implementation intervention tool to promote patient-provider discussion about lung cancer screening. Methods: After the study team drafted educational text messages about lung cancer screening, informed by existing decision aids, participants who had had lung cancer screening were recruited and asked to review and edit text messages. After that, participants eligible for lung cancer screening without the previous screening experience were recruited and were asked to select the messages to be included in this text message intervention. The final set of 14 text messages were delivered to the participants both with and without the previous lung cancer screening over a period of 14 days. Participants completed a telephone survey assessing their reactions to the messages after receiving the last message. Results: We successfully involved twelve participants with lung cancer screening experience and eleven lung cancer screening eligible participants without previous screening experience in the development of educational text messages about lung cancer screening. After one participant withdrew, 22 participants received text messages and completed the survey regarding the messages. Most participants (18 of 22) reported reading all 14 text messages, however most recommended sending fewer messages (median recommended number of messages = 10). Participants found the educational text messages informative. Only four participants reported the text messages triggered anxiety and two reported text messages disrupted their daily activities. Participants perceived the text messages would empower patients to discuss lung cancer screening with their providers. Conclusion: Participants generally supported the use of educational text messages about lung cancer screening to increase patients’ awareness and promote patient-provider discussion. Engaging patients in the development and evaluation of text messages elicited helpful feedback that will inform the content of the messages to be delivered via this lung cancer screening text messages intervention.

After cancer patients have completed active cancer treatment, they have specific follow-up care needs. These needs include ongoing surveillance for new and recurring cancers, managing the side effects of cancer treatment, and psychosocial concerns (Rushton et al., 2015). In the past, cancer centres and oncology specialists provided follow-up care; however, new models of care are needed because cancer centres can no longer provide treatment and follow-up care to all cancer survivors (Jefford et al., 2022). To allocate health care resources, low risk cancer survivors (i.e., breast and colorectal cancer survivors) are being discharged from cancer centres after primary treatment back to their primary care provider (PCP) for follow-up care. Survivorship care plans (SCPs) have been identified as a tool to help survivors and their PCPs with this transition (Rushton et al., 2015). SCPs generally consist of a treatment summary, a schedule for follow-up and surveillance tests, and general health recommendations (i.e., diet and exercise; Howell et al., 2011; Ruston et al., 2015). While SCPs are widely accepted, research on their effectiveness as transition tools has been inconclusive (Hill et al., 2019; Jacobsen et al., 2018). Some studies show positive, neutral, and negative impacts of SCP use, and there are three potential reasons for these mixed findings: 1) there is wide variety in the content, format, delivery, and timing of SCPs which adds considerable variance when studying the impact of SCPs; 2) the use of outcomes to measure the usefulness of SCPs as transition tools that are beyond the scope that information about treatment history and follow-up guidelines could impact and; 3) that SCPs are not effective as transition tools (Hill et al., 2019; Jacobsen et al., 2018). An important first step in clarifying whether SCPs are effective transition tools is to understand how SCPs are being used in real world practice (Hill et al., 2019; Jacobsen et al., 2018). The overall purpose of this study was to develop best practice recommendations for implementing SCPs. This was achieved through three study objectives: 1) to comprehensively identify barriers and facilitators perceived to influence SCP use among cancer survivors and primary care providers (PCPs); 2) to identify evidence-based approaches to address barriers and enhance facilitators of SCP use; and 3) to develop best practice recommendations that can be used by implementors of SCPs that are adaptable across different contexts. Article 1 presents the results of semi-structured interviews with breast and colorectal cancer survivors who had received a SCP at least 12 months prior to the interview. The interviews were based on the Theoretical Domains Framework, version two (TDF-2; Cane et al., 2012) and comprehensively identified barriers and facilitators of SCP use amongst breast and colorectal cancer survivors. Thirty cancer survivors (17 female, 13 male) participated in the 30–45-minute interviews, which were then analyzed using content and thematic analysis. Survivors who had received education about the purpose of SCPs and how to use them reported finding their SCP helpful and that they used it to schedule appointments and communicate with their healthcare providers. Barriers to SCP use that were reported by cancer survivors included having lost or not remembering receiving a SCP, not understanding the importance of their SCP, and wanting information about additional supports to be able to follow the SCP (e.g., regular contact from the cancer centre, avenues for peer support). Overall, study 1 found that in order to SCPs to be used as intended transition tools, survivors benefit from receiving education about how to use them and be informed of the expectation that they be actively involved in their follow-up care. Article 2 presents the TDF-based semi-structured interviews with primary care providers (PCPs). Thirteen PCPs completed 15-20 minute interviews, and content and thematic analysis was conducted. PCPs reported finding SCPs helpful and that they contained relevant information to provide follow-up care. A key facilitator of using the SCP was the table of follow-up tasks (e.g., mammography, colonoscopy) and their frequencies included in the SCP. Two significant barriers for PCPs using SCPs were: a) logistical issues with ordering follow-up tests and receiving results; and b) a lack of clear avenues to consult with oncology specialists (e.g., managing side effects of medications, actions that need to be taken when follow-up tests are abnormal). Overall, article 2 showed that PCPs appreciate and readily use SCPs, and contextual changes to facilitate clear avenues of communication between primary and tertiary care may be beneficial when implementing SCPs. Article 3 is a methodology article that presents a detailed explanation and rationale for the implementation science frameworks used and the data analysis chosen. The TDF-2 and Behaviour Change Techniques Taxonomy (BCTTv1; Michie, et al., 2008; Michie et al., 2013). The Human Behaviour Change Project researchers have empirically linked the 14 TDF domains to behaviour change techniques (BCTs), which allowed for multiple options to be developed to address barriers (and promote facilitators) of SCP use among breast and colorectal cancer survivors and PCPs (https://theoryandtechniquetool.humanbehaviourchange.org/tool; Michie et al., 2021). Using the TDF and BCTTv1 showed a dynamic between oncology specialists (e.g., oncologists, oncology nurses), cancer survivors, and PCPs that is involved in ensuring SCPs are implemented in an optimal way. A logic model was used to organize the barriers and enablers into different phases of SCP development, content, delivery, and use by PCPs and cancer survivors in their follow-up care (Mills et al., 2019). A flowchart organizing the recommendations of implementing SCPs was developed, and comprised 10 steps representing interrelationships between cancer centers, PCPs, and cancer survivors. The detailed methodology article also includes lessons learned and suggestions for implementation science researchers using the TDF and BCTTv1. Finally, article 4 is written for anyone looking for guidance implementing SCPs or improving upon how SCPs have been implemented already. It differs from article 3 in that it provides practical solutions for implementers. Because this work generated many recommendations, article 4 provides a worked example of how to use the results of this study. It is written in a way that outlines who would benefit from using the recommendations, and how to use the flow chart to narrow down the recommendation to those most relevant to implementors. The recommendations are organized into one of the 10 relationships in the flow chart, along with the purpose of the recommendations, how to implement it, to whom the recommendation targets, and those responsible for enacting the recommendations. The core factors associated with facilitating SCP use by PCPs and cancer survivors were: a) a treatment summary and follow-up guidelines included in the SCP; b) SCP provided to both cancer survivors and their PCP; and c) educating cancer survivors about their role as self-managers of their own care and the expectation that they participate in their follow-up cancer care. Future research on the usefulness of SCPs in follow-up care should include detailed information about the content, format, and receivers of SCPs and the outcomes most realistically influenced by the information included in SCPs. Before throwing the proverbial baby out with the bathwater, the implementation of SCPs requires additional standardization before meaningful investigation of their effectiveness as transition tools can be conducted.

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