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Background: Chronic disease (CD) accounts for more than half of the overall global disease burden and physical activity (PA) is an established evidence-based strategy for the prevention and management of CD. Global policy emphasises the value of embedding PA into primary healthcare, highlighting the positive effects on PA behaviour. However, there is limited implementation of PA protocols in primary care, and research is needed to guide its integration into routine practice. The voice of the patient is underrepresented in the literature, resulting in the absence of critical insights into determinants of PA promotion in primary care. The purpose of the research was to identify the perspectives of people at risk of or living with CD on the determinants of PA promotion in primary care and to map these determinants across the six COM-B constructs. Methods: Semi-structured interviews (n = 22), guided by the COM-B model were conducted with people aged 35–60 years, at risk of or living with CD and not meeting the PA guidelines. A hybrid analytic approach of thematic inductive and deductive analysis was applied to the participant transcripts guided by a COM-B informed coding framework. Results: In total, 37 determinants across constructs related to capability, opportunity and motivation were prominent, examples include; physical capability constraints, the conflation of exercise with weight management, credibility of the health services in PA advice, communication styles in PA promotion, expectations of tailored support for PA, social support, accessibility, and integration of PA into routine habits. Conclusion: Exploring the determinants of PA promotion through the lens of the COM-B model facilitated a systematic approach to understanding the primary care user perspective of the healthcare professional (HCP) broaching the topic of PA. Findings emphasise the value of HCPs being supported to broach the issue of PA in a therapeutic and patient-centred manner using diverse and flexible approaches, while highlighting the importance of tailored, accessible PA opportunities that build self-efficacy and foster social support. The research provides valuable learnings to support PA promotion and the development of strategies in primary care through encompassing the perspective of those living with or at risk of CD. [ABSTRACT FROM AUTHOR]

Although there is a growing literature on the use of telepresence robots in institutional dementia care settings, limited research focused on the perspectives of frontline staff members who deliver dementia care. Our objective was to understand staff perspectives on using telepresence robots to support residents with dementia and their families. Guided by the Consolidated Framework for Implementation Research, we conducted four focus groups and 11 semi-structured interviews across four long-term care (LTC) homes and one hospital in Canada. We included 22 interdisciplinary staff members (e.g., registered nurses, social workers, occupational therapists, recreational therapists) to understand their experiences with telepresence robots. Thematic analysis identified three key themes: 1) Staff Training and Support; 2) Robot Features; 3) Environmental dynamics for Implementation. Our results underscore the imperative of structural support at micro-, meso- and macro-levels for staff in dementia care settings to effectively implement technology. This study contributes to future research and practice by elucidating factors facilitating staff involvement in technology research, integrating staff voices into technology implementation planning, and devising strategies to provide structural support to staff, care teams, and care homes. [ABSTRACT FROM AUTHOR]

Background: Despite well-established guidelines to treat diabetes, many people with diabetes struggle to manage their disease. For many, this struggle is related to challenges achieving nutrition-related lifestyle changes. We examined how people with diabetes describe barriers to maintaining a healthy diet and considered the benefits of using a harm reduction approach to assist patients to achieve nutrition-related goals. Methods: This is a secondary analysis of 89 interviews conducted with adults who had type 1 or type 2 diabetes. Interviews were analyzed using a content analysis approach. Themes regarding food or diet were initially captured in a "food" node. Data in the food node were then sub-coded for this analysis, again using a content analysis approach. Results: Participants frequently used addiction language to talk about their relationship with food, at times referring to themselves as "an addict" and describing food as "their drug." Participants perceived their unhealthy food choices either as a sign of weakness or as "cheating." They also identified food's ability to comfort them and an unwillingness to change as particular challenges to sustaining a healthier diet. Conclusion: Participants often described their relationship with food through an addiction lens. A harm reduction approach has been associated with positive outcomes among those with substance abuse disorder. Patient-centered communication incorporating the harm reduction model may improve the patient-clinician relationship and thus improve patient outcomes and quality-of-life while reducing health-related stigma in diabetes care. Future work should explore the effectiveness of this approach in patients with diabetes. Trial registration: Registered on ClinicalTrials.gov, NCT02792777. Registration information submitted 02/06/2016, with the registration first posted on the ClinicalTrials.gov website 08/06/2016. Data collection began on 29/04/2016. [ABSTRACT FROM AUTHOR]

Background: Relationships established between nurses and midwives, and their patients have far-reaching implications; the most significant being their impact on the health-related outcomes of patients. These relationships are especially relevant in the Prevention of Mother-to-Child Transmission (PMTCT) of Human Immunodeficiency Virus (HIV) programme as women, diagnosed with HIV navigate the emotional and psychological effects of their diagnosis while carrying pregnancies. This study aimed to explore the relationships between nurses, midwives and mothers diagnosed with HIV and its impact on retention in the PMTCT Programme. Methods: An Appreciative Inquiry approach that employed qualitative research methods was conducted among twenty-four participants made up of 12 HIV positive mothers, and eight midwives and four community health nurses engaged in the PMTCT programme. Individual generative interviews were conducted among the mothers while paired interviews were conducted among the health professionals. Thematic analysis guided by Colaizzi's approach was conducted. Results: Three main themes emerged each with its subthemes. Under Establishing Rapport, two sub-themes emerged; making the connection and building trusting relationships. The second theme, Journeying Together, describes how the nurse-patient relationship evolved as the participant engaged in the programme; sub-themes include developing mutual goals, impactful communication, and showing commitment and building self-worth. The third theme; Ending the professional relationship details two sub-themes; continuity of care across the cascade, and termination of care which proved unsuccessful in some relationships due to blurring professional boundaries. Conclusions: The nurse-patient relationship in the PMTCT programme evolved as the relationship progressed along the PMTCT cascade. Strengthening of the nurse-patient relationships was underscored by building trust through the maintenance of confidentiality, setting mutual goals, shared emotional experiences and personal stories, and building clients' self-worth. Therefore, there is a need to ensure that professional boundaries are set and maintained to reduce the occurrence of over-dependence of the clients and burnout of the nurses. [ABSTRACT FROM AUTHOR]

Background: Given its apparent benefits, early mobilization is becoming increasingly important in spinal surgery. However, the time point at which patients first get out of bed for mobilization after spinal surgery varies widely. Beginning in January 2022, we conducted a study of early mobilization (mobilization within 4 h postoperatively) following multi-segment lumbar decompression and fusion surgery in elderly patients. The study goal was to better understand elderly patients' perceptions of early mobilization and ultimately contribute to the improvement of elderly patients' perioperative experiences and quality of life. Methods: We employed a qualitative descriptive study design involving face-to-face semi-structured interviews. Forty-five consecutive patients were invited, among whom 24 were enrolled and completed the qualitative investigation from February to June 2022. Of these 24 patients, 10 underwent early mobilization (mobilization within 4 h postoperatively) and 14 underwent mobilization at ≥ 24 h postoperatively. Three researchers conducted a 15-question interview the day before each patient's discharge. The interviews were audio-recorded, and content analysis was used to assess the data. Results: Six themes regarding the patients' experiences and concerns about early mobilization were identified: worries, benefits, daily routines, pain, education, and support. The study results revealed the obstacles in early mobilization practice and highlighted the importance of perioperative education on early mobilization. Conclusions: Clear and explicit guidance on early mobilization and a multidisciplinary mobilization protocol that incorporates a comprehensive pain management plan are essential for effective patient education. These measures may have positive effects on reducing patients' stress and anxiety regarding postoperative early mobilization. [ABSTRACT FROM AUTHOR]

Objective: Communication about patients' values, goals, and prognosis in serious illness (serious illness communication) is a cornerstone of person-centered care yet difficult to implement in practice. As part of Serious Illness Care Program implementation in five health systems, we studied the clinical culture-related factors that supported or impeded improvement in serious illness conversations. Methods: Qualitative analysis of semi-structured interviews of clinical leaders, implementation teams, and frontline champions. Results: We completed 30 interviews across palliative care, oncology, primary care, and hospital medicine. Participants identified four culture-related domains that influenced serious illness communication improvement: (1) clinical paradigms; (2) interprofessional empowerment; (3) perceived conversation impact; (4) practice norms. Changes in clinicians' beliefs, attitudes, and behaviors in these domains supported values and goals conversations, including: shifting paradigms about serious illness communication from 'end-of-life planning' to 'knowing and honoring what matters most to patients;' improvements in psychological safety that empowered advanced practice clinicians, nurses and social workers to take expanded roles; experiencing benefits of earlier values and goals conversations; shifting from avoidant norms to integration norms in which earlier serious illness discussions became part of routine processes. Culture-related inhibitors included: beliefs that conversations are about dying or withdrawing care; attitudes that serious illness communication is the physician's job; discomfort managing emotions; lack of reliable processes. Conclusions: Aspects of clinical culture, such as paradigms about serious illness communication and inter-professional empowerment, are linked to successful adoption of serious illness communication. Further research is warranted to identify effective strategies to enhance clinical culture and drive clinician practice change. [ABSTRACT FROM AUTHOR]

Background: There is growing evidence that conversations between healthcare professionals and patients with serious illness can improve the quality of end-of-life cancer care. Yet, there is lack of insight into how different healthcare professions collaborate to deliver serious illness communication, as well as patients' and caregivers' perceptions of this collaboration between the nurse and physician. This study explores the interdisciplinary collaboration between nurses and physicians in serious illness conversations with patients diagnosed with multiple myeloma and their caregivers. Methods: Eleven dyadic interviews were conducted with 22 patients and caregivers, and two focus group interviews involving four nurses and the other with four physicians. Data analysis and reporting were conducted using reflexive thematic analysis within phenomenological epistemology. Results: The interdisciplinary collaboration was characterized by three main themes: (1) Importance of relationships, (2) Complementary perspectives, and (3) The common goal. Conclusion: This study highlights the importance of interdisciplinarity in serious illness conversations as it enhances the use of existential and descriptive language when addressing medical, holistic, and existential issues. The use of broader language also reflects that interdisciplinary interaction strengthens the expertise of each professional involved in patient care. Through interdisciplinary collaboration, the preferences, hopes, and values of the patient and caregiver can be integrated into the treatment plan, which is key in providing the delivery of optimal care. To promote cohesive and coordinated collaboration, organizational changes are recommended such as supporting continuity in patient–healthcare professional relationships, providing interdisciplinary training, and allocating time for pre-conversation preparation and post-conversation debriefing. [ABSTRACT FROM AUTHOR]

Background: Surgical Nursing is a core subject for nursing undergraduates that requires active and effective learning strategies to cultivate students' autonomous learning competencies and critical thinking. The effects of BOPPPS (Bridge-in, Objectives, Pretest, Participatory Learning, Post-test and Summary) model combined with team-based learning (TBL) have rarely been explored in Surgical Nursing courses. Objective: To explore the effects of BOPPPS combined with TBL in Surgical Nursing for nursing undergraduates. Methods: A mixed research method of quasi-experimental study design and descriptive qualitative research was used. The control group included 27 nursing undergraduates who had finished the Surgical Nursing course using traditional learning. The experimental group included 36 nursing undergraduates were enrolled in to receive the Surgical Nursing course in the teaching mode of BOPPPS combined with TBL. The quantitative data of students' Surgical Nursing final scores, autonomous learning competencies and critical thinking ability of the two groups were collected and compared by t-test. Qualitative results were obtained through semi-structured interviews and data were analyzed by thematic analysis method. Results: Compared with the traditional learning mode, BOPPPS combined with TBL significantly improved nursing students' final examination scores, autonomous learning competencies and critical thinking ability (p < 0.05). Qualitative results from 14 undergraduate nursing students' interviews were summarized into five themes: (1) stimulating learning interest; (2) improving autonomous learning ability; (3) improving the sense of teamwork; (4) exercising critical thinking; and (5) suggestions for improvement. Conclusions: The combination of BOPPPS and TBL positively impacted nursing students by improving their autonomous learning competencies and critical thinking ability. The study suggests BOPPPS combined with TBL learning as an effective, alternative learning mode. [ABSTRACT FROM AUTHOR]

Background: The persistence of racial/ethnic inequities in rates of engagement along the HIV care continuum signals the need for novel approaches. We developed six behavioral intervention components for use in an optimization trial, grounded in a model that integrates critical race theory, harm reduction, and self-determination theory, designed to address various barriers that African American/Black and Latino persons living with HIV (PLWH) experience to the HIV care continuum. The components were: health education, motivational interviewing sessions, pre-adherence skill building, peer mentorship, focused support groups, and navigation. The present qualitative exploratory study describes participants' perspectives on the components' acceptability, feasibility, and impact. Methods: Participants were African American/Black and Latino PLWH poorly engaged in HIV care and with non-suppressed HIV viral load in New York City. From a larger trial, we randomly selected 46 participants for in-depth semi-structured interviews. Interviews were audio-recorded and transcribed verbatim, and data were analyzed using directed content analysis. Quantitative data on sociodemographic and background characteristics and components' acceptability and feasibility were also collected. Results: On average, participants were 49 years old and had lived with HIV for 19 years. Most were cisgender-male and African American/Black. Participants reported a constellation of serious social and structural challenges to HIV management including chronic poverty, unstable housing, and stigma. Across components, a non-judgmental and pressure-free approach and attention to structural and cultural factors were seen as vital to high levels of engagement, but lacking in most medical/social service settings. Prominent aspects of individual components included establishing trust (health education); developing intrinsic motivation, goals, and self-reflection (motivational interviewing sessions); learning/practicing adherence strategies and habits (pre-adherence skill building); reducing social isolation via peer role models (peer mentorship); reflecting on salient goals and common challenges with peers without stigma (focused support groups); and circumventing structural barriers to HIV management with support (navigation). Components were found acceptable and feasible. Findings suggested ways components could be improved. Conclusions: The present study advances research on interventions for African American/Black and Latino PLWH, who experience complex barriers to engagement along the HIV care continuum. Future study of the components is warranted to address racial/ethnic health inequities in HIV. [ABSTRACT FROM AUTHOR]

Background: To address the many challenges health systems and communities face, primary care is constantly searching for new strategies to improve quality of care. One of the strategies is to focus on patients' personal goals to direct the care process. To adopt an explicit focus on patients' personal goals, actions at different levels are required. As a first step in this process, this study aims to explore the experiences of primary care stakeholders (i.e., scholars, primary care providers, and policy makers) and develop a comprehensive understanding on the idea 'putting patients' goals first'. This will help to formulate suggestions about what these actions should include. Method: In this study, 41 primary care stakeholders participating in six focus groups between January 2020 and September 2020, were recruited via maximal variation purposive sampling. Data collection was done through an open-ended semi-structured interview guide. Focus groups were audio-recorded, transcribed verbatim, and analyzed following a phenomenological-hermeneutical philosophy of Lindseth and Norberg. Results: All participants expressed a strong fundamental belief for putting patients' personal goals first. The primary care providers shared that they created space for patients' personal goals by letting them talk about their values and stories. They reported to integrate their medical expertise with patients' personal goals in order to develop a balanced relationship. In this context, they also talked about the importance of taking into account the perspectives of patients' significant others. Primary care providers also talked about how they used patients' personal goals as a guide in interprofessional collaboration. Scholars denoted that (future) care providers need more training to acquire competencies to discuss patients' personal goals. The providers and policy makers talked about organizational limitations in terms of time restrictions and the lack of registration systems to support a workflow oriented towards patients' personal goals. Conclusions: This study can be used to support the coherence of the development of different actions and strategies to get primary care stakeholders fully on board to support the adoption of patients' personal goals in care delivery at different levels. However, models of practice and policy plans are needed to work towards a person-centered integrated system. [ABSTRACT FROM AUTHOR]

Background: Transition from a clinical expert nurse to a part time clinical nursing instructor (PTCNI) poses several challenges. Designing a professional development curriculum to facilitate the transition from a clinical expert nurse to a PTCNI is critical to effective education. A comprehensive competency-based curriculum was developed and implemented with structured mentoring to prepare clinical expert nurses as PTCNIs. Methods: A mixed-methods study with a sequential-exploratory approach was conducted in Iran in 2019. In the qualitative phase, Saylor et al.'s (1981) seven-step model was used, consisting of (1) collecting evidence from a systematic review, (2) conducting interviews with learners, (3) setting goals and objectives, (4) design, (5) implementation, (6) evaluation, and (7) feedback. In the quantitative phase, curriculum domains were evaluated. Additionally, the effective professional communication skills module was implemented using a quasi-experimental study with a pre-test post-test single-group design for 5 PTCNIs in a pilot study. Results: After integrating the findings of the literature review and field interviews in the analysis stage, a curriculum was developed with a total of 150 h, six modules, and 24 topics. Results of the pilot study showed a significant improvement in the confidence of PTCNIs as a result of the implementation of the effective communication skills module using the mentoring method (t = − 16.554, p = 0.0005). Conclusions: This competency-based curriculum was based on the evidence and needs of PTCNIs and provides a complete coverage of their clinical education competencies. It is suggested that managers of educational institutes that offer nursing programs use this curriculum to prepare them in continuing education programs. Further studies are needed to thoroughly evaluate the learning outcomes for students. [ABSTRACT FROM AUTHOR]

Background: Nursing research training is important for improving the nursing research competencies of clinical nurses. Rigorous development of such training programs is crucial for ensuring the effectiveness of these research training programs. Therefore, the objectives of this study are: (1) to rigorously develop a blended emergent research training program for clinical nurses based on a needs assessment and related theoretical framework; and (2) to describe and discuss the uses and advantages of the ADDIE model (Analysis, Design, Development, Implementation, Evaluation) in the instructional design and potential benefits of the blended emergent teaching method. Methods: This intervention development study was conducted in 2017, using a mixed-methods design. A theoretical framework of blended emergent teaching was constructed to provide theoretical guidance for the training program development. Nominal group technique was used to identify learners' common needs and priorities. The ADDIE model (Analysis, Design, Development, Implementation, Evaluation) was followed to develop the research training program for clinical nurses based on the limitations of current nursing research training programs, the needs of clinical nurses, and the theoretical foundation of blended emergent teaching. Results: Following the ADDIE model, a blended emergent research training program for clinical nurses to improve nursing research competence was developed based on the needs of clinical nurses and the theoretical framework of blended emergent teaching. Conclusions: This study indicates that nominal group technique is an effective way to identify learners' common needs and priorities, and that the ADDIE model is a valuable process model to guide the development of a blended emergent training program. Blended emergent teaching is a promising methodology for improving trainees' learning initiative and educational outcomes. More empirical studies are needed to further evaluate blended emergent teaching to promote the development of related theories and practice in nursing education. [ABSTRACT FROM AUTHOR]

Background: Domperidone is the most frequently prescribed medicine used to increase breast milk supply. There is considerable controversy surrounding the use of domperidone in lactation, due to limited evidence about efficacy and concerns about rare but life-threatening side-effects. Despite this, in many high-income settings such as Australia, use of domperidone among breastfeeding mothers appears to be increasing. The aim of this paper was to explore women's experiences of using domperidone during breastfeeding. Methods: Semi-structured interviews were conducted in 2019 with 15 women in Australia who reported using domperidone as a galactagogue during breastfeeding. Interviews were recorded, transcribed and analysed thematically. Results: Women reported a wide variety of practices concerning the timing of initiation of domperidone use, including prophylactic use, as well as the dose and duration of use. Prolonged periods of use and unsupervised dosing were commonly reported, these practices were sometimes associated with a fear of the consequences of stopping, insufficient provision of information about the drug or feeling dismissed by health professionals. Some women indicated that when doctors refused to prescribe domperidone they responded by doctor shopping and seeking anecdotal information about benefits and risks online, leading to unsupervised practices. Women often reported high expectations surrounding the effectiveness of domperidone, and most used the medication in conjunction with food/herbal galactagogues and non-galactagogue support. Positive outcomes following domperidone use included having greater confidence in breastfeeding and pride at achieving breastfeeding goals. Conclusions: This study identified a variety of practices concerning domperidone use, including potentially unsafe practices, linked in some cases to inconsistent advice from health professionals and a reliance on online, anecdotal information sources. These findings emphasise the urgent need for development of clinical practice guidelines and a greater focus on translating existing evidence concerning domperidone into clinical practice, including clinical support that is tailored to women's needs. [ABSTRACT FROM AUTHOR]

Background: Nurse and Midwifery Unit Managers (NMUMs) play pivotal roles in quality patient care, nurse and midwife satisfaction and retention. NMUMs are expected to be both leaders and managers simultaneously, which may create role tension. This study aimed to explore the understanding and experience of NMUMs regarding their role; to explore what barriers and facilitators NMUMs identified to achieving the goals of their clinical area; and to explore NMUMs' career plans. Methods: Set in Victoria, Australia, this study was guided by naturalistic inquiry using a qualitative descriptive approach. Thematic analysis was used to inductively develop core themes, which facilitated the motivations, experience and meanings underlying the data to be elaborated. Results: In all, 39 interviews were conducted with NMUMs across four hospitals. Two overarching themes were identified from the data; system challenges and influences on people and each theme had three sub-themes. In relation to system challenges, participants spoke about the structural challenges that they encountered such as financial stressors and physical infrastructure that made their work difficult. Participants felt they were unprepared for the NMUM role and had limited support in the preparation for the role. Participants also related their frustration of not being included in important decision-making processes within the hospital. Regarding their career plans, most did not envisage a career beyond that of a NMUM. Conclusions: This study of contemporary NMUMs uncovered a continued lack of investment in the orientation, professional development and support of this critical leadership and management role. There is an urgent need for targeted interventions to support and develop capabilities of NMUMs to meet the current and evolving demands of their role. [ABSTRACT FROM AUTHOR]

Background: Providing older persons with information about their health status may increase their involvement in their own health and enhance self-management. However, we need a better understanding of how older persons view their personal results after completing a screening questionnaire on complex health, of their (lack of) motivation and their subsequent action. Methods: In this qualitative study community-dwelling older persons (≥80 years, n = 13) who completed a screening questionnaire on complex health problems were interviewed regarding their perception of the results, the actions they considered taking and their personal motivations. Data were analysed thematically (qualitative content analyses). Results: Participants expressed interest in feedback, as an objective questionnaire might substantiate their own views regarding their personal health. They were mostly unsurprised by the results and/or had already taken precautions and were therefore not inclined to undertake additional action. They admitted difficulty with and appreciated advice from a professional regarding preparation of an action plan. Unexpected negative results would lead them to discuss matters with family and/or their general practitioner, provided they had a good relationship with their GP. Conclusion: Older people were interested in direct feedback regarding their screening questionnaire results and in subsequent advice on possible additional measures. General practices could consider inviting older persons to complete a screening questionnaire and discuss activities and personal goals. This information could serve to better shape future interventions aimed at increasing self-management amongst older persons. [ABSTRACT FROM AUTHOR]

Background: Decision-making on postings and transfers -- that is, the geographic deployment of the health workforce -- is a key element of health workforce governance. When poorly managed, postings and transfers result in maldistribution, absenteeism, and low morale. At stake is managing the balance between organisational (i.e., health system) and individual (i.e., staff preference) needs. The negotiation of this potential convergence or divergence of interests provides a window on practices of postings and transfers, and on the micro-practices of governance in health systems more generally. This article explores the policies and processes, and the interplay between formal and informal rules and norms which underpin postings and transfers practice in two rural districts in the Greater Accra Region of Ghana. Methods: Semi-structured interviews were conducted with eight district managers and 87 frontline staff from the district health administration, district hospital, polyclinic, health centres and community outreach compounds across two districts. Interviews sought to understand how the postings and transfers process works in practice, factors in frontline staff and district manager decision-making, personal experiences in being posted, and study leave as a common strategy for obtaining transfers. Results: Differential negotiation-spaces at regional and district level exist and inform postings and transfers in practice. This is in contrast to the formal cascaded rules set to govern decision-making authority for postings and transfers. Many frontline staff lack policy clarity of postings and transfers processes and thus 'test' the system through informal staff lobbying, compounding staff perception of the postings and transfers process as being unfair. District managers are also challenged with limited decision-space embedded in broader policy contexts of systemic hierarchy and resource dependence. This underscores the negotiation process as ongoing, rather than static. Conclusions: These findings point to tensions between individual and organisational goals. This article contributes to a burgeoning literature on postings and transfers as a distinct dynamic which bridges the interactions between health systems governance and health workforce development. Importantly, this article helps to expand the notion of health systems governance beyond 'good' governance towards understanding governance as a process of negotiation. [ABSTRACT FROM AUTHOR]

Background: Self-monitoring using pedometers is an effective behaviour change technique to support increased physical activity (PA). However, the ways in which pedometers operate as motivational tools in adoption and maintenance of PA is not well understood. This paper investigates men's experiences of pedometers as motivational tools both during and after their participation in a 12-week group-based, weight management programme for overweight/obese men, Football Fans in Training (FFIT). Methods: Semi-structured telephone interviews were conducted with 28 men, purposively sampled to include men who did and did not achieve 5% weight loss during the programme. Data were analysed thematically utilising the framework approach, using Self-Determination Theory (SDT) - namely concepts of behavioural regulation and the basic needs of relatedness, competence and autonomy - as an analytical lens. Results: During the programme, FFIT's context and fellow participants supported relatedness and encouraged use of the pedometer. The pedometer was seen to provide tangible proof of progress, thus increasing competence for change, whilst the ability to monitor one's own progress and take remedial action supported autonomy; these men portrayed the pedometer as an 'ally'. However, a minority found the pedometer 'dispiriting' or controlling when it evidenced their inability to meet their PA targets. After the programme, some men no longer used the device as they had fully internalised their motivations for increased PA. In contrast, others continued to use pedometers or progressed to other self-monitoring technologies because it was enjoyable and facilitated maintenance of their increased PA. However, the minority of men who experienced the pedometer as controlling no longer used it. They were less successful in achieving 5% weight loss and appeared reliant on external factors, including support from coach and group members, to maintain motivation. Conclusion: These findings show how self-monitoring using pedometers and associated goal setting supported the development of autonomous motivation for PA, during and after participation in a group-based programme. They also suggest that programmes could focus on early identification of participants who remain motivated by extrinsic factors or express negative experiences of self-monitoring tools, to offer greater support to identify the benefits of PA based on a person's own values. [ABSTRACT FROM AUTHOR]

Background: In 2005, the World Health Assembly (WHA) of the World Health Organization (WHO) urged member states to aim at achieving affordable universal coverage and access to key promotive, preventive, curative, rehabilitative and palliative health interventions for all their citizens on the basis of equity and solidarity. Since then, some African countries, including Ghana, have taken steps to introduce national health insurance reforms as one of the key strategies towards achieving universal health coverage (UHC). The aim of this study was to get a better understanding of how Ghana's health insurance institutions interact with stakeholders and other health sector programmes in promoting primary health care (PHC). Specifically, the study identified the key areas of misalignment between the operations of the NHIS and that of PHC. Methods: Using qualitative and survey methods, this study involved interviews with various stakeholders in six selected districts in the Upper East region of Ghana. The key stakeholders included the National Health Insurance Authority (NHIA), district coordinators of the National Health Insurance Schemes (NHIS), the Ghana Health Service (GHS) and District Health Management Teams (DHMTs) who supervise the district hospitals, health centers/clinics and the Community-based Health and Planning Services (CHPS) compounds as well as other public and private PHC providers. A stakeholders' workshop was organized to validate the preliminary results which provided a platform for stakeholders to deliberate on the key areas of misalignment especially, and to elicit additional information, ideas and responses, comments and recommendations from respondents for the achievement of the goals of UHC and PHC. Results: The key areas of misalignments identified during this pilot study included: delays in reimbursements of claims for services provided by health care providers, which serves as a disincentive for service providers to support the NHIS; inadequate coordination among stakeholders in PHC delivery; and inadequate funding for PHC, particularly on preventive and promotive services. Other areas are: the bypassing of PHC facilities due to lack of basic services at the PHC level such as laboratory services, as well as proximity to the district hospitals; and finally the lack of clear understanding of the national policy on PHC. Conclusion: This study suggests that despite the progress that has been made since the establishment of the NHIS in Ghana, there are still huge gaps that need urgent attention to ensure that the goals of UHC and PHC are met. The key areas of misalignment identified in this study, particularly on the delays in reimbursements need to be taken seriously. It is also important for more dialogue between the NHIA and service providers to address key concerns in the implementation of the NHIS which is key to achieving UHC. [ABSTRACT FROM AUTHOR]

Background: Mobile technology may serve as a cost-effective and scalable tool for delivering behavioral nutrition interventions. This research sought to iteratively develop a theory-driven mobile app, Vegethon, to increase vegetable consumption. Methods: Development of Vegethon followed phases outlined by the IDEAS framework: 1) empathize with users (qualitative interviews, n = 18); 2) specify target behavior; 3) ground in behavioral theory; 4) ideate implementation strategies; 5) prototype potential products; 6) gather user feedback (qualitative interviews, n = 14; questionnaire, n =41); 7) build minimum viable product; and 8) pilot potential efficacy and usability (pilot RCT, n =17). Findings from each phase informed subsequent phases. The target population that informed intervention development was 18-50 years of age, had BMIs of 28-40 kg/m², and lived in the geographical area surrounding Stanford University. A full description of the final version of Vegethon is included in the paper. Results: Qualitative findings that shaped initial intervention conception were: participants' interests in accountability without judgment; their desire for simple and efficient dietary self-monitoring; and the importance of planning meals in advance. Qualitative findings identified during intervention refinement were the need for a focus on vegetable self-monitoring; inclusion of vegetable challenges; simplification of features; advice and inspiration for eating vegetables; reminder notifications; and peer comparison. Pilot RCT findings suggested the initial efficacy, acceptance, and feasibility of the intervention. The final version of Vegethon enabled easy self-monitoring of vegetable consumption and included a range of features designed to engage the user (e.g., surprise challenges; leaderboard; weekly reports). Vegethon was coded for its inclusion of 18 behavior change techniques (BCTs) (e.g., goal setting; feedback; social comparison; prompts/cues; framing/reframing; identity). Conclusions: Vegethon is a theory-based, user-informed mobile intervention that was systematically developed using the IDEAS framework. Vegethon targets increased vegetable consumption among overweight adults and is currently being evaluated in a randomized controlled efficacy trial. Trial registration: Clinical Trials.gov: NCT01826591 [ABSTRACT FROM AUTHOR]

Background: Postgraduate medical trainees are not well prepared difficult conversations about goals of care with patients and families in the acute care clinical setting. While contextual nuances within the workplace can impact communication, research to date has largely focused on individual communication skills. Our objective was to explore contextual factors that influence conversations between trainees and patients/families about goals of care in the acute care setting. Methods: We conducted an exploratory qualitative study involving five focus groups with Internal Medicine trainees (n = 20) and a series of interviews with clinical faculty (n = 11) within a single Canadian centre. Thematic framework analysis was applied to categorize the data and identify themes and subthemes. Results: Challenges and factors enabling goals of care conversations emerged within individual, interpersonal and system dimensions. Challenges included inadequate preparation for these conversations, disconnection between trainees, faculty and patients, policies around documentation, the structure of postgraduate medical education, and resource limitations; these challenges led to missed opportunities, uncertainty and emotional distress. Enabling factors were awareness of the importance of goals of care conversations, support in these discussions, collaboration with colleagues, and educational initiatives enabling skill development; these factors have resulted in learning, appreciation, and an established foundation for future educational initiatives. Conclusions: Contextual factors impact how postgraduate medical trainees communicate with patients/families about goals of care. Attention to individual, interpersonal and system-related factors will be important in designing educational programs that help trainees develop the capacities needed for challenging conversations. [ABSTRACT FROM AUTHOR]

Background: In 2013, the World Health Organization (WHO) published new guidelines for the management of conditions specifically related to stress, including symptoms of acute stress, bereavement, and post-traumatic stress disorder (PTSD). It is important to evaluate potential challenges for the implementation of these guidelines in low-resource settings, however, there is a dearth of research in this area. The current qualitative study aimed to assess perspectives on the feasibility and acceptability of the new guidelines in four clinics that provide mental health services in post-conflict northern Uganda.Methods: In-depth interviews were conducted with 19 mental health-care providers and program developers in northern Uganda to address three major research objectives: (1) describe the current standard practices and guidelines used for treating conditions related to stress in Uganda; (2) identify barriers and challenges associated with implementing the new WHO guidelines; and (3) identify and describe potential strategies for overcoming these barriers and challenges. An emergent thematic analysis was used to develop a coding scheme for the transcribed interviews.Results: Practices for managing conditions related to stress included group psychological interventions, psychoeducation, and medication for clients with severe signs and symptoms. Several themes were identified from the interviews on barriers to guideline implementation. These included (1) a lack of trained and qualified mental health professionals to deliver WHO-recommended psychological interventions; (2) a perception that psychological interventions developed in high-income countries would not be culturally adaptable in Uganda; and (3) reluctance about blanket statements regarding medication for the management of acute stress symptoms and PTSD. Identified strategies for overcoming these barriers included (1) training and capacity building for current mental health staff; (2) a stepped care approach to mental health services; and (3) cultural modification of psychological interventions to improve treatment acceptability by clients.Conclusions: Guidelines were viewed positively by mental health professionals in Uganda, but barriers to implementation were expressed. Recommendations for implementation include (1) strengthening knowledge on effectiveness of existing cultural practices for improving mental health; (2) improving supervision capacity of current mental health staff to address shortage in human resources; and (3) increasing awareness of help-seeking clients on the potential effectiveness of psychological vs. pharmacological interventions. [ABSTRACT FROM AUTHOR]

Background Lifestyle modification is recommended for management of prehypertension, yet finding effective interventions to reach rural women is a public health challenge. This community-based clinical trial compared the effectiveness of standard advice to two multi-component theory-based tailored interventions, using web-based or print-mailed delivery, in reducing blood pressure among rural women, ages 40–69, with prehypertension. Methods 289 women with prehypertension enrolled in the Wellness for Women: DASHing towards Health trial, a 12-month intervention with 12-month follow-up. Women were randomly assigned to groups using a 1:2:2 ratio, comparing standard advice (30-minute counseling session) to two interventions (two 2-hour counseling sessions, 5 phone goal-setting sessions, strength-training video, and 16 tailored newsletters, web-based or print-mailed). Linear mixed model methods were used to test planned pairwise comparisons of marginal mean change in blood pressure, healthy eating and activity, adjusted for age and baseline level. General estimating equations were used to examine the proportion of women achieving normotensive status and meeting health outcome criteria for eating and activity. Results Mean blood pressure reduction ranged from 3.8 (SD = 9.8) mm Hg to 8.1 (SD = 10.4) mm Hg. The 24-month estimated marginal proportions of women achieving normotensive status were 47% for web-based, and 39% for both print-mailed and standard advice groups, with no group differences (p = .11 and p = .09, respectively). Web-based and print-mailed groups improved more than standard advice group for waist circumference (p = .017 and p = .016, respectively); % daily calories from fat (p = .018 and p = .030) and saturated fat (p = .049 and p = .013); daily servings of fruit and vegetables (p = .008 and p < .005); and low fat dairy (p < .001 and p = .002). Greater improvements were observed in web-based versus standard advice groups in systolic blood pressure (p = .048) and estimated VO2max (p = .037). Dropout rates were 6% by 6-months, 11.4% by 24 months, with no differences across groups. Conclusions Rural women with prehypertension receiving distance-delivery theory-based lifestyle modifications can achieve a reduction of blood pressure and attainment of normotensive status. [ABSTRACT FROM AUTHOR]

Introduction Overweight and obesity are associated with an increased risk of morbidity. Mindfulness training could be an effective strategy to optimize lifestyle behaviors related to body weight gain. The aim of this study was to evaluate the effectiveness of a worksite mindfulness-based multi-component intervention on vigorous physical activity in leisure time, sedentary behavior at work, fruit intake and determinants of these behaviors. The control group received information on existing lifestyle behavior- related facilities that were already available at the worksite. Methods In a randomized controlled trial design (n = 257), 129 workers received a mindfulness training, followed by e-coaching, lunch walking routes and fruit. Outcome measures were assessed at baseline and after 6 and 12 months using questionnaires. Physical activity was also measured using accelerometers. Effects were analyzed using linear mixed effect models according to the intention-to-treat principle. Linear regression models (complete case analyses) were used as sensitivity analyses. Results There were no significant differences in lifestyle behaviors and determinants of these behaviors between the intervention and control group after 6 or 12 months. The sensitivity analyses showed effect modification for gender in sedentary behavior at work at 6-month follow-up, although the main analyses did not. Conclusions This study did not show an effect of a worksite mindfulness-based multi-component intervention on lifestyle behaviors and behavioral determinants after 6 and 12 months. The effectiveness of a worksite mindfulness-based multi-component intervention as a health promotion intervention for all workers could not be established. [ABSTRACT FROM AUTHOR]

Background: Goal setting is a recommended approach in clinical care that can help individuals with multi-morbidities and their caregivers manage chronic conditions. In this paper, the types of goals that were important for older persons with multi-morbidities were explored from the perspectives of patients, their caregivers and physicians. Comparisons of goals were made across each patient, caregiver and physician triad to determine alignment. Methods: The study was a qualitative descriptive study facilitated through semi-structured one-on-one interviews. The study took place between May and October 2012 at a Family Health Team located in Ontario, Canada. The sample included 28 family medicine patients, their informal caregivers and family physicians. Socio-demographic data were analyzed via descriptive statistics in SPSS Version 17. Open ended questions pertaining to patient goals of care were analyzed thematically using NVivo9. Themes were derived on patient care goals for each of the participant groups (patients, caregivers and family physicians). Following this, alignment of goals across each of the triads was examined. Goal alignment was defined as concurrence on at least one goal by all three parties in a particular triad (i.e., patient, caregiver and family physician). Results: Just over half of the patients were male (56%); they had an average age of 82.3 years and 4.61 health conditions. Most of the caregivers were female (82%); and 61% were a spouse of the care recipient. At the aggregate level, common goals expressed among patients, caregivers and family physicians were the maintenance of functional independence of patients and the management of their symptoms or functional challenges. Despite these common goals at the aggregate level, little alignment of goals was found when looking across patient-caregiver and physician triads. Lack of alignment tended to occur when patients had unstable or declining functional or cognitive health; when safety threats were noted; and when enhanced care services were required. Conclusions: The data suggest that goal divergence tends to occur when patients are less medically stable. While goal divergence may be expected due to the different roles and responsibilities of each of the players involved, these perspectives should be illuminated when building care plans. Further research is required to observe the extent to which goal setting occurs in family practice as well as how it can be embedded as a standard of practice. [ABSTRACT FROM AUTHOR]

Background: Multimorbidity poses a challenge for decision-making processes and requires that more attention is paid to patient goals, preferences and needs; however, goal setting is not yet widely recognised as a core aspect of the shared decision-making (SDM) approach. This study aims to analyse clinician perceptions of the concept of goal setting within the context of SDM with older patients with multimorbidity. Methods: Semi-structured interviews with general practitioners (GPs) and clinical geriatricians (CGs) were analysed using a framework analysis. The integrative model of SDM was used to develop a categorisation matrix, including goal setting as an additional component. Results: Sixteen of the 33 clinicians mentioned explicit Goal setting as an integrated component of their definition of SDM, which was comparable to the number of clinicians who listed Patient values and preferences (n = 16), Doctor knowledge and recommendations (n = 19) and Make or explicitly defer a decision (n = 19), elements which are commonly considered to be important aspects of SDM. The other 17 clinicians (6 CGs and 11 GPs) did not mention Goal setting as an explicit component of SDM. Our analysis revealed two potential reasons for this observation. Besides the use of other terminology, part of clinicians viewed collaborative goal setting and SDM as separate but related processes. Conclusions: Our study on clinician perspectives highlighted goal setting as component of a SDM approach and could therefore be considered supportive of recent theoretical insights that SDM models that lack an explicit goal-setting component appear to be deficient and overlook an important aspect of engaging patients in decision-making, particularly for patients with complex multimorbidities. We therefore call for the further development of a comprehensive SDM approach for older patients with multimorbidity to include explicit and unequivocal goal setting elements to sufficiently meet the expectations and needs of clinicians and their patients. [ABSTRACT FROM AUTHOR]

Background: In 2010, a shelter programme was established in the Netherlands to provide social and health services for trafficked people. This article describes how service users in this programme conceptualized and experienced their own process of recovery. Methods: In 2012, 14 people of non-Dutch nationality who had been trafficked for the purpose of sexual exploitation were interviewed at all three shelters of the programme. Data analysis followed a grounded theory approach. Results: Participants felt a strong need to turn over a new leaf in life, leaving negative experiences of the past behind and moving towards a life with a job, a family and friends. In contrast with their willingness to work towards realizing that future, they experienced a lack of autonomy and a thwarted sense of agency in redressing their present situation. Together with the ostracized nature of their place in Dutch society this left them 'in limbo': a feeling of standing still, while wanting to move forward. This led participants to find it more difficult to deal with problems related to their pasts and futures. They particularly appreciated Dutch language training, vocational skills training and opportunities for volunteer work. Conclusions: Participants exhibited a strong desire to fulfil the basic psychological needs of competence, relatedness and autonomy, but were thwarted in pursuing these goals. Seemingly against all odds, while faced with several external regulators that limited their agency to change their situation, participants found ways to pursue these goals, through their enthusiasm for activities that helped them get closer to their envisioned futures (language and skills training and volunteer work). Identifying pathways toward attaining their goals allowed them to hope for a better future. That hope and pursuing their goals helped them to cope with the problems of their past and their worries about the future. Therefore, to facilitate service users' recovery in a post-trafficking setting, there is a need to provide them with opportunities to hope for, pursue and attain their personal goals within the structural boundaries of their situation. A future-orientated, strengths-based approach towards service provision and responsive and supportive environments help to do this. [ABSTRACT FROM AUTHOR]

Background: Patients should receive follow-up serum creatinine tests after an initial abnormal result to diagnose chronic kidney disease. However, half of the time this fails to occur in primary care. We interviewed primary care providers to better understand their perceptions of enablers and barriers to following this guideline-recommended care. Methods: We performed a qualitative descriptive study guided by the Theoretical Domains Framework (TDF), a framework for behavioural change. We used purposeful sampling to recruit primary care providers (physicians and nurse practitioners) based on provider and practice characteristics (rural, solo versus team practice, etc.) from Ontario, Canada. We completed one-on-one interviews with providers using a semi-structured and open-ended interview guide based on the 14 TDF domains. We alternated between data collection and analysis, where we used directed content analysis to identify frequent, important, and conflicting enablers and barriers. Results: We completed 13 interviews with nine primary care physicians and four nurse practitioners. Nine themes related to the TDF emerged from the data: 1) environmental context and resources, 2) knowledge, 3) memory, attention, and decision processes, 4) beliefs about consequences, 5) goals, 6) social or professional role, 7) behavioural regulation, 8) skills, and 9) optimism. Within these themes, we identified 16 enablers and five barriers. Some enablers included, providers' knowledge on appropriate testing, their motivation to order these tests, and their use of tools and resources to help order follow-up serum creatinine tests. However, providers perceived some barriers including that ordering confirmatory laboratory tests for chronic kidney disease was not always a priority in regards to other care they wish to provide. Providers also noted that a perceived barrier is patients not going to the laboratory to complete the test. Conclusions: We identified novel enablers and barriers to primary care providers completing guideline recommended repeat testing for the diagnosis of chronic kidney disease. Similar research is needed to understand the views of patients. These research findings can be used to inform strategies to improve the quality of care. [ABSTRACT FROM AUTHOR]

Background: Teamwork during obstetric emergency ensures good outcomes for both the woman and her baby. Effective teams are characterised by mutual respect, support, and cooperation among team members. Methods: This qualitative, interpretive, phenomenological analysis study was conducted on a purposive sample of five, fourth-year Bachelor of Nursing Science student midwives at the University of Fort Hare (UFH). In-depth semi-structured interviews were conducted. Data analysis applied the interpretative phenomenological analysis method. Results: Superordinate theme demonstrated teamwork elicited four clustered themes namely delegation of duties, the importance of teamwork, team support, and confident team leader. The participants recognised that there should be a team leader who is capable of delegating duties to other team members in the management of an obstetric emergency, Participants were confident not only to assign duties but to be kept updated of the intervention. They expressed the need to work collaboratively as a team to achieve the desired goal of providing quality care to the woman. The participants maintained that the team must be supportive and be able to help in decision making during simulation of an obstetric emergency. A sense of mutual respect is echoed by some participants in the process of caring for the woman. Some participants were confident at being team leaders and could see themselves as leaders in the real-life clinical situation. Conclusion: The participants acknowledge the importance of teamwork in resolving obstetric emergencies. The importance of delegating duties to other team members, providing updated progress report ensures better outcomes for the woman. [ABSTRACT FROM AUTHOR]