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Background Eating outside the home contributes to poor dietary habits worldwide and is associated with increased body fat and weight gain. Evidence shows menu labelling is effective in promoting healthier food choices; however, implementation issues have arisen. The purpose of this systematic review was to synthesise the evidence on the perceived barriers and facilitators to implementation of menu labelling interventions from the perspective of the food service industry. Methods Peer-reviewed and grey literature were searched using databases, specialised search engines and public health organisation websites. Screening reference lists, citation chaining and contacting authors of all included studies were undertaken. Primary research studies relevant to direct supply-side stakeholders were eligible for inclusion. There were no restrictions on menu labelling scheme or format, study methods, publication year or language. At least two independent reviewers performed study selection, data extraction and quality appraisal. The results were synthesised using the ‘best fit’ framework synthesis approach, with reference to the Consolidated Framework for Implementation Research (CFIR). Results Seventeen studies met the eligibility criteria, with the majority rated as average quality (n = 10). The most frequently cited barriers were coded to the CFIR constructs ‘Consumer Needs & Resources’ (e.g. lack of customer demand for/interest in menu labelling, risk of overwhelmed/confused customers) and ‘Compatibility’ with organisation work processes (e.g. lack of standardised recipes, limited space on menus). Frequently cited facilitators were coded to the CFIR constructs ‘Relative Advantage’ of menu labelling (e.g. improved business image/reputation) and ‘Consumer Needs & Resources’ (e.g. customer demand for/interest in menu labelling, providing nutrition information to customers). An adapted framework consisting of a priori and new constructs was developed, which illustrates the relationships between domains. Conclusion This review generates an adapted CFIR framework for understanding implementation of menu labelling interventions. It highlights that implementation is influenced by multiple interdependent factors, particularly related to the external and internal context of food businesses, and features of the menu labelling intervention. The findings can be used by researchers and practitioners to develop or select strategies to address barriers that impede implementation and to leverage facilitators that assist with implementation effort. Trial registration Systematic review registration: PROSPERO CRD42017083306.

BACKGROUND: Despite evidence-based guidelines, high-quality diabetes care is not always achieved. Identifying factors associated with the quality of management in primary care may inform service improvements, facilitating the tailoring of quality improvement interventions to practice needs and resources. METHODS: We searched MEDLINE, EMBASE, CINAHL and Web of Science from January 1990 to March 2019. Eligible studies were cohort studies, cross-sectional studies and randomised controlled trials (baseline data) conducted among adults with diabetes, which examined the relationship between any physician and/or practice factors and any objective measure(s) of quality. Studies which examined patient factors only were ineligible. Where possible, data were pooled using random-effects meta-analysis. RESULTS: In total, 82 studies were included. The range of individual quality measures and the construction of composite measures varied considerably. Female physicians compared with males ((odds ratio (OR) = 1.07, 95% CI: 1.04, 1.10), 8 studies), physicians with higher diabetes volume compared with lower volume (OR = 1.24, 95% CI: 1.05–1.47, 4 studies) and practices with Electronic Health Records (EHR) versus practices without (OR = 1.43, 95% CI: 1.11–1.84, 4 studies) were associated with a higher quality of care. There was no association between physician experience, practice location and type of practice and quality. Based on the narrative synthesis, increasing physician age and higher practice socio-economic deprivation may be associated with lower quality of care. DISCUSSION: Identification of physician- and practice-level factors associated with the quality of care (female gender, younger age, physician-level diabetes volume, practice deprivation and EHR use) may explain differences across practices and physicians, provide potential targets for quality improvement interventions and indicate which practices need specific supports to deliver improvements in diabetes care. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-020-05676-7) contains supplementary material, which is available to authorized users.

The haemoglobin A1c (HbA1c) level has become the standard of care for monitoring type 2 diabetes as it reflects a person’s average blood glucose level over the previous 2–3 months, is correlated with risk of long-term complications and can be measured cheaply and easily. International guidelines recommend testing HbA1c every 6–12 months for those with stable type 2 diabetes, and every 3–6 months in adults with unstable type 2 diabetes until HbA1c is controlled on unchanging therapy.1–3 However, these guidelines are based on expert consensus rather than robust evidence on whether the frequency of HbA1c measurement impacts patient outcomes. To date, most studies have focused on the association between testing frequency and glycaemic control.4–6 In this issue of BMJ Quality & Safety Imai and colleagues go further, demonstrating an association between adherence to guideline-recommended testing frequency and health outcomes.7 Using data from electronic health records (EHRs), they examined adherence to guideline-recommended HbA1c testing frequency over a 5-year period in 6424 people with type 2 diabetes across 250 general practices in Australia. An adherence rate was calculated for each person with type 2 diabetes, dividing the number of tests performed within the recommended intervals by the total number of conducted tests (minus 1). Patients were categorised into low-adherence ( 66%). Where there was high adherence to guideline-recommended testing frequency, HbA1c values remained stable or improved over time. In contrast, with low adherence, HbA1c values remained unstable or deteriorated over the 5-year period. The risk of developing chronic kidney disease was lower among those with high adherence compared to those with low adherence (OR 0.42, 95% CI 0.18 to 0.99). There was no evidence of an association between the rate of adherence and the development of ischaemic heart disease. This study provides support for the importance …

ObjectivesDiabetic retinopathy screening (DRS) uptake is suboptimal in many countries with limited evidence available on interventions to enhance DRS uptake in primary care. We investigated the feasibility and preliminary effects of an intervention to improve uptake of Ireland’s national DRS programme, Diabetic RetinaScreen, among patients with type 1 or type 2 diabetes.Design/settingWe conducted a cluster randomised pilot trial, embedded process evaluation and cost analysis in general practice, July 2019 to January 2020.ParticipantsEight practices participated in the trial. For the process evaluation, surveys were conducted with 25 staff at intervention practices. Interviews were conducted with nine staff at intervention practices, and 10 patients who received the intervention.InterventionsThe intervention comprised practice reimbursement, an audit of attendance, electronic prompts targeting professionals, General Practice-endorsed patient reminders and a patient information leaflet. Practices were randomly allocated to intervention (n=4) or wait-list control (n=4) (usual care).OutcomesStaff and patient interviews explored their perspectives on the intervention. Patient registration and attendance, including intention to attend, were measured at baseline and 6 months. Microcosting was used to estimate intervention delivery cost.ResultsThe process evaluation identified that enablers of feasibility included practice culture and capacity to protect time, systems to organise care, and staff skills, and workarounds to improve intervention ‘fit’. At 6 months, 22/71 (31%) of baseline non-attenders in intervention practices subsequently attended screening compared with 15/87 (17%) in control practices. The total delivery cost across intervention practices (patients=363) was €2509, averaging €627 per practice and €6.91 per audited patient. Continuation criteria supported proceeding to a definitive trial.ConclusionsThe Improving Diabetes Eye screening Attendance intervention is feasible in primary care; however, consideration should be given to how best to facilitate local tailoring. A definitive trial of clinical and cost-effectiveness is required with preliminary results suggesting a positive effect on uptake.Trial registration numberNCT03901898.

ObjectivesImproving detection of depression in people with diabetes is recommended. However, little is known about how different health systems compare in depression detection. We estimated and compared the (1) prevalence of depression detection in people with and without diabetes, and (2) association between diabetes and undiagnosed depression across three health systems.DesignCross-sectional analysis of three nationally representative studies: The Irish Longitudinal Study on Ageing, the English Longitudinal Study on Ageing and the Health and Retirement Study.SettingCommunity-dwelling adults in Ireland, England and the USA.ParticipantsAdults aged ≥50 years.Primary and secondary outcome measuresThe primary outcome was depression diagnosis. The secondary outcome was any depression. Any depression was defined by the presence of self-reported doctor-diagnosed depression or current depression symptoms on the Centre for Epidemiological Studies-Depression scale. Depression diagnosis was categorised as: undiagnosed, symptomatic and diagnosed, and asymptomatic and diagnosed. We estimated age-standardised prevalence of depression diagnosis by country and diabetes status. Anyone who self-reported having ever received a doctor diagnosis of diabetes was classified as having diabetes. Among respondents with depression, we estimated the association between diabetes and undiagnosed depression by country using multivariable logistic regression.ResultsThe prevalence of depression (diagnosed and undiagnosed) was higher in people with diabetes in each country with absolute rates varying by country; undiagnosed prevalence (Ireland: diabetes 10.1% (95% CI 7.5% to 12.8%) vs no diabetes 7.5% (95% CI 6.8% to 8.2%), England: diabetes 19.3% (95% CI 16.5% to 22.2%) vs no diabetes 11.8% (95% CI 11.0% to 12.6%), USA: diabetes 7.4% (95% CI 6.4% to 8.4%) vs no diabetes 6.1% (95% CI 5.7% to 6.6%)). In the fully adjusted model, there was no clear pattern of association between diabetes status and undiagnosed depression; Ireland: OR=0.82 (95% CI 0.5 to 1.3), England: OR=1.47 (95% CI 1.0 to 2.1), USA: OR=0.80 (95% CI 0.7 to 1.0).ConclusionsAlthough undiagnosed depression was more prevalent among people with diabetes, the relationship between diabetes and undiagnosed depression differed by country. Targeted efforts are needed to improve depression detection among community-dwelling older adults, particularly those with diabetes.

Background Multifactorial falls risk assessment is an evidence-based practice recommended to prevent falls among older people. Previous research has identified cultural, practical and professional challenges to implementing complex fall prevention interventions. Fall prevention interventions are frequently delivered by multidisciplinary teams (MDTs). This requires multiple health professionals, who practice under different professional norms and governance structures, to accommodate new ways of working. Our aim is to explore disciplinary differences in the perceived acceptability, appropriateness and feasibility of community-based multifactorial falls risk assessment clinics during initial implementation. Methods A mixed methods study is being conducted with analysis of administrative data on delivery of risk assessments (2016-2018), and semi-structured interviews staff involved in multidisciplinary teams (physiotherapists (PT, n=5), occupational therapists (OT, n=6), and public health nurses (n=4)]. Interviews were conducted prior to implementation and at 6 months (n=30 interviews total). Framework-driven thematic analysis was used to identify factors influencing implementation and explore perceptions of acceptability, appropriateness and feasibility. Results Implementation varied across disciplines; 28% of assessments were conducted by nurses (n=83), 36% (n=111) by physiotherapists, and 36% (n=108) by OTs. Preliminary qualitative analysis suggests that OTs welcomed the opportunity to expand their scope of practice. Conducting assessments at set times in static clinics was incompatible with public health nurses’ workflow. Their limited availability and time-sensitive competing priorities were barriers to the feasibility of an MDT-approach. Physiotherapists questioned the relative advantage of a broad assessment, and whether it was an appropriate use of resources given waiting lists for physiotherapy intervention. Data analysis is ongoing. Conclusion The study results have already been used to inform service adaptations including the introduction of dedicated intervention sessions. Training and implementation support for multidisciplinary teams may need to be tailored to the needs of different professional groups to enhance adoption and fidelity.

Background Falls are one of the most common threats to older peoples’ independence. In Ireland, approximately one in three adults aged ≥65 years fall each year. Multifactorial interventions, which include an assessment of an individual's risk of falling followed by customised interventions or referral have been shown to reduce the rate of falls among community-dwelling older people. As part of an Integrated Falls Prevention Pathway initiated in 2016, six multidisciplinary risk assessment clinics were established in Cork city and county. The aim of this study is to examine whether recommended follow-on interventions were received following a falls risk assessment in the community. Methods Routinely collected administrative data for clients who attended a falls risk assessment clinic are being collated. Data include client demographics, onward referrals, waiting times and receipt of intervention. A process map of the patient pathway following a falls risk assessment is under development and will be refined based on the study findings. Results Preliminary analysis of a two-year implementation period (April 2016-2018) indicates that following assessment, clients received an average of 2.4 onward referrals. Most referrals were made to general practice (29%, n=315), community physiotherapy (25%, n=272), and community occupational therapy (15%, n=165). Other referrals were to public health nurses (n=104, 10%) and falls prevention classes (n=60, 6%). Further analysis will identify the percentage of individuals who receive interventions, the type of interventions received, the percentage of patients who do not attend and the waiting lists. Conclusion The Integrated Falls Prevention Service is the sole example of an operational integrated falls pathway in Ireland. This research will identify potential roadblocks for providers and clients along the pathway and will identify opportunities to. The results will also be used to inform service planning and resource allocation to ensure that this model of care is sustainable.

Background The co-occurrence of depression and diabetes is an emerging global challenge but any association is influenced by variations in prevalence, study design and measure used. We compared depression prevalence in older adults with and without diabetes across three health systems using a validated measure to examine the causal association between diabetes and depression. Methods We used data of adults aged over 49 years, from three nationally representative ageing datasets; The Irish Longitudinal Study on Ageing (TILDA), the English Longitudinal Study on Ageing (ELSA) and the Health and Retirement Study (HRS). Data were collected during 2009–2011 (TILDA), and 2010 (ELSA, HRS). The 8-item CESD scale categorised depression using recommended cut-off scores of < 3 for ELSA and HRS and < 8 for TILDA. Self-reported individual, environmental, behavioural risk, and health system exposure variables were selected a-priori using literature and a directed acyclic graph. Prevalence was presented as a percentage with corresponding 95% confidence intervals. Binomial logistic regression examined the odds of depression by diabetes status. Data were analysed in Stata v15 using the ‘svy’ function. Results Diabetes prevalence (Ireland;8%[(95%CI:7.5–8.6), England;11%(95%CI:10.6–12.0) and USA;19%[(95%CI:18.8-20.1);p Conclusion Among older adults in different health systems, depression was consistently higher among people with versus without diabetes. The findings support incorporation of holistic approaches to diabetes management across health systems.

The conceptual basis of early childhood feeding interventions for obesity prevention is poorly understood. The aim of this systematic review is to characterise these interventions' use of behaviour change techniques (BCTs) and psychological theory, focusing on interventions delivered by healthcare professionals for children ≤ 2 years. We searched seven electronic databases from inception to January 2019 and identified 12 trials. BCTs and theory use were identified using the Behaviour Change Technique Taxonomy v1 and the Theory Coding Scheme respectively. Interventions used 19 BCTs, most commonly 'Instruction on how to perform the behaviour' (12 of 12 studies) and 'Social support (unspecified)' (8 of 12 studies). The mean number of BCTs used was 5.1. Six trials explicitly stated basing interventions on theory, most commonly social cognitive theory and responsive feeding (4 of 6 studies each). Links between theory use and BCTs were poor. Early childhood feeding interventions have insufficiently integrated psychological theories into their development and evaluation. We recommend greater consideration of psychological theory incorporating family and systems approaches and responsive feeding in future intervention development. Moreover, these theories should explicitly link with BCTs. These theories and BCTs should also be included in the evaluation phase.

Introduction: The American College of Cardiology Foundation (ACCF) with other professional societies developed appropriate use criteria (AUC) for diagnostic coronary angiography. This study aims to examine the appropriate use of elective coronary angiography for patients with suspected stable coronary artery disease in an Irish tertiary referral center. Methods: A retrospective chart review of all elective outpatient diagnostic coronary angiograms performed in Cork University Hospital in 2014 was carried out. Data on demographics, risk factors, clinical presentation, and prior non-invasive investigations were extracted. Each patient was evaluated according to the 2012 ACCF appropriate use criteria and classified as appropriate, uncertain, or inappropriate. Univariable and multivariable logistic regression analysis was performed to investigate the factors that predict patients undergoing appropriate diagnostic coronary angiography. Results: Of 417 elective outpatient diagnostic coronary angiograms, 259 (62%) were included in the analysis. Of these, 108 (42%) were classified as appropriate, 97 (37%) as uncertain, and 54 (21%) as inappropriate. In multivariable analysis, those with private health insurance were more likely to have an appropriate indication for coronary angiogram (OR 2.1, 95% CI 1.2–3.7) as were those with atrial fibrillation (OR 3.9, 95% CI 1.2–12.8). Ever smokers were less likely to have an appropriate indication for coronary angiogram than never smokers (OR 0.5, 95% CI 0.3–0.9). Conclusion: This is the first Irish study to evaluate the appropriate use of elective coronary angiography. Rates were similar to those of studies in other jurisdictions; however, there remains significant potential for quality improvement.

Aim Synthesise qualitative evidence of healthcare professionals’ (HCP) experiences of diabetes distress and depression screening in people with type 2 diabetes (T2DM) in primary care to identify HCP barriers and enablers to screening implementation. Methods Searched six electronic databases in October 2020 for qualitative studies exploring HCPs’ experiences of diabetes distress and depression screening in T2DM populations. Applying a best-fit framework synthesis, data were coded to the theoretical domains framework (TDF), followed by thematic analysis of data that did not fit the TDF. Study quality and confidence in findings were assessed using CASP and GRADE-CERQual respectively. Findings Of 4942 unique records identified, 10 articles were included. We identified fifteen barriers and enablers in 8 TDF domains and 1 new domain; people with T2DM factors. One barrier (poor awareness about the rationale for screening) and 2 enablers (perceived impacts on T2DM care, receiving financial reimbursement) were assessed as findings of high confidence. Conclusion HCPs experience many barriers and enablers to diabetes distress and depression screening among people with T2DM in primary care. Future interventions and policies should ensure HCPs understand the rationale for screening, highlight the benefits of screening, resource screening appropriately and address HCP group specific barriers.

Background The application of economic analysis within implementation science is still developing and the cost of intervention development, which differs markedly from the costs of initial implementation and maintenance, is often overlooked. Our aim was to retrospectively cost the development of a multifaceted intervention in primary care to improve attendance at diabetic retinopathy screening. Methods A retrospective micro costing of developing the intervention from the research funder perspective was conducted. It was based on a systematic intervention development process involving analysis of existing audit data and interviews with patients and healthcare professionals (HCPs), conducting consensus meetings with patients and HCPs, and using these data together with a rapid review of the effectiveness of interventions, to inform the final intervention. Both direct (non-personnel, e.g. travel, stationary, room hire) and indirect (personnel) costs were included. Data sources included researcher time logs, payroll data, salary scales, an online financial management system, invoices and purchase orders. Personnel involved in the intervention development were consulted to determine the activities they conducted and the duration of their involvement. Sensitivity and scenario analyses were conducted to estimate uncertainty around parameters and scope. Results The total cost of intervention development (July 2014–January 2019) was €40,485 of which 78% were indirect (personnel) costs (€31,451). In total, personnel contributed 1368 h to intervention development. Highest cost activities were the patient interviews, and consensus process, contributing 23% and 34% of the total cost. Varying estimated time spent on intervention development activities by + 10% increased total intervention development cost by 6% to €42,982. Conclusions Our results highlight that intervention development requires a significant amount of human capital input, combining research experience, patient and public experience, and expert knowledge in relevant fields. The time committed to intervention development is critical but has a significant opportunity cost. With limited resources for research on developing and implementing interventions, capturing intervention development costs and incorporating them as part of assessment of cost-effective interventions, could inform research priority and resource allocation decisions.

Background Screening for depression and diabetes distress in people with type 2 diabetes (T2DM) in primary care is increasingly recommended but implementation in practice is suboptimal. As health care professionals influence detection practices, their perceptions and experiences of screening recommendations can improve understanding of aspects that work, and those which are difficult to implement. We aim to synthesise the available qualitative evidence on healthcare professionals’ perceived barriers and enablers to recognising possible depression and diabetes distress in people with T2DM using validated screening tools compared to clinical questioning or no screening. Methods Primary qualitative and mixed method studies were identified using systematic database searching of six databases and supplementary searching. We selected ‘best-fit framework synthesis’ to synthesise primary data using the RETREAT (Review question-Epistemology-Time/Timescale-Resources-Expertise-Audience and purpose-Type of Data) framework. We selected the theoretical domains framework (TDF) as the a priori best fit framework as the TDF is derived from existing behaviour change theories. Quality appraisal of primary studies and confidence in the overall review findings will be determined using the CASP (Critical-Appraisal-Skills-Programme) and the GRADE-CERQual (Grading-of-Recommendations-Assessment-Development-and-Evaluation-Confidence-in-the-Evidence-from-Reviews-of-Qualitative-research) respectively. The study is registered on the international Prospective Register of Systematic Reviews (PROSPERO; registration number: CRD42019145483). Results Ten primary qualitative studies were identified from five countries; England (n=4), China (n=1), the Netherlands (n=3), Australia (n=1), Canada (n=1). No studies on detection of diabetes-distress were identified. Data extraction and analysis is ongoing. Tentative findings indicate that primary care health professionals experience barriers and enablers to detection unique in T2DM populations; symptom overlap, perceptions of role and responsibilities, the perceived value of screening in the T2DM population, and integrating screening protocols into T2DM review visits. Additional barriers to depression screening in the T2DM population; mental health stigma, patient-clinician relationship, were pertinent to depression screening in primary care populations more generally. Discussion Findings may (1) improve understanding of how depression can be more appropriately identified in people with T2DM in primary care settings from a health care professional perspective, (2) inform the design of future depression screening interventions or (3) inform depression screening recommendations for people with T2DM. The application of recommended qualitative evidence synthesis approaches i.e. RETREAT, GRADE-CERQual, enhances the overall robustness of the study. The protocol is available at https://hrbopenresearch.org/articles/2-26/v2.

Background ‘Integrated care’ for chronic conditions is considered central to international health system reform. However, models of integrated care work differently in different circumstances. In Ireland, the National Diabetes Programme aimed to integrate diabetes care across primary, secondary and tertiary settings based on patient complexity through the introduction of new clinical posts and guidance for diabetes care. We conducted a realist evaluation to determine how and why the implementation of the programme worked (or not) across the country. Methods Through documentary analysis and qualitative interviews (n=19) with a purposive sample of national stakeholders, we developed an initial theory on how the programme was expected to work. We then refined this theory in semi-structured interviews (n=39) with professionals purposively sampled to represent different clinical disciplines involved in implementation. We applied a realist logic of analysis and synthesis to iteratively build CMO configurations. Results National stakeholders assumed that: 1) introducing guidance would formalise and standardise how care was provided, 2) that professionals would ‘buy in’ and align their work with new ways of working, and 3) that the new clinical posts would become catalysts for service changes at local level. At a national level, important contexts included varying levels of awareness about the programme, no plan for communicating service changes, and no established approach to implementation or professional oversight. Locally, experience delivering diabetes care, resource demands and familiarity with the intended purpose of the new clinical posts were important contextual factors. The extent to which integrated care was adopted and implemented depended on judgements made by health professionals (GPs, nurses, specialists and podiatrists) working in these contexts, specifically; judging the relative advantage of the programme and whether to engage in negotiations to legitimize their roles in diabetes care. Conclusion Theory-based evaluations are better equipped to deal with the complexity of introducing multi-component interventions into dynamic health systems. This study suggests that, given a disconnect between responsibility for programme design and implementation, in the absence of systematic communication about the nature of changes and lack of clarity around governance and reporting structures, professionals used their judgment to adopt, implement and adapt interventions to match their priorities and circumstances.

An amendment to this paper has been published and can be accessed via the original article.

ObjectivesMultifactorial falls risk assessments reduce the rate of falls in older people and are recommended by international guidelines. Despite their effectiveness, their potential impact is often constrained by barriers to implementation. Attendance is an issue. The aim of this study was to explore why older people attend community-based multifactorial falls risk assessment clinics, and to map these reasons to a theoretical framework.DesignThis is a qualitative study. Semi-structured interviews were conducted and analysed thematically. Each theme and subtheme were then mapped onto the Theoretical Domains Framework (TDF) to identify the determinants of behaviour.ParticipantsOlder adults (aged 60 and over) who attended community-based multifactorial falls risk assessments.ResultsSixteen interviews were conducted. Three main themes explained participants’ reasons for attending the multifactorial risk assessment; being that ‘type of person’, being ‘linked in’ with health and community services and having ‘strong social support’. Six other themes were identified, but these themes were not as prominent during interviews. These were knowing what to expect, being physically able, having confidence in and being positive towards health services, imagining the benefits given previous positive experiences, determination to maintain or regain independence, and being ‘crippled’ by the fear of falling. These themes mapped on to nine TDF domains: ‘knowledge’, ‘skills’, ‘social role and identity’, ‘optimism’, ‘beliefs about consequences’, ‘goals’, ‘environmental context and resources’, ‘social influences’ and ‘emotion’. There were five TDF domains that were not relevant to the reasons for attending.ConclusionsThese findings provide theoretically based factors that influence attendance which can be used to inform the development of interventions to improve attendance to falls prevention programmes.

Aims: To estimate the health service use and direct healthcare costs attributable to diabetes using best available data and methods. Methods: A nationally representative sample of adults aged ≥50 years was analysed (n=8107). Health service use in the previous 12 months included the number of general practitioner visits, outpatient department visits, hospital admissions, and accident and emergency department attendances. Multivariable negative binomial regression was used to estimate the associations between diabetes and frequency of visits. Average marginal effects were applied to unit costs for each health service and extrapolated to the total population, calculating the incremental costs associated with diabetes. Results: The prevalence of diabetes was 8.0% (95% CI 7.4, 8.6). In fully adjusted models, diabetes was associated with additional health service use. Compared to those without diabetes, people with diabetes have, on average, 1.49 (95% CI 1.10, 1.88) additional general practitioner visits annually. Diabetes was associated with an 87% increase in outpatient visits, a 52% increase in hospital admissions and a 33% increase in accident and emergency department attendances (P

Aim: To examine the quality of care delivered by a structured primary care‐led programme for people with Type 2 diabetes mellitus in 1999–2016. Methods: The Midland Diabetes Structured Care Programme provides structured primary care‐led management. Trends over time in care processes were examined (using a chi‐squared trend test and age‐ and gender‐adjusted logistic regression). Screening and annual review attendance were reviewed. A composite of eight National Institute for Health and Care Excellence‐recommended processes was used as a quality indicator. Participants who were referred to diabetes nurse specialists were compared with those not referred (Student's t‐test, Pearson's chi‐squared test, Wilcoxon–Mann–Whitney test). Proportions achieving outcome targets [HbA1c ≤58 mmol/mol (7.5%), blood pressure ≤140/80 mmHg, cholesterol

Background general practitioners (GPs) have identified the management of behavioural and psychological symptoms of dementia (BPSD) as a particularly challenging aspect of dementia care. However, there is a paucity of research on why GPs find BPSD challenging and how this influences the care they offer to their patients with dementia. Objectives to establish the challenges GPs experience when managing BPSD; to explore how these challenges influence GPs’ management decisions; and to identify strategies for overcoming these challenges. Design qualitative study of GPs experiences of managing BPSD. Methods semi-structured interviews were conducted with 16 GPs in the Republic of Ireland. GPs were purposively recruited to include participants with differing levels of experience caring for people with BPSD in nursing homes and in community settings to provide maximum diversity of views. Interviews were analysed thematically. Results three main challenges of managing BPSD were identified; lack of clinical guidance, stretched resources and difficulties managing expectations. The lack of relevant clinical guidance available affected GPs’ confidence when managing BPSD. In the absence of appropriate resources GPs felt reliant upon sedative medications. GPs believed their advocacy role was further compromised by the difficulties they experienced managing expectations of family caregivers and nursing home staff. Conclusions this study helps to explain the apparent discrepancy between best practice recommendations in BPSD and real-life practice. It will be used to inform the design of an intervention to support the management of BPSD in general practice.

To estimate the cost of preeclampsia from the national health payer’s perspective using secondary data from the SCOPE study (Screening for Pregnancy End Points). SCOPE is an international observational prospective study of healthy nulliparous women with singleton pregnancies. Using data from the Irish cohort recruited between November 2008 and February 2011, all women with preeclampsia and a 10% random sample of women without preeclampsia were selected. Additional health service use data were extracted from the consenting participants’ medical records for maternity services which were not included in SCOPE. Unit costs were based on estimates from 3 existing Irish studies. Costs were extrapolated to a national level using a prevalence rate of 5% to 7% among nulliparous pregnancies. Within the cohort of 1774 women, 68 developed preeclampsia (3.8%) and 171 women were randomly selected as controls. Women with preeclampsia used higher levels of maternity services. The average cost of a pregnancy complicated by preeclampsia was €5243 per case compared with €2452 per case for an uncomplicated pregnancy. The national cost of preeclampsia is between €6.5 and €9.1 million per annum based on the 5% to 7% prevalence rate. Postpartum care was the largest contributor to these costs (€4.9–€6.9 million), followed by antepartum care (€0.9–€1.3 million) and peripartum care (€0.6–€0.7 million). Women with preeclampsia generate significantly higher maternity costs than women without preeclampsia. These cost estimates will allow policy-makers to efficiently allocate resources for this pregnancy-specific condition. Moreover, these estimates are useful for future research assessing the cost-effectiveness of preeclampsia screening and treatment.

SummaryBackground There is an increasing tendency to reconfigure acute hospital care towards a more centralised and specialised model, particularly for complex care conditions. Although centralisation is presented as “evidence-based”, the relevant studies are often challenged by groups which hold perspectives and values beyond those implicit in the literature. This study investigated stakeholder perspectives on the rationale for the reconfiguration of urgent and emergency care in Ireland. Specifically, it considered the hypothesis that individuals from different stakeholder groups would endorse different positions in relation to the motivation for, and goals of, reconfiguration. Methods Documentary analysis of policy documents was used to identify official justifications for change. Semi-structured interviews with 175 purposively sampled stakeholders explored their perspectives on the rationale for reconfiguration. Results While there was some within-group variation, internal and external stakeholders generally vocalised different lines of argument. Clinicians and management in the internal stakeholder group proposed arguments in favour of reconfiguration based on efficiency and safety claims. External stakeholders, including hospital campaigners and local political representatives expressed arguments that focused on access to care. A “voter” argument, focused on the role of local politicians in determining the outcome of reconfiguration planning, was mentioned by both internal and external stakeholders, often in a critical fashion. Conclusion Our study adds to an emerging literature on the interaction between a technocratic approach to health system planning advocated by clinicians and health service managers, and the experiential “non-expert” claims of the public and patients.

Background Guidelines recommend involving intervention users in the intervention development process. However, there is limited guidance on how to involve users in a meaningful and effective way. Objective The aim of this Study within a trial was to compare participants' experiences of taking part in one of three types of consensus meetings-people with diabetes-only, combined people with diabetes and health-care professionals (HCPs) or HCP-only meeting. Design The study used a mixed methods convergent design. Quantitative (questionnaire) and qualitative (observation notes and semi-structured telephone interviews) data were collected to explore participants' experiences. A triangulation protocol was used to compare quantitative and qualitative findings. Participants People with diabetes (recruited via multiple strategies) were randomly assigned to attend the people with diabetes or combined meeting. HCPs (recruited through professional networks) attended the HCP or combined meeting based on their availability. Results Sixteen people with diabetes and 15 HCPs attended meetings, of whom 18 participated in a telephone interview. Participants' questionnaire responses suggested similar positive experiences across the three meetings. Observation and semi-structured interviews highlighted differences experienced by participants in the combined meeting relating to: perceived lack of common ground; feeling empowered versus undervalued; needing to feel safe and going off task to fill the void. Conclusions The qualitative theme 'needing to feel safe' may explain the dissonance (disagreement) between quantitative and qualitative data. In this study, involving patients and HCPs simultaneously in a consensus process was not found to be as suitable as involving each stakeholder group separately.

BackgroundTo address deficits in the delivery of acute services in Ireland, the National Acute Medicine Programme (NAMP) was established in 2010 to optimise the management of acutely ill medical patients in the hospital setting, and to ensure their supported discharge to primary and community-based care. NAMP aims to reduce inappropriate hospital admissions, reduce length of hospital stay and ensure patients receive timely treatment in the most appropriate setting. It does so primarily via the development of Acute Medical Assessment Units (AMAUs) for the rapid assessment and management of medical patients presenting to hospitals, as well as streamlining the care of those admitted for further care. This study will examine the impact of this programme on patient care and identify the factors influencing its implementation and operation.MethodsWe will use a multistage mixed methods evaluation with an explanatory sequential design. Firstly, we will develop a logic model to describe the programme’s outcomes, its components and the mechanisms of change by which it expects to achieve these outcomes. Then we will assess implementation by measuring utilisation of the Units and comparing the organisational functions implemented to that recommended by the NAMP model of care. Using comparative case study research, we will identify the factors which have influenced the programme’s implementation and its operation using the Consolidated Framework for Implementation Research to guide data collection and analysis. This will be followed by an estimation of the impact of the programme on reducing overnight emergency admissions for potentially avoidable medical conditions, and reducing length of hospital stay of acute medical patients. Lastly, data from each stage will be integrated to examine how the programme’s outcomes can be explained by the level of implementation.DiscussionThis formative evaluation will enable us to examine whether the NAMP is improving patient care and importantly draw conclusions on how it is doing so. It will identify the factors that contribute to how well the programme is being implemented in the real-world. Lessons learnt will be instrumental in sustaining this programme as well as planning, implementing, and assessing other transformative programmes, especially in the acute care setting.

Background ‘Implementation interventions’ refer to methods used to enhance the adoption and implementation of clinical interventions such as diabetic retinopathy screening (DRS). DRS is effective, yet uptake is often suboptimal. Despite most routine management taking place in primary care and the central role of health care professionals (HCP) in referring to DRS, few interventions have been developed for primary care. We aimed to develop a multifaceted intervention targeting both professionals and patients to improve DRS uptake as an example of a systematic development process combining theory, stakeholder involvement, and evidence. Methods First, we identified target behaviours through an audit in primary care of screening attendance. Second, we interviewed patients (n = 47) and HCP (n = 30), to identify determinants of uptake using the Theoretical Domains Framework, mapping these to behaviour change techniques (BCTs) to develop intervention content. Thirdly, we conducted semi-structured consensus groups with stakeholders, specifically users of the intervention, i.e. patients (n = 15) and HCPs (n = 16), regarding the feasibility, acceptability, and local relevance of selected BCTs and potential delivery modes. We consulted representatives from the national DRS programme to check intervention ‘fit’ with existing processes. We applied the APEASE criteria (affordability, practicability, effectiveness, acceptability, side effects, and equity) to select the final intervention components, drawing on findings from the previous steps, and a rapid evidence review of operationalised BCT effectiveness. Results We identified potentially modifiable target behaviours at the patient (consent, attendance) and professional (registration) level. Patient barriers to consent/attendance included confusion between screening and routine eye checks, and fear of a negative result. Enablers included a recommendation from friends/family or professionals and recognising screening importance. Professional barriers to registration included the time to register patients and a lack of readily available information on uptake in their local area/practice. Most operationalised BCTs were acceptable to patients and HCPs while the response to feasibility varied. After considering APEASE, the core intervention, incorporating a range of BCTs, involved audit/feedback, electronic prompts targeting professionals, HCP-endorsed reminders (face-to-face, by phone and letter), and an information leaflet for patients. Conclusions Using the example of an intervention to improve DRS uptake, this study illustrates an approach to integrate theory with user involvement. This process highlighted tensions between theory-informed and stakeholder suggestions, and the need to apply the Theoretical Domains Framework (TDF)/BCT structure flexibly. The final intervention draws on the trusted professional-patient relationship, leveraging existing services to enhance implementation of the DRS programme. Intervention feasibility in primary care will be evaluated in a randomised cluster pilot trial.

Objectives and design There is growing recognition of the need for effective behaviour change interventions to prevent chronic diseases that are feasible and sustainable and can be implemented within routine health care systems. Focusing on implementation from the outset of intervention development, and incorporating multiple stakeholder perspectives to achieve this, is therefore essential. This study explores the development of the Choosing Healthy Eating for Infant Health (CHErIsH) childhood obesity prevention intervention and implementation strategy to improve infant feeding behaviours. Methods Five qualitative and quantitative evidence syntheses, two primary qualitative studies, and formal/informal consultations were conducted with practice, policy, research, and parent stakeholders. The Behaviour Change Wheel was used to guide the integration of findings. Results The CHErIsH intervention targets parent-level behaviour change and comprises (1) brief verbal messages and (2) trustworthy resources, to be delivered by health care professionals (HCPs) during routine infant vaccination visits. The implementation strategy targets HCP-level behaviour change and comprises (1) a local opinion leader, (2) incentivized training, (3) HCP resources and educational materials, (4) electronic delivery prompts, (5) awareness-raising across all primary care HCPs, and (6) local technical support. Conclusions This study provides a rigorous example of the development of an evidence-based intervention aimed at improving parental infant feeding behaviours, alongside an evidence-based behaviour change strategy to facilitate implementation and sustainability in primary care. This approach demonstrates how to systematically incorporate multiple stakeholder perspectives with existing literature and move from multiple evidence sources to clearly specified intervention components for both the intervention and implementation strategy. Statement of Contribution What is already known? Incorporating insights from practice, policy, and public/patient stakeholders plays a key role in developing behaviour change interventions that are feasible and sustainable and can be implemented within routine health care systems. However, there are limited examples that provide in-depth guidance of how to do this using a systematic approach. What this study adds? This study describes an innovative use of the Behaviour Change Wheel to integrate multiple sources of evidence collected from practice, policy, research, and parent stakeholders to concurrently develop an evidence-based intervention to improve parental infant feeding behaviours and an implementation strategy to facilitate sustainable delivery by health care professionals in routine primary care.

Background Evidence-based healthcare innovations require complementary evidence-based implementation strategies to support their translation into practice. Efforts to test, refine and replicate implementation strategies are frustrated by insufficient description. Our aim was to examine the extent to which implementation strategies could be specified using the Behaviour Change Technique (BCT) taxonomy, a behavioural science tool for describing the active ingredients of interventions. Methods The data source was a compilation of 73 implementation strategies, developed through evidence synthesis and expert consensus. The definition of each strategy (n=73) was deductively coded using the BCT Taxonomy, containing 93 discrete techniques. A typology was developed iteratively to categorise the extent of overlap between strategies and BCTs. The number of BCTs per strategy and extent of overlap was estimated. In the next stage, 3 experts will independently rate 1) their level of agreement with the categorisation and 2) level of agreement with the BCT(S) identified within each strategy. Results During preliminary analysis, 87 BCTs were coded across 73 strategies (average 1.2 per strategy). Five types of overlap were identified. For 8% of strategies (n=6), there was direct overlap between the strategy description and BCT (e.g. strategy: remind clinicians/BCT: prompts and cues). For 36% of strategies (n=26), there was at least 1 BCT clearly subsumed under the strategy description which could be used to guide initial operationalisation (e.g. strategy: provide clinical supervision/BCT: restructure social environment). For 26% of strategies (n=19), a BCT(s) was probably subsumed under the strategy given its definition and/or title but other BCTs were possible depending on how the strategy is operationalised (e.g. strategy: visit other implementation sites/BCT: social comparison). For 11% (n=8), there were no BCTs clearly indicated in the strategy definition or title (e.g. strategy: make training dynamic). Finally, 19% of strategies (n=14) did not focus on behaviour change to support implementation (e.g. strategy: access new funding). Conclusion Many implementation strategies require further specification in order to apply them in a setting, relying on assumptions and inference on the part of the intervention developer, be it researcher or practitioner. This creates an opportunity for inconsistent application and limits the potential for replication and synthesis of evidence of effectiveness. This study is the first step towards moving from general descriptions of implementation strategies to full descriptions of their active ingredients. This is essential to understand how strategies at an organisational and professional level can lead to observable changes in individual behaviour.

Background Intervention development is a critical first step when conducting trials or observational studies. Research suggests that involving multiple stakeholders in this process increases the likelihood of developing interventions that are acceptable, engaging, feasible and effective. However, there is little guidance for researchers on the best ways to involve multiple stakeholders in a meaningful way. The aim of this Study Within A Trial (SWAT) is to identify the most suitable approach to involve patients and healthcare professionals in a consensus process to inform the development of the Improve Diabetes Eye-screening Attendance (IDEA’s) intervention. Methods This is a qualitative study. Three meetings were held to establish consensus on the content and delivery of the intervention. Meeting included 1 patients only, meeting 2 included a combination of patients and healthcare professionals and meeting 3 included healthcare professionals only. Stakeholders were asked to agree on intervention components which target patients and general practices. Each meeting was audio recorded and field notes were taken. After the meeting, semi-structured telephone interviews were carried to explore stakeholders’ experiences of taking part. Data were transcribed verbatim and managed using NVivo V12 software. Thematic analysis was performed to identify themes relating to members’ experiences of taking part. Results All three meetings put forward feasible ideas which were incorporated into the final intervention. Each meeting had ideas which were not put forward by the other groups but were incorporated into the final intervention (Meeting 1=6 ideas, Meeting 2=2 ideas and Meeting 3=5 ideas). Thematic analysis suggests that stakeholders in meetings 1 and 3 felt comfortable expressing their opinions and grateful that they were given the opportunity to be heard. Stakeholders in meeting 2 felt they had to hold back on their opinions as they were aware that the other stakeholder group was in the room. They also felt that their contributions were undervalued by the other stakeholder group. Conclusion Involving patients and healthcare professionals together in a consensus process is not a suitable approach to involvement. This study will guide researchers on the most suitable approach to involve patients and healthcare professionals in a consensus process and will contribute to the evolving literature on the potential impact of involving multiple stakeholders in the intervention development process.

Background Diabetic retinopathy is a common complication of diabetes affecting the blood vessels at the back of the eye. Despite evidence that diabetic retinopathy screening (DRS) is effective, uptake continues to be sub-optimal in many countries, including Ireland. As routine management of type 2 diabetes largely takes place in primary care, it is arguably the best setting in which to implement interventions to improve DRS uptake. This study aims to develop a theory-based implementation intervention to improve uptake. Methods A four-stage systematic development process was undertaken. Target behaviours were identified through a multi-phase sequential mixed methods study involving key stakeholder interviews (n=19), and an audit of screening attendance in two primary care centres. Barriers and enablers to uptake were identified through coding interviews with patients (n=48) and health care professionals (HCP) (n=30) using the Theoretical Domains Framework (TDF). Barriers and enablers were mapped to behaviour change techniques (BCTs) to develop intervention content. The APEASE (affordability, practicability, effectiveness, acceptability, side effects and equity) criteria was used to select the components. Effectiveness was determined through a rapid evidence review. Feasibility, local relevance and acceptability of the intervention were identified through consensus group meetings with patients (n=15) and HCPs (n=16), and key stakeholder consultation, including the national DRS programme. Results Three key behaviours were identified; one HCP-level (registration of patients for screening), and two patient-level (consent for the programme to hold their details, and attendance). Modifiable patient barriers and enablers were associated with six TDF domains. Barriers included confusion between screening and routine eye checks (‘Knowledge’), forgetting (‘Memory, attention, decision processes’), anticipation of a negative result (‘Beliefs about consequences’). Enablers included a recommendation from friends/family or HCPs (‘Social Influences’), recognising the importance of screening for early detection (‘Beliefs about consequences’), ownership over their condition (‘Identity’), and being in a routine of attending tests (‘Beliefs about capabilities’). HCP barriers included the time to register patients which was impeded or supported by practice resources (‘Environmental context and resources’), and a lack information on screening uptake in their local area (‘Knowledge’). Following the consensus meetings, consultation and evidence review, ten BCTs were included and operationalised as an implementation intervention targeting professionals (reimbursement, training, audit/feedback and electronic prompt) and patients (face-to-face/phone reminder messages, GP-endorsed reminder letter and information leaflet). Conclusion A multi-stage process combining theory, consultation of multiple stakeholders and existing evidence, was used to develop a multifaceted implementation intervention, targeting both professional and patients, to increase uptake of DRS. The feasibility of delivering the intervention in primary care will be evaluated through a pilot trial.

Background: Promotion of good nutrition is essential for reducing the risk of chronic disease and premature death. Evidence shows menu labeling interventions should be implemented in workplaces as part of a comprehensive approach to improve employees’ dietary habits; however, implementation challenges have arisen. This article describes a protocol for a multiple case study to explore the factors that impact on implementation of a calorie menu labeling policy in Irish public hospitals. Methods: Using a multiple case study design, comprising four Irish acute public hospitals, this study will draw on multiple perspectives and sources of evidence (observations followed by interviews, focus groups, and documentary analysis) to allow for a comprehensive depth and breadth of inquiry. Data collection and analysis will be guided by the Consolidated Framework for Implementation Research, bringing together constructs from implementation theories to understand the complexity of implementing policies. Hospitals will be categorized into high and low implementers of the policy based on quantitative data obtained from structured observations. Using framework analysis, within- and cross-case analyses will be performed to identify factors influencing policy implementation and to identify distinguishing patterns across high and low implementers and across hospital direct and indirect stakeholders. Strategies will be employed to ensure rigorous case study research, for example, triangulation, audit trail, reflexivity, and thick descriptions. An integrated knowledge translation approach, where researchers work with stakeholders throughout the research process, will be adopted to facilitate the translation of research into policy and practice. Discussion: This protocol highlights methodological insights in utilizing case study research to gain a greater understanding of the menu labeling implementation process. Study findings will be relevant to policy makers and other stakeholders involved in the rollout of such interventions and will provide a foundation to select and tailor implementation strategies to assist with scale-up of calorie menu labeling across the health service.

Background Medication costs are the primary driver of increasing medical expenditure on diabetes. We explore trends in pharmaceutical expenditure on diabetes between 2011 and 2015, examining the impact of newer blood glucose-lowering medications, and estimating the effect of cost-containment measures implemented during this time. Methods Data from a national pharmacy claims database were analysed. Patients dispensed items used in the treatment or management of diabetes were identified. Total expenditure associated with diabetes was calculated by extracting data on all diabetes-related items dispensed to eligible patients. Costs were categorised into two groups; diabetes-specific items include items used directly in the treatment of diabetes and other items include all other condition-related. The impact of two specific cost-containment measures, co-payments and reference pricing, implemented over the study period were assessed using segmented linear regression analyses of interrupted time series. Results Total expenditure varied over the study period, peaking at €216,994,441 in 2012. Expenditure on diabetes-specific items increased steadily by 18% reaching €153,621,477 in 2015, with blood glucose-lowering medications accounting for 73% of this increase. During the same period, expenditure on other items decreased by 32% to €50,835,856. The introduction of reference pricing for atorvastatin in November 2013 resulted in immediate costs savings of €2.4 million per yearly quarter (level change p Conclusion The increasing costs of blood glucose-lowering medications overshadows the effect of cost-containment measures. Innovative policies are required to ensure high quality diabetes care can be provided at an equitable, affordable and sustainable rate.

Background The optimal organisation of emergency and urgent care services (EUCS) is a perennial problem internationally. Similar to other countries, the Health Service Executive in Ireland pursued EUCS reconfiguration in response to quality and safety concerns, unsustainable costs and workforce issues. However, the implementation of reconfiguration has been inconsistent at a regional level. Our aim was to identify the factors that led to this inconsistency. Methods Using a multiple case study design, case study regions were selected based on the extent of emergency department reconfiguration in the region (categorised as full, partial and little/no reconfiguration). Semi-structured interviews were conducted with a purposive sample of stakeholders who were centrally involved in the reconfiguration process in each region. Interview data were supplemented with documentary analysis of proposals for EUCS in each region. Data were analysed using a framework approach, drawing on an existing conceptual framework for major system change. Cross-case analysis was conducted iteratively to identify patterns and differences across the regions. Results Six regions were selected for analysis and 42 interviews were analysed. The impetus to reconfigure ED services was triggered by patient safety events, and to a lesser extent by having a region-specific plan and an obvious starting point for changes. However, the complexity of the next steps and political influence impeded reconfiguration in several regions. Implementation was more strategic in regions that reconfigured later, facilitated by clinical leadership and ‘lead-in time’ to plan and sell changes. Conclusion While the global shift towards centralisation of EUCS is driven by universal challenges, decisions about when, where and how much to implement are influenced by local drivers including context, people and politics. This can contribute to a public perception of inequity and distrust in proposals for major systems change.

Background Valid and reliable estimates for the incremental costs attributable to diabetes at country-level are required to provide more precise estimates of the global cost of diabetes and to encourage and inform national responses to the diabetes epidemic. The most recent estimates for Ireland come from the CODEIRE study which uses data from the years 1999/2000 and employs a sum-all medical approach for a hospital-based sample of people with diabetes. Indirect costs are not estimated We estimate the total costs, direct and indirect, attributable to diabetes in older Irish adults. Methods Adopting a societal perspective and using a prevalence-based approach, we estimate the direct costs (healthcare utilisation and medications) and indirect costs (participation in the labour force and premature mortality) attributable to diabetes in 2013. A human capital approach was used to estimate indirect costs. Where possible, incremental costing methodology was employed. Data sources include a nationally representative cohort study, a national pharmacy claims database and national vital statistics. Results The estimated total cost of diabetes was €536,668,060 (95% CI: 360,172,044–751,720,140); €238,155,072 (95% CI: 192,023,954–278,959,992) in direct costs and €298,512,988 (95% CI: 168,148,090–472,760,148) in indirect costs. People with diabetes were 41% less likely to be employed than those without diabetes (p Conclusion We establish the societal costs attributable to diabetes in older adults in Ireland and therefore identify costs that can be directly targeted by prevention and treatment strategies. Primary, secondary and tertiary prevention of diabetes can result in significant cost savings, not only in terms of direct healthcare costs but also indirect costs.

Maternal obesity is associated with increased risk of gestational diabetes and other complications. Although antenatal interventions to help prevent these complications are ongoing, an understanding of overweight and obese pregnant women's opinions and attitudes is lacking. Therefore, this study aims to explore these women's experiences and perceptions of dietary behaviours and weight management during pregnancy. Secondary analysis of qualitative data originally collected to examine lifestyle behaviours in pregnant women was conducted. The data were from a purposive sample of overweight and obese pregnant women attending a public antenatal clinic in Cork, Ireland. The data were explored using thematic analysis. Interviews with 30 overweight and obese pregnant women were analysed. Three themes were developed relating to overweight and obese women's dietary behaviours and weight management perceptions including ‘pregnancy's influence on dietary behaviours’, ‘external influences on dietary behaviours’ and ‘perception of and preferences for weight related advice and resources’. Together these themes reveal women's experiences of diet and how pregnancy factors (physiological changes) and external factors (family and friends) can influence dietary behaviours. Furthermore, perceptions of weight management advice and lack thereof were highlighted with women drawing attention to potential resources for future use during pregnancy. This study provides important insights into overweight and obese pregnant women's dietary behaviours and perceptions of weight management. According to these findings, there is a need for clear and unambiguous information about weight management, acceptable weight gain, food safety and how to achieve a balanced diet.

ObjectiveThe aim of this study was to identify the social, biological, behavioural and psychological factors related to physical activity (PA) in early pregnancy.DesignThis is a secondary analysis of data from a prospective cohort study.SettingThe study was conducted in Cork, Ireland.ParticipantsNulliparous women with singleton pregnancies were recruited and then interviewed at 15±1 weeks’ gestation.Primary and secondary outcomesThe biopsychosocial model identified factors including social (age), biological (body mass index), behavioural (diet) and psychological (anxiety) at 15±1 weeks’ gestation. PA subgroups were identified based on a latent class analysis of their responses to a set of questions about the amount and intensity of activity they were engaging in during the pregnancy. Associations were estimated with multivariable multinomial logistic regression models.ResultsFrom a total of 2579, 1774 (69%) women were recruited; ages ranged from 17 to 45 years. Based on a combination of model fit, theoretical interpretability and classification quality, the latent class analyses identified three PA subgroups:lowPA (n=393),moderatePA (n=960) andhighPA (n=413). The fully adjusted model suggests non-smokers, and consumers of fruit and vegetables were more likely to be in the high PA subgroup (vs low). Women with more than 12 years of schooling and a higher socioeconomic status were more likely to be in the moderate PA subgroup (vs low).ConclusionThe findings highlight potential links between PA, a low education level and a low socioeconomic background. These factors should be considered for future interventions to improve low PA levels during pregnancy.Trial registration numberACTRN 12607000551493.

The initiation of complementary feeding (CF; introducing infants to food/drink other than milk) is recommended close to 6 months and not before 4 months of age. Low socio‐economic status (SES) is a determinant of nonadherence to CF recommendations, but there is an evidence gap around reasons for nonadherence among these parents. This study investigated knowledge, attitudes, and practices of disadvantaged families (in terms of SES and social support) and use of guidance for CF, in the Republic of Ireland and Northern Ireland. Parents of infants aged 3–14 months were recruited via community groups. Semistructured focus groups aided by vignettes were used. Data were analysed using an inductive thematic approach. Nineteen focus groups took place with parents (n = 83). A range of factors influence parents when introducing solids. Sources of guidance extend to family, friends, the internet, and commercial resources. Parents experience uncertainty and anxiety during this time, driven by lack of knowledge and conflicting advice. Five major themes were identified: (a) more guidance that is accessible, timely, and respectfully needed; (b) the challenge of choosing safe, nutritious food; (c) “everybody has an opinion”; (d) feelings of inadequacy, embarrassment, and guilt; and (e) decisions are ultimately based on individual circumstances. CF advice should be culturally appropriate, practical, and empowering, emphasising the rationale behind updates to recommendations and consequences of nonadherence. Future training of health professionals for delivery of CF advice and guidance should consider these findings. Compliance with CF recommendations is influenced by health professionals, the wider family, and the commercial baby‐food sector.

ObjectiveThe aim of this study was to explore healthcare professionals’ (HCPs) beliefs and attitudes towards weight management for pregnant women with a body mass index (BMI) ≥25 kg/m2.DesignQualitative study.SettingA public antenatal clinic in a large academic maternity hospital in Cork, Ireland, and general practice clinics in the same region.ParticipantsHCPs such as hospital-based midwives and consultant obstetricians and general practitioners (GPs).MethodSemistructured interviews were conducted with a purposive sample of hospital-based HCPs and a sample of GPs working in the same region. Interviews were recorded, transcribed and thematically analysed using NVivo software.ResultsSeventeen HCPs were interviewed (hospital based=10; GPs=7). Four themes identified the complexity of weight management in pregnancy and the challenges HCPs faced when trying to balance the medical and psychosocial needs of the women. HCPs acknowledged weight as a sensitive conversation topic, leading to a ‘softly-softly approach’to weight management. HCPs tried to strike a balance between being woman centred and empathetic and medicalising the conversation. HCPs described ‘doing what you can with what you have’ andshifting the focus to managing obstetric complications. Furthermore, there wereunclear roles and responsibilitiesin terms of weight management.ConclusionHCPs need to have standardised approaches and evidence-based guidelines that support the consistent monitoring and management of weight during pregnancy.

The success of childhood weight management programmes relies on family engagement. While attendance offers many benefits including the support to make positive lifestyle changes, the majority of families referred to treatment decline. Moreover, for those who do attend, benefits are often compromised by high programme attrition. This systematic review investigated factors influencing attendance at community-based lifestyle programmes among families of overweight or obese children. A narrative synthesis approach was used to allow for the inclusion of quantitative, qualitative and mixed-method study designs. Thirteen studies met the inclusion criteria. Results suggest that parents provided the impetus for programme initiation, and this was driven largely by a concern for their child's psychological health and wellbeing. More often than not, children went along without any real reason or interest in attending. Over the course of the programme, however, children's positive social experiences such as having fun and making friends fostered the desire to continue. The stigma surrounding excess weight and the denial of the issue amongst some parents presented barriers to enrolment and warrant further study. This study provides practical recommendations to guide future policy makers, programme delivery teams and researchers in developing strategies to boost recruitment and minimise attrition.

Objective. To explore risk factors for macro- and microvascular complications in a nationally representative sample of adults aged 50 years and over with type 2 diabetes in Ireland.Methods. Data from the first wave of The Irish Longitudinal Study on Ageing (TILDA) (2009–2011) was used in cross-sectional analysis. The presence of doctor diagnosis of diabetes, risk factors, and macro- and microvascular complications were determined by self-report. Gender-specific differences in risk factor prevalence were assessed with the chi-squared test. Binomial regression analysis was conducted to explore independent associations between established risk factors and diabetes-related complications.Results. Among 8175 respondents, 655 were classified as having type 2 diabetes. Older age, being male, a history of smoking, a lower level of physical activity, and a diagnosis of high cholesterol were independent predictors of macrovascular complications. Diabetes diagnosis of 10 or more years, a history of smoking, and a diagnosis of hypertension were associated with an increased risk of microvascular complications. Older age, third-level education, and a high level of physical activity were protective factors (p<0.05).Conclusions. Early intervention to target modifiable risk factors is urgently needed to reduce diabetes-related morbidity in the older population in Ireland.

Background: Depression and diabetes distress are common in people with type 2 diabetes (T2DM). These conditions are independently associated with poorer T2DM outcomes and increased healthcare utilisation and costs. Questions remain regarding the most appropriate ways of initially detecting depression and diabetes distress in this group. Diabetes guidelines recommend depression screening in primary care for people with T2DM but their implementation in practice is suboptimal. As health care professionals influence detection practices, their perceptions and experiences of these guidelines can improve understanding of aspects of the guidelines that work, and those which are more difficult to implement in practice. This study describes the protocol for a qualitative evidence synthesis of primary care health professionals’ perceived barriers and enablers to screen for and diagnose depression and diabetes distress in people with T2DM. Methods and analysis: Primary qualitative and mixed method studies will be identified using a systematic search of electronic databases and the CLUSTER (Citations, Lead authors, Unpublished materials, Scholar searches, Theories, Early examples, Related projects) approach. We selected ‘best-fit framework synthesis’ as the approach to synthesise primary data using the RETREAT (Review question-Epistemology-Time/Timescale-Resources-Expertise-Audience and purpose-Type of Data) framework. Quality appraisal of primary studies and confidence in the overall review findings will be determined using the CASP (Critical Appraisal Skills Programme) and the GRADE-CERQual (Grading of Recommendations Assessment, Development, and Evaluation Confidence in the Evidence from Reviews of Qualitative research), respectively. Discussion: The planned review will provide the first, single point of reference of the available synthesised qualitative evidence on this topic. It will apply recommended approaches to ensure rigor and robustness of study and contribute meaningfully to understanding of how depression and diabetes distress can be initially detected in people with T2DM. This protocol is awaiting processing by the International Prospective Register of Systematic Reviews (PROSPERO) [ID number 145483].

Background Maternal behaviours during pregnancy have short- and long-term consequences for maternal and infant health. Pregnancy is an ideal opportunity to encourage positive behaviour change. Despite this, limited information exists about the nature and content of lifestyle advice provided by healthcare professionals during antenatal care. Pregnancy Risk Assessment Monitoring System (PRAMS) Ireland is based on the Centers for Disease Control and Prevention (CDC) developed PRAMS that monitors maternal behaviours and experiences before, during and after pregnancy. The aim of the study was to assess the prevalence of preventive health counselling during pregnancy. Methods Secondary data analysis of the PRAMS Ireland study. Using hospital discharge records, a sampling frame of 2424 mother-infant pairs was used to alternately sample 1212 women whom had recently given birth. Preventive health counselling was defined as advice during antenatal care on smoking, alcohol, infant feeding and weight gain. Self-reported maternal behaviours (smoking/alcohol cessation, gestational weight gain, infant feeding). Univariate and multivariable analyses were conducted, adjusting for maternal characteristics. Results Among 718 women (61% response rate), the reported counselling rates were 84.8% for breastfeeding (n = 592), 48.4% for alcohol (n = 338), 47.6% for smoking (n = 333) and 31.5% for weight gain (n = 218). Women who smoked pre–pregnancy (23.7%, n = 170) were more likely to receive counselling on its effects compared to non-smokers (Adjusted Odds Ratio (AOR) 2.72 (95% Confidence Interval (CI), 1.84–4.02)). In contrast, women who did not breastfeed (AOR 0.74, 95%CI 0.44–1.26) and those who reported alcohol consumption pre-pregnancy (AOR 0.94, 95%CI 0.64–1.37) were not more likely to receive counselling on these topics. Conclusion Pregnancy is an ideal opportunity to encourage positive behaviour change. Preventive health counselling during pregnancy is not routinely provided and rates vary widely depending on the health behaviour. This study suggests that additional strategies are needed to promote positive behaviour before and during the unique opportunity provided by pregnancy.

Background Falls are one of the most serious and common threats facing older adults. Multifactorial falls risk assessment can reduce the rate of falls among community dwelling older adults and is recommended as a first step in the early detection and management of risk factors. It is used as a gateway for older people to access evidence-based interventions targeting their individual risk factors. However, effective interventions will only reduce the rate and risk of falls if there is a high level of uptake in the population and suboptimal uptake is a common challenge. The aim of this study is to understand the reasons for the patterns of uptake of multifactorial fall risk assessment clinics in the community. Methods A convergent mixed methods study design was used. Data on attendance/non-attendance during the first 12 months at each clinic (n=4) were extracted from a centralised administrative database. Semi-structured interviews (n-16) were conducted with a purposive sample of people who attended a clinic (criteria: male/female, age: 55–69, 70–79, 80+, and clinic), selected from those who had opted in during a preceding service-user experience survey. Administrative data were analysed descriptively using STATA (v13) software. Thematic analysis was performed and themes were mapped onto the Theoretical Domains Framework (TDF). Data were merged during analysis and interpretation using qualitative themes to expand on the patterns emerging in the quantitative data. Results Of the 588 older adults invited, 484 attended the assessment which resulted in an uptake rate of 82.3% (range: 77.5–86.1). Reasons for attending were summarised into themes which mapped onto 10 theoretical domains. Key themes identified were always attending medical appointments and adhering to medical advice (social/professional role and identity), having a positive attitude towards health services (optimism), being linked in with health professionals and community services (environmental context and resources) and having strong social support from family and friends (social influences). Other themes included understanding what the clinic was about (knowledge), having a fear of falling (emotion), supposing the benefits of attending (beliefs about consequences) and wanting to prevent further falls (goals). Conclusion The results suggest older people attend fall prevention services if they have existing (positive) links to health services and are well supported in their homes and communities. To improve the spread of fall prevention programmes, there is a need to reach older adults who are less well supported.

Background: Diabetic retinopathy (DR) affects 8.2% of the Irish population with type 2 diabetes over 50 years and is one of the leading causes of blindness among working-age adults. Regular diabetic retinopathy screening (DRS) can reduce the risk of sight loss. In 2013, the new national screening programme (RetinaScreen) was introduced in Ireland. Maximising DRS uptake (consent to participate in the programme and attendance once invited) is a priority, therefore it is important to identify characteristics which determine DRS uptake among those with diabetes in Ireland. We report uptake in an Irish primary care population during the initial phase of implementation of RetinaScreen and investigate factors which predict consenting to participate in the programme. Methods: In two primary care practices, data were extracted from records of people with diabetes (type 1 and type 2) aged ≥18 years who were eligible to participate in RetinaScreen between November 2013 and August 2015. Records were checked for a RetinaScreen letter. RetinaScreen were contacted to establish the status of those without a letter on file. Multivariable Poisson regression was used to examine associations between socio-demographic variables and consenting. Adjusted incident rate ratios (IRR) with 95% CI were generated as a measure of association. Results: Of 722 people with diabetes, one fifth (n=141) were not registered with RetinaScreen. Of 582 who were registered, 63% (n=365) had participated in screening. Most people who consented subsequently attended (n=365/382, 96%). People who had attended another retinopathy screening service were less likely to consent (IRR 0.65 [95%CI 0.5-0.8]; p Conclusions: Over one third of people eligible to participate in RetinaScreen had not consented. Research is needed to understand barriers and enablers of DRS uptake in the Irish context. Implementing strategies to improve DRS uptake (consent and attendance) should be a priority.

Background Implementation strategies are needed to ensure that evidence-based healthcare interventions are adopted successfully. However, strategies are generally poorly described and those used in everyday practice are seldom reported formally or fully understood. Characterising the active ingredients of existing strategies is necessary to test and refine implementation. We examined whether an implementation strategy, delivered across multiple settings targeting different stakeholders to support a fall prevention programme, could be characterised using the Behaviour Change Technique (BCT) Taxonomy. Methods Data sources included project plans, promotional material, interviews with a purposive sample of stakeholders involved in the strategy’s design and delivery and observations of staff training and information meetings. Data were analysed using TIDieR to describe the strategy and determine the levels at which it operated (organisational, professional, patient). The BCT Taxonomy identified BCTs which were mapped to intervention functions. Data were coded by three researchers and finalised through consensus. Results We analysed 22 documents, 6 interviews and 4 observation sessions. Overall, 21 out a possible 93 BCTs were identified across the three levels. At an organisational level, identifiable techniques tended to be broadly defined; the most common BCT was restructuring the social environment. While some activities were intended to encourage implementation, they did not have an immediate behavioural target and could not be coded using BCTs. The largest number and variety of BCTs were used at the professional level to target the multidisciplinary teams delivering the programme and professionals referring to the programme. The main BCTs targeting the multidisciplinary team were instruction on how to perform the (assessment) behaviour and demonstration of (assessment) behaviour; the main BCT targeting referrers was adding objects to the environment. At the patient level, few BCTs were used to target attendance. Conclusion In this study, several behaviour change techniques were evident at the individual professional level; however, fewer techniques were identifiable at an organisational level. The BCT Taxonomy was useful for describing components of a multilevel implementation strategy that specifically target behaviour change. To fully and completely describe an implementation strategy, including components that involve organisational or systems level change, other frameworks may be needed. Electronic supplementary material The online version of this article (10.1186/s13012-018-0798-6) contains supplementary material, which is available to authorized users.

Objective The optimal organisation of emergency and urgent care services (EUCS) is a perennial problem internationally. Similar to other countries, the Health Service Executive in Ireland pursued EUCS reconfiguration in response to quality and safety concerns, unsustainable costs and workforce issues. However, the implementation of reconfiguration has been inconsistent at a regional level. Our aim was to identify the factors that led to this inconsistency. Methods Using a multiple case study design, six case study regions represented full, partial and little/no reconfiguration at emergency departments (EDs). Data from documents and key stakeholder interviews were analysed using a framework approach with cross-case analysis. Results The impetus to reconfigure ED services was triggered by patient safety events, and to a lesser extent by having a region-specific plan and an obvious starting point for changes. However, the complexity of the next steps and political influence impeded reconfiguration in several regions. Implementation was more strategic in regions that reconfigured later, facilitated by clinical leadership and “lead-in time” to plan and sell changes. Conclusion While the global shift towards centralisation of EUCS is driven by universal challenges, decisions about when, where and how much to implement are influenced by local drivers including context, people and politics. This can contribute to a public perception of inequity and distrust in proposals for major systems change.

Aim To investigate the prevalence of diagnosed Type 2 diabetes and its related complications in a nationally representative sample of older adults in the Republic of Ireland. Methods Cross-sectional analysis of a population-based sample of adults aged ≥ 50 years from the first wave of The Irish Longitudinal Study on Ageing (TILDA), (2009–2011). Diagnosed Type 2 diabetes prevalence was estimated by self-report or the use of oral hypoglycaemic agents. The prevalence of microvascular and macrovascular complications was determined by self-report. Results Diagnosed Type 2 diabetes prevalence was 8.4% [95% confidence interval (CI): 7.8–9.0%] and was higher among men [10.3% (95% CI: 9.4–11.2%)] than women [6.6% (95% CI: 5.9–7.5%)]; P ≤ 0.001. Among participants with diagnosed Type 2 diabetes, the overall prevalence of microvascular complications was 26.0% (95% CI: 22.4–30.0%) with no evidence of gender-specific differences (P = 0.7). The overall prevalence of macrovascular complications was 15.1% (95% CI: 12.2–18.4%) and was higher among men [17.8% (95% CI: 14.3–23.1%)] than women [11.4% (95% CI: 7.7–16.4%)]; P ≤ 0.001. Conclusions In the absence of a national diabetes register, these findings provide a robust estimate of the national prevalence of diagnosed Type 2 diabetes and level of complications among adults aged 50 years and over in Ireland.

Background There is little research on overall cardiovascular (CV) health among couples. Our aim was to examine concordance levels for CV health among couples, using the American Heart Association ideal health metrics, and to investigate if the CV health of an individual is associated with that of his or her partner. Hypothesis There is a positive association between the overall cardiovascular health of an individual and that of his/her partner. Methods The Mitchelstown Study is a community-based cohort study of middle-aged Irish adults. Potential couples were identified as 2 study participants living at the same address. This list was cross-referenced with self-reported marital status and telephone number in the electronic patient record. Information on CV health metrics (smoking, body mass index, physical activity, diet, blood pressure, cholesterol, and glucose) was collected using standardized methods. Participants were categorized as ideal, intermediate, or poor for each of the metrics and for overall CV health. The 0- to 14-point CV health metrics score was compared within couples using linear regression. Results Of 2047 participants, 191 potential couples were identified. We excluded 6 sibling pairs, 1 divorced couple, and 3 couples who self-reported being single. The analysis includes 181 couples. There were significant associations between partners for smoking, diet, blood pressure, cholesterol, and glucose (P < 0.05). No couple had ideal CV health (ie, both partners with 7 ideal metrics). Most couples (n = 127, 69%) were concordant for poor CV health. There was a significant relationship between partners for the CV health metrics score (P < 0.05). Conclusions Our results suggest an individual's CV health is associated with that of his or her partner. Therefore, prevention strategies targeting couples and families may be appropriate.