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Background: Despite their influence, outer setting barriers (e.g., policies, financing) are an infrequent focus of implementation research. The objective of this systematic review was to identify and assess the psychometric properties of measures of outer setting used in behavioral and mental health research. Methods: Data collection involved (a) search string generation, (b) title and abstract screening, (c) full-text review, (d) construct mapping, and (e) measure forward searches. Outer setting constructs were defined using the Consolidated Framework for Implementation Research (CFIR). The search strategy included four relevant constructs separately: (a) cosmopolitanism, (b) external policy and incentives, (c) patient needs and resources, and (d) peer pressure. Information was coded using nine psychometric criteria: (a) internal consistency, (b) convergent validity, (c) discriminant validity, (d) known-groups validity, (e) predictive validity, (f) concurrent validity, (g) structural validity, (h) responsiveness, and (i) norms. Frequencies were calculated to summarize the availability of psychometric information. Information quality was rated using a 5-point scale and a final median score was calculated for each measure. Results: Systematic searches yielded 20 measures: four measures of the general outer setting domain, seven of cosmopolitanism, four of external policy and incentives, four of patient needs and resources, and one measure of peer pressure. Most were subscales within full scales assessing implementation context. Typically, scales or subscales did not have any psychometric information available. Where information was available, the quality was most often rated as “1-minimal” or “2-adequate.” Conclusion: To our knowledge, this is the first systematic review to focus exclusively on measures of outer setting factors used in behavioral and mental health research and comprehensively assess a range of psychometric criteria. The results highlight the limited quantity and quality of measures at this level. Researchers should not assume “one size fits all” when measuring outer setting constructs. Some outer setting constructs may be more appropriately and efficiently assessed using objective indices or administrative data reflective of the system rather than the individual.

Background: Older people are among the most vulnerable patients in acute care hospitals. The hospitalisation process can result in newly acquired functional or cognitive deficits termed hospital associated decline (HAD). Prioritising fundamental care including mobilisation, nutrition, and cognitive engagement can reduce HAD risk. Aim: The Frailty Care Bundle (FCB) intervention aims to implement and evaluate evidence-based principles on early mobilisation, enhanced nutrition and increased cognitive engagement to prevent functional decline and HAD in older patients. Methods: A hybrid implementation science study will use a pragmatic prospective cohort design with a pre-post mixed methods evaluation to test the effect of the FCB on patient, staff, and health service outcomes. The evaluation will include a description of the implementation process, intervention adaptations, and economic costs analysis. The protocol follows the Standards for Reporting Implementation Studies (StaRI). The intervention design and implementation strategy will utilise the behaviour change theory COM-B (capability, motivation, opportunity) and the Promoting Action on Research Implementation in Health Services (i-PARIHS). A clinical facilitator will use a co-production approach with staff. All patients will receive care as normal, the intervention is delivered at ward level and focuses on nurses and health care assistants (HCA) normative clinical practices. The intervention will be delivered in three hospitals on six wards including rehabilitation, acute trauma, medical and older adult wards. Evaluation: The evaluation will recruit a volunteer sample of 180 patients aged 65 years or older (pre 90; post 90 patients). The primary outcomes are measures of functional status (modified Barthel Index (MBI)) and mobilisation measured as average daily step count using accelerometers. Process data will include ward activity mapping, staff surveys and interviews and an economic cost-impact analysis. Conclusions: This is a complex intervention that involves ward and system level changes and has the potential to improve outcomes for older patients.

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.

Introduction Understanding primary care practices’ ‘readiness’ to engage in trials and their experience is important to inform trial procedures and supports. Few studies report on the feasibility of study procedures though this is a central part of pilot trials. We explored the acceptability and feasibility of study procedures of a cluster randomised pilot trial of an intervention in primary care to improve uptake of Ireland’s national diabetic retinopathy programme. Methods As part of the embedded mixed-methods process evaluation, quantitative and qualitative data were gathered across four general practices participating in the intervention. Interviews were conducted with a purposive sample of staff. Research logs on time spent on intervention delivery, staff assignment, resources, problems/changes, and reasons for drop-outs, were maintained over the course of intervention rollout, and practice audit data were analysed. Quantitative outcomes included recruitment, retention, completion, and data quality and completeness. Qualitative data on perceptions and experience of the pilot trial procedures were analysed using the Framework Method. Findings Nine staff (3 GPs, 4 nurses, 2 administrators) were interviewed. An interest in the topic area or in research motivated practices to take part in the trial. Reimbursement meant they could ‘afford’ to participate. Staff valued the researcher briefing at the start of the trial, to avoid ‘going in slightly blind’. While staff varied in audit skills and confidence, and some found this aspect of data collection challenging, a ‘step-by-step’ audit manual and regular researcher contact, helped them stay on track and troubleshoot during data collection. Audit quality was acceptable overall, however there were some issues, incorrect assignment of patient status being most common. Conclusion The IDEAs trial procedures were acceptable and feasible for primary care staff, however, challenges with conducting the audit may reflect staff skills gaps and the need for greater guidance and support from researchers.

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.

Objectives Major changes have been made to how emergency care services are configured in several regions in the Republic of Ireland. This study investigated the hypothesis that engagement activities undertaken prior to these changes influenced stakeholder perspectives on the proposed changes and impacted on the success of implementation. Methods A comparative case-study approach was used to explore the changes in three regions. These regions were chosen for the case study as the nature of the proposals to reconfigure care provision were broadly similar but implementation outcomes varied considerably. Documentary analysis of reconfiguration planning reports was used to identify planned public engagement activities. Semi-structured interviews with 74 purposively-sampled stakeholders explored their perspectives on reconfiguration, engagement activities and public responses to reconfiguration. Framework analysis was used, integrating inductive and deductive approaches. Results Approaches to public engagement and success of implementation differed considerably across the three cases. Regions that presented the public with the reconfiguration plan alone reported greater public opposition and difficulty in implementing changes. Engagement activities that included a range of stakeholders and continued throughout the reconfiguration process appeared to largely address public concerns, contributing to smoother implementation. Conclusions The presentation of reconfiguration reports alone is not enough to convince communities of the case for change. Genuine, ongoing and inclusive engagement offers the best opportunity to address community concerns about reconfiguration.

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.

Background: Integrated care, organising care delivery within and between services, is an approach to improve the quality of care. Existing specialist roles have evolved to work across settings and services to integrate care. However, there is limited insight into how these expanded roles are implemented, including how they may be shaped by context. This paper examines how new diabetes nurse specialists working across care boundaries, together with hospital-based diabetes nurse specialists, adapt to support the implementation of integrated care. Methods: We conducted semi-structured focus groups and interviews with diabetes nurse specialists purposively sampled by work setting and health service region (n = 30). Analysis was data-driven, coding actions or processes to stay closer to the data and using In Vivo codes to preserve meaning. Findings: Community nurse specialists described facing a choice of “sink or swim” when appointed with limited guidance on their role. To ‘swim’ and implement their role, required them to use their initiative and adapt to the local context. When first appointed, both community and hospital nurse specialists actively managed misconceptions of their role by other staff. To establish clinics in general practices, community nurse specialists capitalised on professional contacts to access GPs who might utilise their role. They built GP trust by adopting practice norms and responding to individual needs. They adapted to the lack of a multidisciplinary team “safety net” in the community, by “practicing at a higher level”, working more autonomously. Developing professional links and pursuing on-going education was a way to create an alternative ‘safety net’ so as to feel confident in their clinical decision-making when working in the community. Workarounds facilitated information flow (i.e. patient blood results, treatment, and appointments) between settings in the absence of an electronic record shared between general practices and hospital settings. Conclusions: Flexibility and innovation facilitates a new way of working across boundaries. Successful implementation of nurse specialist-led integrated care requires strategies to address elements in the inner (differences in practice organisation, role acceptance) and outer (information systems) context.

Objective The 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. Design Qualitative study. Setting A public antenatal clinic in a large academic maternity hospital in Cork, Ireland, and general practice clinics in the same region. Participants HCPs such as hospital-based midwives and consultant obstetricians and general practitioners (GPs). Method Semistructured 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. Results Seventeen 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’ and shifting the focus to managing obstetric complications. Furthermore, there were unclear roles and responsibilities in terms of weight management. Conclusion HCPs need to have standardised approaches and evidence-based guidelines that support the consistent monitoring and management of weight during pregnancy.

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.

Introduction: In Ireland, there has been an increased investment in Clinical Nurse Specialists (CNS) in Diabetes Integrated Care, placed in the community to support the delivery of a new model of integrated diabetes care whereby patients with uncomplicated type 2 diabetes (T2DM) are managed in primary care, and patients with complicated T2DM are managed between primary and secondary care. We describe care processes relating to new (2013-2015) and existing community CNS to examine the implementation of the new model. Methods: CNS recorded care processes for April–June 2016 including practices visited, practice visits, GPs interested in the service, service capacity, patient contacts, and cases discussed with a member of the multidisciplinary team (MDT) as an indicator of service integration. Data were recorded in Excel and submitted to the National Diabetes Programme manager. Results are reported by Whole Time Equivalent (WTE) (based on CNS returning data), and by Community Healthcare Organisations (CHO), nine regional networks of community-based services in Ireland. Results: Of 27 CNS, 25 (93%) (23.36 WTE) returned data. Overall, 395 practices were visited (23.8 per WTE; median(range) per CHO, 47(10-88) per CHO), 533 practice visits were conducted (24.9 per WTE; 48 (10-111) per CHO). Most of the practices visited were attended regularly by the CNS (n=359, 91%), while 9% (n=36) were new practices visited for the first time in that quarter. Of the 22 CNSs who reported on service capacity, 68% (n=15) indicated they were not in a position to take on new practices. Among CNS reporting on GP engagement (n=20), 17 had ≥1 practice waiting to avail of the service. There were 2817 patient contacts (121 per WTE; 194(40-728) per CHO), primarily patients with complicated T2DM (n=1947, 69.1%), with few non-attenders (n=387, 12.1%). Overall, 339 patients (12%) were discussed with the MDT, 33(10–114) per CHO. Discussion: CNS activity varied across CHOs, possibly reflecting differences in regional allocation of CNS, and how diabetes services are organised locally. Conclusions: (key findings) Patient contacts were mainly complicated T2DM in keeping with the national model of care. CNS activity was concentrated in practices already accessing their service, with most reporting their service is at capacity. Lessons learned: Despite GP interest in the service, most CNS are unable to take on new practices. The new diabetes ‘cycle of care’ national funding initiative, which will remunerate GPs for management of patients with uncomplicated T2DM, is expected to increase demand for CNS support in the community. Regional disparities in resourcing should be addressed, and CNS supported to work with new practices. Limitations: Provision of patient and professional education, also part of the CNS role, was not captured. There are no baseline data against which to benchmark current activity. While outcomes of care are important, our initial focus has been on processes to develop a culture of data collection and monitoring. Suggestions for future research: These data will form part of an audit and feedback cycle with CNS, to develop the data collection process, inform future service delivery, and work towards creating key performance indicators.

Introduction: In Ireland, a diabetes ‘cycle of care’ funding initiative (2015) will remunerate GPs for management of patients with uncomplicated Type 2 diabetes (T2DM), establishing formal requirements for registering, recording and documenting care processes. However, limited research exists on the long-term performance of structured, primary care-led diabetes management both in Ireland and internationally. The Midlands Diabetes Structured Care Programme (MDSCP) encompasses evidence-based strategies to integrate and coordinate diabetes management within general practice (clinical integration) and with other disciplines (professional integration), including patient registration and recall, regular diabetes review visits, active role of the practice nurse in coordination and ongoing management, multidisciplinary specialist access (e.g. clinical nurse specialists (CNS), dietetics, ophthalmology, chiropody), professional education, and remuneration. We examine the quality of care delivered to patients with T2DM using data from 16 years of the programme.Methods: At four time points, 1998, 2003, 2008 and 2015, data on the documentation of care processes and outcomes were collected by CNS from patients with T2DM (≥18 years) registered with participating practices. Data were extracted from patient notes using a paper-based data collection form. Using Stata, chi-square tests for trend were used to test differences in processes and outcomes over time, benchmarked against national guidelines(1) and the English National Diabetes Audit (NDA) 2014-2015;(2) a suitable comparator given that structured diabetes care in the UK is supported by existing policy and financial incentives. Results: Data on 331 patients with T2DM in 1998 (10 practices); 843 in 2003 (20 practices); 989 in 2008 (30 practices), and 1106 (30 practices) in 2015 were available for analysis. Documentation of all processes improved significantly over time (p97%) was comparable with the NDA with the exception of BMI (69.5%) and smoking (78.9%). The proportion of patients with a blood pressure

Introduction: Limited data exists, internationally and in Ireland, on long-term outcomes among people with diabetes who are managed in primary care. The Midlands Diabetes Structured Care Programme takes a multifaceted approach to primary-care-led management, encompassing evidence-based strategies to integrate diabetes management within general practice (clinical integration) and with other disciplines (professional integration), including patient registration and recall, regular diabetes review visits, active role of the practice nurse in coordination and ongoing management, multidisciplinary specialist access (e.g. nurse specialists, dietetics, ophthalmology, chiropody), professional education, and remuneration. Our aim was to examine mortality, complications and clinical outcome targets among patients with diabetes enrolled in the programme since its establishment in 1998.Methods: Data were collected in 1998 and 2015, on patient outcomes (mortality (2015), complications (2008–2015), and clinical parameters (1998, 2015)), among patients with diabetes (≥18 years) registered with participating practices. Data were extracted from patient notes by clinical nurse specialists using a paper-based data collection form. Using Stata, chi-square tests were used to test differences in clinical outcomes over time and to examine baseline factors associated with mortality.Results: Overall 376 patients (10 practices) were followed up to 2015. Among survivors (n=192, 51%), 23% (n=30) had experienced a macrovascular complication; primarily heart failure (n=9, 7%) or CVA (n=7, 5%), and 2% (n=1) had a minor amputation. In 1998, 15% (n=14) had retinopathy, increasing to 72% (n=118) by 2015. The proportion of patients with a recommended blood pressure target (

Introduction: Diabetic foot disease is a common and costly complication of diabetes and is a leading cause of lower extremity amputations worldwide. It requires coordinated input from multi-disciplinary teams (MDT) for prevention, monitoring and treatment. In Ireland, in 2012, the national clinical programme for diabetes recruited additional podiatrists and introduced a model of care for the diabetic foot. It outlined appropriate risk-stratified pathways, with the aim to reduce foot ulcers, lower extremity amputations and hospital costs. However, international evidence suggests complex interventions do not always translate into routine practice. Our aim is to identify and explain which aspects of the model of care are working (or not working), for whom and in what circumstances. Methods: This study is a realist evaluation, adopting a multi-stage mixed-methods design. Analysis of documents pertaining to the design, development and implementation of the model of care and semi-structured interviews with national stakeholders (n=19) were carried out to develop initial theories about how the model of care was intended to work. These theories were tested at a regional level using a multiple case study design (n=4 regions). Interviews are ongoing with local stakeholders including general practitioners, integrated care nurses, podiatrists and endocrinologists (n=15/case), supplemented with analysis of routine activity data. Data will be analysed to refine or revise the initial programme theories. Results: It was envisaged that by publishing and disseminating the model of care document, which outlined appropriate risk stratified pathways and clinical governance at each stage, healthcare professionals would ‘re-align’ their work and the appropriate patients would be referred and managed in the appropriate setting. According to national stakeholders, implementation was hindered from the outset; there were gaps in the pathways across both primary and secondary care because there was variation in existing services and limited new resources to support full implementation of the model of care. Preliminary findings from regional case studies concur, suggesting that health professionals are unable to make appropriate referrals where gaps exist in the pathways, for instance in areas where there are no community podiatrists. However, the regional case studies have also identified additional contextual factors that influence the implementation of the pathways. These factors include an awareness around the diabetic foot and an understanding of the role of podiatrists as well as the presence of an established MDT for diabetes care. Discussions/conclusion: Our realist evaluation suggests that while the successful implementation of the risk-stratified pathways is dependent on the presence of all necessary healthcare professionals along the care continuum, it is also influenced by additional contextual factors, particularly awareness around the diabetic foot and the presence of an established MDT. Lessons learned: It is important that integrated care is adequately resourced across the care continuum. Lack of awareness around the diabetic foot and the role of podiatrists hinders the full implementation of the model of care. Limitations: In the absence of a national diabetes register and audit data, the quantitative component of the study has relied on routine activity data. Future research: Refinement of programme theories is ongoing.

Introduction: In 2008, the national strategy for the prevention of falls and fractures in Ireland was published. In 2009, a detailed mapping exercise in our region demonstrated the size of our problem showing 4,680 emergency department attendances locally for falls annually, 21,500 acute bed-days used after falls and falls-related local health cost of €31 million. We had elements of good practice but services for falls management were neither coordinated nor integrated. Practice change: We took a whole-system approach to the delivery of services for falls in older people. Since 2012 a multidisciplinary clinician group has worked with regional management to improve falls services. Our project has four main work streams: building community capacity for fall risk assessment; re-engineering specialist fall services to improve access; standardising continuing care falls assessment; and promoting healthy ageing to prevent falls. Aim: We aim to deliver 1,300 additional multifactorial fall risk assessment places yearly. Our objective was to implement an integrated pathway between emergency department, community services and specialist services for falls prevention. Targeted population: Our catchment population has ~300,000 people in mixed urban and rural settings. A large stakeholder workshop was held in July 2014. The change management process is coordinated through monthly steering group meetings along with weekly teleconferences with four project work-streams leads. Highlights: In 2015, a regional falls coordinator and an administrator were appointed. The continuing care work-stream has separate funding, allowing an experienced nurse support 17 community units for 12 months to implement a standardized approach to falls. Otherwise, all developments were within existing resources. A simplified referral pathway with a single point of access was established. Five new community-based falls risk assessment clinics using validated user-friendly assessment tool were formed. Mentoring by experienced staff is important to support each new community clinic. Pathways now exist linking the emergency department, geriatric medicine specialist services and the community falls services. A medical fall clinic and a multidisciplinary community rehabilitation team were integrated into a single specialist fall service and a weekly triage meeting started. The referral rate has doubled in the past six months with over 80 new cases now triaged monthly. By re-engineering the specialist service, we reduced the waiting times for medical appointments from over three months to two weeks. Conclusions & Discussion: By following a national strategy supported by detailed local data a change management approach has delivered a system-wide integrated falls service in our region. The success of this project has depended on securing buy in from key stakeholders. With complex interacting services having a single point of contact through the falls service coordinator has been essential. Clinicians and management building trust and working together over time was central to this project. A robust evaluation of “how” this change has been achieved is underway to ensure the learning is transferable to other areas. Lessons learned: Resilience is essential in such a large project Change of this scale requires top down support for a bottom up approach Ongoing ownership by those involved in service delivery is important

Background Obesity during pregnancy is associated with a number of complications including gestational diabetes mellitus (GDM). Currently, little is known about guidelines in clinical practice and the challenges faced by heath care professionals (HCPs). The aim of this study was to understand the perceptions, approach and challenges faced by midwives, obstetricians and general practitioners who provide antenatal care to women who are overweight and obese during pregnancy with the view to informing the development of an antenatal lifestyle intervention. Methods Semi-structured interviews were conducted with a purposive sample of health care professionals (HCPs) from Cork University Maternity Hospital (CUMH) (n=10) and with a sample of General Practitioners (GPs) working in primary care in the region (n=7). Data was collected until data saturation occurred. Interviews were digitally recorded and transcribed into NVivo V.10 software. Thematic analysis is on-going. Results Preliminary results identified ‘knowledge of weight management’ and ‘antenatal services’ as key issues. A lack of knowledge was evident involving risks, complications and initiating a conversation around overweight and obesity in pregnancy. Variation exists around what is considered appropriate weight gain and whether HCPs were following any particular guidelines. HCPs expressed concern about the dramatic increase in the number of pregnant women who are overweight and obese and how weight perception has changed in society. Large ‘caseloads’ meant that lifestyle factors were not routinely discussed with the women and furthermore, a lack of communication is very evident between HCPs in the hospital and GPs in terms of the services provided. Conclusion HCPs expressed challenges when communicating with their patients about weight management in pregnancy. By ensuring midwives and other HCPs have the knowledge, skills and opportunity to discuss weight and lifestyle factors with pregnant women, the women, in turn, may be more motivated to maintain healthy behaviour’s during pregnancy.

Background Regular Physical Activity (PA) during pregnancy is associated with a number of health benefits such as preventing pregnancy complications, limiting pregnancy weight gain, and decreasing the risk of gestational diabetes. Despite this, women’s PA levels often reduce or cease during pregnancy. Various factors like body mass index, unemployment, and educational levels have been shown to be associated with PA levels during pregnancy. Using the Screening for Pregnancy Endpoint (SCOPE) data, this study aimed to examine the association of health behaviours and psychological well-being on PA levels in pregnancy using the biopsychosocial model. Methods Nulliparous women with a singleton pregnancy were recruited from a large academic maternity hospital in Cork, Ireland (CUMH) as part of the international SCOPE study. Data was collected at 15±1 week’s gestation including personal information, lifestyle and psychological measures. The outcome of interest was PA categorised as low, moderate or high levels and covariates were selected using the biopsychosocial model including social (age; years of schooling; socioeconomic status), biological (body mass index), behavioural (diet; smoking) and psychological factors (anxiety; response to pregnancy). Univariate and multivariable multinomial logistic regression examined the association between covariates and PA using Stata IC13. Results 1774 pregnant women were recruited to SCOPE and women were classified as having low (22.3%), moderate (54.4%) or high (23.4%) PA levels (n=1766). In the fully adjusted model, preliminary findings indicate that age categories 30–34 years (OR 2.34 [95% CI: 1.26–4.37]),≥35 years (OR 2.06 [95% CI: 1.01–4.19]) compared to those Conclusion Social and behavioural factors appear to be the most influential factors driving PA levels. The results should be used to guide the development of educational campaigns and behaviour change intervention to encourage younger women to be active and to target those with lower education attainment and of lower socioeconomic status.

Background In Ireland, more Diabetes Nurse Specialists (DNSs) have been introduced into the community as part of a national programme to standardise and improve diabetes care. DNSs support the delivery of a new model of care whereby uncomplicated type 2 diabetes (T2DM) is managed in primary care, and complicated T2DM is managed between primary and secondary care. Historically diabetes care in Ireland has often been delivered in an unstructured way, lacking integration between primary and secondary care. Given this context we wanted to understand the challenges faced by community-based DNSs in delivering a standardised service. Methods We purposively sampled DNSs from community-based respondents to a national survey (n=25) according to four administrative regions of the national health service. We conducted focus groups and interviews using a semi-structured topic guide. Interviews were digitally recorded and transcribed into NVivo V.11 software for coding and analysis. Data analysis is on-going using thematic analysis. Results Sixteen DNSs participated in 2 focus groups, and 8 interviews. Preliminary analysis suggested elements of the role presented a challenge. As DNSs require their Collaborative Practice Agreement to be signed off by each GP using their service, they were currently unable to prescribe in the community. Despite describing this as ‘frustrating’, DNSs suggested that prescribing could remove opportunities for relationship-building with GPs through discussion of medications. In the community, DNSs lacked the safety net of the hospital team to check things with, and had to work more autonomously, described as ‘daunting’. Role understanding by other staff was another challenge; DNSs felt managers did not understand how the community role should work, which created difficulty when negotiating aspects of the role, including flexible working hours. The lack of a shared record between settings meant patient information from hospital appointments was not readily accessible by DNSs at GP practices and vice versa. This made patient follow-up and case discussion difficult when DNSs were off-site. The absence of administrative support in the role, considered ‘crucial’, was also highlighted. Further interviews with community DNSs are ongoing. Conclusion Community-based DNSs faced challenges presented by aspects of their role, their relationship with other staff, their work environment, and the available organisational infrastructure and resources. Although recent policy reforms in Ireland have focused on improving the integrated management of diabetes in the community, findings from this study suggest DNSs may need to be better supported to ensure delivery of a standardised model of diabetes care.

Background Limited data exists, internationally and in Ireland, on long-term outcomes among people with diabetes who are managed in primary care. The Midlands Diabetes Structured Care Programme encompasses evidence-based strategies to structure diabetes management within general practice: patient registration and recall, regular diabetes review visits, active role of the practice nurse in ongoing management, multidisciplinary specialist access, professional education, and remuneration. Our aim was to examine clinical outcome targets, complications and mortality among patients with diabetes enrolled in the programme since its establishment in 1998. Methods Data were collected in 1999, 2003, 2008 and 2015, on outcomes (clinical parameters, complications and mortality) among patients with diabetes (≥18 years) registered with participating practices. Data were extracted from patient notes by clinical nurse specialists using a paper-based data collection form. Cause and date of death were obtained from national death records. Using Stata, chi-square tests were used to test differences in clinical outcomes over time. Cox proportional hazards regression was used to examine the association of baseline factors and mortality. Results Patients from 1999 (n=376), were followed up in 2003 (n=229), 2008 (n=96) and 2016 (n=376).The proportion of patients with a recommended blood pressure target ( Discussion Improvements in the clinical profile of patients enrolled in the programme since its introduction suggests primary-care-led integrated diabetes management can perform favourably in the long-term. However, the high incidence of macrovascular complications, prevalence of retinopathy and mortality rate indicates the importance of effective management.

Background Obesity during pregnancy is associated with increased risk of gestational diabetes mellitus (GDM) and other complications. Physical activity is a modifiable lifestyle factor that may help to prevent these complications but many women reduce their physical activity levels during pregnancy. Interventions targeting physical activity in pregnancy are on-going but few identify the underlying behaviour change mechanisms by which the intervention is expected to work. To enhance intervention effectiveness, recent tools in behavioural science such as the Theoretical Domains Framework (TDF) and COM-B model (capability, opportunity, motivation and behaviour) have been employed to understand behaviours for intervention development. Using these behaviour change methods, this study aimed to identify the enablers and barriers to physical activity in overweight and obese pregnant women. Methods Semi-structured interviews were conducted with a purposive sample of overweight and obese women at different stages of pregnancy attending a public antenatal clinic in a large academic maternity hospital in Cork, Ireland. Interviews were recorded and transcribed into NVivo V.10 software. Data analysis followed the framework approach, drawing on the TDF and the COM-B model. Results Twenty one themes were identified and these mapped directly on to the COM-B model of behaviour change and ten of the TDF domains. Having the social opportunity to engage in physical activity was identified as an enabler; pregnant women suggested being active was easier when supported by their partners. Knowledge was a commonly reported barrier with women lacking information on safe activities during pregnancy and describing the information received from their midwife as ‘limited’. Having the physical capability and physical opportunity to carry out physical activity were also identified as barriers; experiencing pain, a lack of time, having other children, and working prevented women from being active. Conclusion A wide range of barriers and enablers were identified which influenced women’s capability, motivation and opportunity to engage in physical activity with “knowledge” as the most commonly reported barrier. This study is a theoretical starting point in making a ‘behavioural diagnoses’ and the results will be used to inform the development of an intervention to increase physical activity levels among overweight and obese pregnant women. Electronic supplementary material The online version of this article (10.1186/s12884-018-1816-z) contains supplementary material, which is available to authorized users.

ObjectivesInternational evidence suggests the diabetes nurse specialist (DNS) has a key role in supporting integrated management of diabetes. We examine whether hospital and community DNS currently support the integration of care, examine regional variation in aspects of the service relevant to the delivery of integrated care and identify barriers to service delivery and areas for improvement.DesignA cross-sectional survey of hospital and community-based DNS in Ireland.MethodsBetween September 2015 and April 2016, a 67-item online survey, comprising closed and open questions on their clinical role, diabetes clinics, multidisciplinary working, and barriers and facilitators to service delivery, was administered to all eligible DNS (n=152) in Ireland. DNS were excluded if they were retired or on maternity leave or extended leave.ResultsThe response rate was 66.4% (n=101): 60.6% (n=74) and 89.3% (n=25) among hospital and community DNS, respectively. Most DNS had patients with stable (81.8%) and complicated type 2 diabetes mellitus (89.9%) attending their service. The majority were delivering nurse-led clinics (81.1%). Almost all DNS had a role liaising with (91%), and providing support and education to (95%), other professionals. However, only a third reported that there was local agreement on how their service should operate between the hospital and primary care. Barriers to service delivery that were experienced by DNS included deficits in the availability of specialist staff (allied health professionals, endocrinologists and DNS), insufficient space for clinics, structured education and issues with integration.ConclusionsDelivering integrated diabetes care through a nurse specialist-led approach requires that wider service issues, including regional disparities in access to specialist resources and formalising agreements and protocols on multidisciplinary working between settings, be explicitly addressed.