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The aim of the BETTER WISE intervention is to address cancer and chronic disease prevention and screening (CCDPS) and lifestyle risks in patients aged 40–65. The purpose of this qualitative study is to better understand facilitators and barriers to the implementation of the intervention. Patients were invited for a 1-h visit with a prevention practitioner (PP), a member of a primary care team, with specific skills in prevention, screening, and cancer survivorship. We collected and analyzed data from 48 key informant interviews and 17 focus groups conducted with 132 primary care providers and from 585 patient feedback forms. We analyzed all qualitative data using a constant comparative method informed by grounded theory and then employed the Consolidated Framework for Implementation Research (CFIR) in a second round of coding. The following key elements were identified: (1) Intervention characteristics—relative advantage and adaptability; (2) Outer setting—PPs compensating for increased patient needs and decreased resources; (3) Characteristics of individuals—PPs (patients and physicians described PPs as compassionate, knowledgeable, and helpful); (4) Inner setting—network and communication (collaboration and support in teams or lack thereof); and (5) Process—executing the implementation (pandemic-related issues hindered execution, but PPs adapted to challenges). This study identified key elements that facilitated or hindered the implementation of BETTER WISE. Despite the interruption caused by the COVID-19 pandemic, the BETTER WISE intervention continued, driven by the PPs and their strong relationships with their patients, other primary care providers, and the BETTER WISE team.

Background The COVID-19 pandemic challenged healthcare systems worldwide and disrupted primary care, particularly prevention, screening, and lifestyle counselling. BETTER WISE is a comprehensive and structured approach that proactively addresses cancer and chronic disease prevention and screening (CCDPS), including cancer survivorship and screening for poverty and lifestyle risks for patients aged 40 to 65. Patients from 13 primary care clinics (urban, rural, and remote) in Alberta, Ontario, and Newfoundland & Labrador, Canada were invited for a 1-hour visit with a prevention practitioner (PP), a member of the primary care team with specialized training in CCDPS to provide patients an overview of eligible screening and assist with lifestyle counselling. This qualitative sub-study describes how the COVID-19 pandemic impacted BETTER WISE in a constantly changing medical landscape. Methods We conducted 17 focus groups and 48 key informant interviews with a total of 132 primary care providers (PPs, physicians, allied health professionals, and clinic staff) over three different time points to better understand their perspectives on the BETTER WISE project. We also received 585 patient feedback forms of the 1005 patients who agreed to participate in the study. We also collected field notes and memos and employed thematic analysis using a constant comparative method focused on the impact of the pandemic on BETTER WISE. Results We identified four themes related to how the COVID-19 pandemic impacted the BETTER WISE study: 1) Switch of in-person visits to visits over the phone; 2) Lack of access to preventive care and delays of screening tests; 3) Changes in primary care providers’ availability and priorities; 4) Mental health impacts of the pandemic on patients and primary care providers. Conclusions The COVID-19 pandemic had and, at the time of writing, continues to have an impact on primary care, particularly on prevention, screening, and lifestyle counselling. Despite structural, procedural, and personal challenges throughout different waves of the pandemic, the primary care clinics participating in BETTER WISE were able to complete the study. Our results underscore the importance of the role of primary care providers in adapting to changing circumstances and support of patients in these challenging times. Trial registration This qualitative study is a sub-component of the BETTER WISE pragmatic, cRCT, trial registration ISRCTN21333761 (date of registration 19/12/2016).

It was highlighted that the original article [1] contained some mistakes in some of the authors’ affiliations. This Correction article shows the correct affiliations. The original article has been updated.

Background The BETTER (Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care) intervention was designed to integrate the approach to chronic disease prevention and screening in primary care and demonstrated effective in a previous randomized trial. Methods We tested the effectiveness of the BETTER HEALTH intervention, a public health adaptation of BETTER, at improving participation in chronic disease prevention and screening actions for residents of low-income neighbourhoods in a cluster randomized trial, with ten low-income neighbourhoods in Durham Region Ontario randomized to immediate intervention vs. wait-list. The unit of analysis was the individual, and eligible participants were adults age 40–64 years residing in the neighbourhoods. Public health nurses trained as “prevention practitioners” held one prevention-focused visit with each participant. They provided participants with a tailored prevention prescription and supported them to set health-related goals. The primary outcome was a composite index: the number of evidence-based actions achieved at six months as a proportion of those for which participants were eligible at baseline. Results Of 126 participants (60 in immediate arm; 66 in wait-list arm), 125 were included in analyses (1 participant withdrew consent). In both arms, participants were eligible for a mean of 8.6 actions at baseline. At follow-up, participants in the immediate intervention arm met 64.5% of actions for which they were eligible versus 42.1% in the wait-list arm (rate ratio 1.53 [95% confidence interval 1.22–1.84]). Conclusion Public health nurses using the BETTER HEALTH intervention led to a higher proportion of identified evidence-based prevention and screening actions achieved at six months for people living with socioeconomic disadvantage. Trial registration NCT03052959, registered February 10, 2017.

Background This qualitative study is a sub-component of BETTER WISE, a comprehensive and structured approach that proactively addresses chronic disease prevention, screening, and cancer survivorship, including screening for poverty and addressing lifestyle risks for patients aged 40 to 65. Patients (n = 527) from 13 primary care clinics (urban, rural, and remote) in Alberta, Ontario, and Newfoundland & Labrador, Canada agreed to participate in the study and were invited to a one-hour prevention visit delivered by a Prevention Practitioner (PP) as part of BETTER WISE. We identified the key components of a BETTER WISE prevention visit based on patients’ and primary care providers’ perspectives. Methods Primary care providers (PPs, physicians and their staff) participated in 14 focus groups and 19 key informant interviews to share their perspectives on the BETTER WISE project. Of 527 patients who agreed to participate in the study and were invited for a BETTER WISE prevention visit with a PP, we received 356 patient feedback forms. We also collected field notes and memos and employed thematic analysis using a constant comparative method focusing on the BETTER WISE prevention visit. Results We identified four key themes related to a BETTER WISE prevention visit: 1) Creating a safe environment and building trust with patients: PPs provided sufficient time and a safe space for patients to share what was important to them, including their concerns related to poverty, alcohol consumption, and mental health, topics that were often not shared with physicians; 2) Providing personalized health education: PPs used the BETTER WISE tools to provide patients with a personalized overview of their health status and eligible screening; 3) Non-judgmental empowering of patients: Instead of directing patients on what to do, PPs evoked patients’ preferences and helped them to set goals (if desired); and 4) Integrating care for patients: PPs clarified information from patients’ charts and surveys with physicians and helped patients to navigate resources within and outside of the primary care team. Conclusions The results of this study underscore the importance of personalized, trusting, non-judgmental, and integrated relationships between primary care providers and patients to effectively address chronic disease prevention, screening, and cancer survivorship as demonstrated by the BETTER WISE prevention visits. Trial registration This qualitative study is a sub-component of the BETTER WISE pragmatic, cRCT, trial registration ISRCTN21333761 (date of registration 19/12/2016)

BackgroundThe Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care (BETTER) randomised control trial (RCT) showed that the BETTER Program improved chronic disease prevention and screening (CDPS) by 32.5% in urban team-based primary care clinics.AimTo evaluate outcomes from implementation of BETTER in diverse clinical settings.Design & settingAn implementation study was undertaken to apply the CDPS intervention from the BETTER trial to diverse settings in BETTER 2. Patients aged 40–65 years were invited to enrol in the study from three clinics in Newfoundland and Labrador, Canada.MethodAt baseline, eligibility for 27 CDPS actions (for example, cancer, diabetes and hypertension screening, lifestyle) was determined. Patients then met with a trained provider and prioritised goals to address their eligible CDPS actions. Providers received training in behaviour change theory and practice. Descriptive analysis of clinical outcomes and success factors were reported.ResultsA total of 154 patients (119 female and 35 male) had a baseline visit; 106 had complete outcome assessments, and the remainder had partial outcome assessments. At baseline, patients were eligible for a mean of 12.3 CDPS actions and achieved a mean of 6.0 (49%, 95% confidence intervals [CI] = 24% to 74%) at 6-month follow-up, including reduced hypertension (86% of eligible patients, 95% CI = 67% to 96%), weight control (51% of eligible patients, 95% CI = 42% to 60%), and smoking cessation (36% of eligible patients, 95% CI = 17% to 59%). Male, highly educated, and lower income individuals achieved a higher proportion of CDPS manoeuvers than their counterparts.ConclusionClinical outcomes from this implementation study were comparable with those of the prior BETTER RCT, providing support for the BETTER Program as an effective approach to CDPS in more diverse general practice settings.

BackgroundChronic disease prevention and screening (CDPS) has been identified as a top priority in primary care. However, primary care providers often lack time, evidence-based tools, and consistent guidelines to effectively address CDPS. Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care (BETTER) is a novel approach that introduces a new role, that of the prevention practitioner; the prevention practitioner meets with patients, one on one, to undertake a personalised CDPS visit. Understanding patients’ perspectives is important for clinicians and other stakeholders aiming to address and integrate CDPS.AimTo describe patients’ perspectives regarding visits with a prevention practitioner in BETTER 2, an implementation study that was carried out after the BETTER trial and featured a higher proportion of patients in rural and remote locations.Design & settingQualitative description based on patient feedback surveys, completed by patients in three primary care clinics (urban, rural, and remote) in Newfoundland and Labrador, Canada.MethodPatients’ perspectives were assessed based on responses from 91 feedback forms. In total, 154 patients (aged 40–65 years) received ≥1 prevention visit(s) from a prevention practitioner and were asked to provide written feedback. In addition to demographics, patients were asked what they liked about their visit(s), what they would have liked to be different, and invited to make any other comments. Qualitative description was used to analyse the data.ResultsFour main themes emerged from patients’ feedback: value of visit (patients appreciated the visit with a prevention practitioner); visit characteristics (the visit was personalised, comprehensive, and sufficiently long); prevention practitioners' characteristics (professionalism and interpersonal skills); and patients’ concerns (termination of the programme and access to preventative care).ConclusionPatients appreciated the visits they received with a prevention practitioner and expressed their desire to receive sustained CDPS in primary care.

To assess primary care providers' (PCPs') experiences with, perceptions of, and desired role in personalized medicine, with a focus on cancer.Qualitative study involving focus groups.Urban and rural interprofessional primary care team practices in Alberta and Ontario.Fifty-one PCPs.Semistructured focus groups were conducted and audiorecorded. Recordings were transcribed and analyzed using techniques informed by grounded theory including coding, interpretations of patterns in the data, and constant comparison.Five focus groups with the 51 participants were conducted; 2 took place in Alberta and 3 in Ontario. Primary care providers described limited experience with personalized medicine, citing breast cancer and prenatal care as main areas of involvement. They expressed concern over their lack of knowledge, in some circumstances relying on personal experiences to inform their attitudes and practice. Participants anticipated an inevitable role in personalized medicine primarily because patients seek and trust their advice; however, there was underlying concern about the magnitude of information and pace of discovery in this area, particularly in direct-to-consumer personal genomic testing. Increased knowledge, closer ties to genetics specialists, and relevant, reliable personalized medicine resources accessible at the point of care were reported as important for successful implementation of personalized medicine.Primary care providers are prepared to discuss personalized medicine, but they require better resources. Models of care that support a more meaningful relationship between PCPs and genetics specialists should be pursued. Continuing education strategies need to address knowledge gaps including direct-to-consumer genetic testing, a relatively new area provoking PCP concern. Primary care providers should be mindful of using personal experiences to guide care.

Background: The Building on Existing Tools to Improve Chronic Disease Prevention and Screening (BETTER) intervention has improved uptake of chronic disease prevention and screening activities in primary care. The BETTER intervention consists of 1:1 visits between prevention practitioners (PPs) and patients (40-65 years). It is unknown if an adapted BETTER could be effective in the community with public health nurses as PPs. Aim: The presentation objective is to describe community engagement strategies in a cluster RCT in low income neighborhoods with low cancer screening rates and low uptake of primary care. Methods: Principles of community-based participatory research were used to design the community engagement strategy in Durham region, Ontario. Key elements included close collaboration with public health partners to identify stakeholders and creating a community advisory committee (CAC) and a primary care engagement group to provide advice. Results: We identified 15 community stakeholder groups (∼47 subgroups) including service organizations, faith groups, and charitable organizations representing diverse constituents. Community outreach activities included in-person meetings and information displays at local events. The CAC is comprised of members of the public and representatives from primary care, social services, and community organizations. The CAC and primary care engagement groups have provided advice on trial recruitment strategies and on the design of the PP visit. Conclusion: The partnership between public health, primary care, and the study team has been crucial to connect with community stakeholders. Community engagement is essential in raising awareness about the study and will contribute to successful recruitment. Trial Registration: NCT03052959

Qualitative researchers aim to explore, understand, and conceptualize the experiences and perspectives of their participants, particularly participants' own interpretations of their thoughts, feelings, and actions (Richards & Morse, 2007). Interviewing is the most popular data collection strategy for this endeavor (Liamputtong, 2010). Denzin and Lincoln (1994), for instance, claim that interviewing is "the favorite methodological tool of the qualitative researcher" (p. 353). Two underlying assumptions of the interview as a data collection strategy are that participants are reasonably comfortable with a question and answer format and with expressing themselves verbally in such a format. Yet, our experiences and those of other researchers suggest that these assumptions are not equally valid across populations.Recently, we conducted a study with young fathers (ranging in age from 16 to 25) and were surprised when we encountered difficulties in both recruiting and interviewing them. The purpose of this paper is to describe our experiences interviewing young fathers using both conventional interviews, characterized by one-on-one, face-to-face interactions (Johnson, 2002) and photo-interviewing, characterized by using photographs as props during an interview (Hurworth, 2003). We do not argue that one data collection strategy is necessarily better than the other, but we theorize as to why photo-interviewing may make young fathers more comfortable participating in interviews. Overall, our aim in this paper is to encourage discussion of alternative data collection strategies to engage young fathers, and possibly other populations, in research.In this paper, we describe the challenges we encountered using conventional interviews with young fathers. We then describe photo-interviewing by positioning it within the context of other popular visual research methods. Lastly, we share our observations of the possible benefits of photo-interviewing for conducting research with young fathers.Our Experiences Interviewing Young FathersYoung fathers have often faced challenges that make sharing their experiences difficult and undesirable. They may come from unstable and low-income families (Devault et al., 2008), may lack the resources to financially provide for their children (Mollborn, 2007), and may experience social stigma and marginalization (Weber, 2012). These characteristics were true for the participants in our study.Understanding this, we created an environment that we thought would make it appealing for young, vulnerable fathers to speak with us. For example, we established a close relationship with the support agency that worked with the fathers; we let the fathers choose if they wanted their outreach workers present during the interview; we obtained consent orally; we asked questions in a conversational manner rather than using a formal interview guide; and we used a casual interviewing style, allowing participants to take the lead whenever possible. Even so, we had significantly more difficulty recruiting young fathers into this study than we did recruiting young mothers from the same agency for a similar kind of study. And, although the interviews went reasonably well (i.e., rapport was developed, participants were cooperative and tried to answer questions), the experience left a sense of dissatisfaction with the interviewer. Participants often appeared to be somewhat uncomfortable or anxious, they often fidgeted and physically faced away from the interviewer during the interview, they did not make or hold eye contact in a typical fashion often focusing their eyes on what appeared to be a random spot in the room, and their answers did not have the depth hoped for by the interviewer. Quite simply, the interviews did not flow as comfortably as similar interviews with young, vulnerable moms.Although the literature on the challenges of including men in social science research is scarce, some researchers have addressed men's unwillingness to participate in research, particularly in family research. …

Background BETTER (Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care) is a patient-based intervention to improve chronic disease prevention and screening (CDPS) for cardiovascular disease, diabetes, cancer, and associated lifestyle factors in patients aged 40 to 65. The key component of BETTER is a prevention practitioner (PP), a health care professional with specialized skills in CDPS who meets with patients to develop a personalized prevention prescription, using the BETTER toolkit and Brief Action Planning. The purpose of this qualitative study was to understand facilitators and barriers of the implementation of the BETTER 2 program among clinicians, patients, and stakeholders in three (urban, rural, and remote) primary care settings in Newfoundland and Labrador, Canada. Methods We collected and analyzed responses from 20 key informant interviews and 5 focus groups, as well as memos and field notes. Data were organized using Nvivo 10 software and coded using constant comparison methods. We then employed the Consolidated Framework for Implementation Research (CFIR) to focus our analysis on the domains most relevant for program implementation. Results The following key elements, within the five CFIR domains, were identified as impacting the implementation of BETTER 2: (1) intervention characteristics—complexity and cost of the intervention; (2) outer setting—perception of fit including lack of remuneration, lack of resources, and duplication of services, as well as patients’ needs as perceived by physicians and patients; (3) characteristics of prevention practitioners—interest in prevention and ability to support and motivate patients; (4) inner setting—the availability of a local champion and working in a team versus working as a team; and (5) process—planning and engaging, collaboration, and teamwork. Conclusions The implementation of a novel CDPS program into new primary care settings is a complex, multi-level process. This study identified key elements that hindered or facilitated the implementation of the BETTER approach in three primary care settings in Newfoundland and Labrador. Employing the CFIR as an overarching typology allows for comparisons with other contexts and settings, and may be useful for practices, researchers, and policy-makers interested in the implementation of CDPS programs.

Family physicians (fps) play a role in aspects of personalized medicine in cancer, including assessment of increased risk because of family history. Little is known about the potential role of fps in supporting cancer patients who undergo tumour gene expression profile (gep) testing. We conducted a mixed-methods study with qualitative and quantitative components. Qualitative data from focus groups and interviews with fps and cancer specialists about the role of fps in breast cancer gep testing were obtained during studies conducted within the pan-Canadian canimpact research program. We determined the number of visits by breast cancer patients to a fp between the first medical oncology visit and the start of chemotherapy, a period when patients might be considering results of gep testing. The fps and cancer specialists felt that ordering gep tests and explaining the results was the role of the oncologist. A new fp role was identified relating to the fp&ndash, patient relationship: supporting patients in making adjuvant therapy decisions informed by gep tests by considering the patient&rsquo, s comorbid conditions, social situation, and preferences. Lack of fp knowledge and resources, and challenges in fp&ndash, oncologist communication were seen as significant barriers to that role. Between 28% and 38% of patients visited a fp between the first oncology visit and the start of chemotherapy. Our findings suggest an emerging role for fps in supporting patients who are making adjuvant treatment decisions after receiving the results of gep testing. For success in this new role, education and point-of-care tools, together with more effective communication strategies between fps and oncologists, are needed.

Background The objectives of this paper are to describe the planned implementation and evaluation of the Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care (BETTER 2) program which originated from the BETTER trial. The pragmatic trial, informed by the Chronic Care Model, demonstrated the effectiveness of an approach to Chronic Disease Prevention and Screening (CDPS) involving the use of a new role, the prevention practitioner. The desired goals of the program are improved clinical outcomes, reduction in the burden of chronic disease, and improved sustainability of the health-care system through improved CDPS in primary care. Methods/design The BETTER 2 program aims to expand the implementation of the intervention used in the original BETTER trial into communities across Canada (Alberta, Ontario, Newfoundland and Labrador, the Northwest Territories and Nova Scotia). This proactive approach provides at-risk patients with an intervention from the prevention practitioner, a health-care professional. Using the BETTER toolkit, the prevention practitioner determines which CDPS actions the patient is eligible to receive, and through shared decision-making and motivational interviewing, develops a unique and individualized ‘prevention prescription’ with the patient. This intervention is 1) personalized; 2) addressing multiple conditions; 3) integrated through linkages to local, regional, or national resources; and 4) longitudinal by assessing patients over time. The BETTER 2 program brings together primary care providers, policy/decision makers and researchers to work towards improving CDPS in primary care. The target patient population is adults aged 40–65. The reach, effectiveness, adoption, implementation, maintain (RE-AIM) framework will inform the evaluation of the program through qualitative and quantitative methods. A composite index will be used to quantitatively assess the effectiveness of the prevention practitioner intervention. The CDPS actions comprising the composite index include the following: process measures, referral/treatment measures, and target/change outcome measures related to cardiovascular disease, diabetes, cancer and associated lifestyle factors. Discussion The BETTER 2 program is a collaborative approach grounded in practice and built from existing work (i.e., integration not creation). The program evaluation is designed to provide an understanding of issues impacting the implementation of an effective approach for CDPS within primary care that may be adapted to become sustainable in the non-research setting.