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Introduction: Excessive alcohol consumption is a leading global risk factor for ill-health and premature death. Digital alcohol interventions can be effective at reducing alcohol consumption, but their widespread adoption is lagging behind. This study aimed to identify factors promoting or inhibiting the implementation of a digital alcohol intervention in Norwegian primary care, by using Normalization Process Theory (NPT). Methods: A mixed methods feasibility study combining quantitative and qualitative methods. A digital alcohol intervention called "Endre" was implemented across four GP practices in Stavanger and Oslo. Usage of the intervention was logged on the digital platform. General practitioners (GPs) reported their perceived uptake of the intervention via a web-based survey. The Normalization MeAsure Development (NoMAD) survey was used to measure support staff's perceived normalization of the intervention. Qualitative data were analyzed using the NPT framework, with quantitative data analyzed descriptively and using χ 2 and Wilcoxon signed-rank test for differences in current and future normalization. Results: Thirty-seven GPs worked in the clinics and could recruit patients for the digital intervention. Thirty-six patients registered for the intervention. Nine patients dropped out early and 25 completed the intervention as intended. Low normalization scores at follow-up (n = 27) indicated that Endre did not become fully embedded in and across practices. Nonetheless, staff felt somewhat confident about their use of Endre and thought it may become a more integral part of their work in the future. Findings from six semi-structured group interviews suggested that limited implementation success may have been due to a lack of tailored implementation support, staff's lack of involvement, their diminished trust in Endre, and a lack of feedback on intervention usage. The outbreak of the Covid-19 pandemic further limited opportunities for GPs to use Endre. Conclusion: This study investigated the real-world challenges of implementing a digital alcohol intervention in routine clinical practice. Future research should involve support staff in both the development and implementation of digital solutions to maximize compatibility with professional workflows and needs. Integration of digital solutions may further be improved by including features such as dashboards that enable clinicians to access and monitor patient progress and self-reported outcomes. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Introduction: As a workforce crisis is causing recruitment and retention issues for new to practice GPs, we designed Catalyst, a one-year pilot career development program aiming to help new to practice GPs develop the skills of advanced generalist practice and build capacity for the complex work of primary care. In this paper, we report the findings of our evaluation of Catalyst. Methods: We used normalization process theory to investigate how Catalyst was contributing to the participants' understanding and implementation of generalist practice. We conducted 36 interviews and six focus groups investigating the participants' clinical practice and experience with the program and analyzed data using framework analysis. Results: Establishing a shared language and reframing professional identity helped GPs develop an understanding of their role through generalist lenses. Generalist practice was legitimized by access to scientific evidence and facilitated interactive learning. Integration of scientific, applied knowledge and quality improvement work fostered the enactment of such practice. Structured reflection and research-informed quality improvement projects contributed to the participants' awareness of the primary care context. Discussion: Knowledge creation activities observed through interactive learning and the integration of different types of knowledge facilitated the implementation of advanced generalist practice. The participants valued the community of practice gained through the program and would come to rely on programs designed to encourage networking and enable peer support. Finally, research-informed quality improvement projects built to analyze problems and monitor solutions are crucial for an early career physician to develop a sense of agency that shapes their primary care practice. [ABSTRACT FROM AUTHOR]

Background: This paper uses Normalization Process Theory (NPT) to examine staff impressions of Montessori-based program training and implementation at Veterans Affairs Community Living Centers (VA CLCs; nursing homes). Methods: We conducted a mixed-methods evaluation of Montessori Approaches to Person-Centered Care (MAP-VA) at eight VA CLCs. Trainings were conducted as either a live virtual course or a pre-recorded asynchronous class. Two NPT constructs, coherence building and cognitive participation, informed qualitative interview questions, surveys, and analyses focused on staff movement from knowledge to action during initial implementation. Data collection included staff-completed standardized post-training exams (N = 906), post-training evaluations (N = 761), and optional validated surveys on perceptions of Montessori training (N = 307). Champions (peer-leaders) from each CLC completed semi-structured qualitative interviews post-training (N = 22). Findings: The majority of staff (83%–90%) passed all courses. Staff evaluated the training highly (80%+ agreement) on learning relevant new knowledge and confidence applying new skills. On average, staff felt MAP-VA would become a normal part of their work (7.68/10 scale), and reported increased familiarity with Montessori approaches after training (p =.002). Qualitative interview data from staff trained in Montessori supported three themes concordant with the NPT dimensions of coherence building and cognitive participation. (1) Coherence regarding Montessori: staff demonstrated an understanding of the program and mentioned the benefits of Montessori compared to their previous usual routines. Cognitive participation or engagement with Montessori: (2) staff had positive feelings about Montessori principles/applications and demonstrated a willingness to try the Montessori approach, and (3) staff made sense of the new intervention through early rehearsal of Montessori principles/practices and recognized opportunities for using Montessori in future interactions. Conclusions: Montessori virtual training resulted in high levels of coherence and cognitive participation among multidisciplinary staff, evidenced by high knowledge, self-efficacy, and readiness to act. The asynchronous and synchronous trainings were accessible, relevant, and supported diverse learners. [ABSTRACT FROM AUTHOR]

Background: In low- and middle-income countries (LMICs), such as Tanzania, the competency of healthcare providers critically influences the quality of pediatric care. To address this issue, we introduced Pediatric Acute Care Education (PACE), an adaptive learning program to enhance provider competency in Tanzania's guidelines for managing seriously ill children. Adaptive learning is a promising alternative to current in-service education, yet optimal implementation strategies in LMIC settings are unknown. Objectives: (1) To evaluate the initial PACE implementation in Mwanza, Tanzania, using the construct of normalization process theory (NPT); (2) To provide insights into its feasibility, acceptability, and scalability potential. Methods: Mixed-methods study involving healthcare providers at three facilities. Quantitative data was collected using the Normalization MeAsure Development (NoMAD) questionnaire, while qualitative data was gathered through in-depth interviews (IDIs) and focus groups discussions (FGDs). Results: Eighty-two healthcare providers completed the NoMAD survey. Additionally, 24 senior providers participated in IDIs, and 79 junior providers participated in FGDs. Coherence and cognitive participation were high, demonstrating that PACE is well understood and resonates with existing healthcare goals. Providers expressed a willingness to integrate PACE into their practices, distinguishing it from existing educational methods. However, challenges related to resources and infrastructure, particularly those affecting collective action, were noted. Early indicators point toward the potential for long-term sustainability of the PACE, but assessment of reflexive monitoring was limited due to the study's focus on PACE's initial implementation. Conclusion: This study offers vital insights into the feasibility and acceptability of implementing PACE in a Tanzanian context. While PACE aligns well with healthcare objectives, addressing resource and infrastructure challenges as well as conducting a longer-term study to assess reflexive monitoring is crucial for its successful implementation. Furthermore, the study underscores the value of the NPT as a framework for guiding implementation processes, with broader implications for implementation science and pediatric acute care in LMICs. [ABSTRACT FROM AUTHOR]

Abstract Background In low- and middle-income countries (LMICs), such as Tanzania, the competency of healthcare providers critically influences the quality of pediatric care. To address this issue, we introduced Pediatric Acute Care Education (PACE), an adaptive learning program to enhance provider competency in Tanzania’s guidelines for managing seriously ill children. Adaptive learning is a promising alternative to current in-service education, yet optimal implementation strategies in LMIC settings are unknown. Objectives (1) To evaluate the initial PACE implementation in Mwanza, Tanzania, using the construct of normalization process theory (NPT); (2) To provide insights into its feasibility, acceptability, and scalability potential. Methods Mixed-methods study involving healthcare providers at three facilities. Quantitative data was collected using the Normalization MeAsure Development (NoMAD) questionnaire, while qualitative data was gathered through in-depth interviews (IDIs) and focus groups discussions (FGDs). Results Eighty-two healthcare providers completed the NoMAD survey. Additionally, 24 senior providers participated in IDIs, and 79 junior providers participated in FGDs. Coherence and cognitive participation were high, demonstrating that PACE is well understood and resonates with existing healthcare goals. Providers expressed a willingness to integrate PACE into their practices, distinguishing it from existing educational methods. However, challenges related to resources and infrastructure, particularly those affecting collective action, were noted. Early indicators point toward the potential for long-term sustainability of the PACE, but assessment of reflexive monitoring was limited due to the study’s focus on PACE’s initial implementation. Conclusion This study offers vital insights into the feasibility and acceptability of implementing PACE in a Tanzanian context. While PACE aligns well with healthcare objectives, addressing resource and infrastructure challenges as well as conducting a longer-term study to assess reflexive monitoring is crucial for its successful implementation. Furthermore, the study underscores the value of the NPT as a framework for guiding implementation processes, with broader implications for implementation science and pediatric acute care in LMICs.

Background: While Cardiac Rehabilitation (CR) programs have shown effectiveness in improving cardiac outcomes, there is limited understanding of how patients perceive and adapt to these interventions. Furthermore, alternative modes of delivering CR that have received positive evaluations from participants remain underexplored, yet they have the potential to enhance CR uptake. Objectives: To explore the patient experience in CR programmes following Acute Myocardial Infarction (AMI) and describe their adaptive processing. Patients and Methods: This qualitative study was conducted at a nationally certified centre in China between July 2021 and September 2022, encompassing three stages: in-hospital, centre-based, and home-based CR programs. Purposive sampling was used to select eligible AMI patients for in-depth semi-structured interviews. The interview outline and analytical framework were aligned with the key concepts derived from the middle-range theory of adaptation to chronic illness and the normalization process theory. The findings were reported following the Consolidated Criteria for Reporting Qualitative Research checklist. Results: Forty AMI patients were recruited. Four main themes describing the process of AMI patients normalizing CR intervention were identified, including (1) experiencing CR service driving by role's responsibilities, (2) engaging in collaborative relationship based on interpersonal trust, (3) exploring a personalized rehabilitation plan by complex integration, and (4) expecting a promised outcome to shape decision-making. Conclusion: Integrated care interventions for AMI patients could benefit from a collaborative co-designed approach to ensure that CR interventions are normalized and fit into patients' daily lives. Organizational-level CR services should align with the rehabilitation needs and expectations of patients. [ABSTRACT FROM AUTHOR]

Abstract Background Alcohol-related mortality and morbidity increased during the COVID-19 pandemic in England, with people from lower-socioeconomic groups disproportionately affected. The North East and North Cumbria (NENC) region has high levels of deprivation and the highest rates of alcohol-related harm in England. Consequently, there is an urgent need for the implementation of evidence-based preventative approaches such as identifying people at risk of alcohol harm and providing them with appropriate support. Non-alcohol specialist secondary care clinicians could play a key role in delivering these interventions, but current implementation remains limited. In this study we aimed to explore current practices and challenges around identifying, supporting, and signposting patients with Alcohol Use Disorder (AUD) in secondary care hospitals in the NENC through the accounts of staff in the post COVID-19 context. Methods Semi-structured qualitative interviews were conducted with 30 non-alcohol specialist staff (10 doctors, 20 nurses) in eight secondary care hospitals across the NENC between June and October 2021. Data were analysed inductively and deductively to identify key codes and themes, with Normalisation Process Theory (NPT) then used to structure the findings. Results Findings were grouped using the NPT domains ‘implementation contexts’ and ‘implementation mechanisms’. The following implementation contexts were identified as key factors limiting the implementation of alcohol prevention work: poverty which has been exacerbated by COVID-19 and the prioritisation of acute presentations (negotiating capacity); structural stigma (strategic intentions); and relational stigma (reframing organisational logics). Implementation mechanisms identified as barriers were: workforce knowledge and skills (cognitive participation); the perception that other departments and roles were better placed to deliver this preventative work than their own (collective action); and the perceived futility and negative feedback cycle (reflexive monitoring). Conclusions COVID-19, has generated additional challenges to identifying, supporting, and signposting patients with AUD in secondary care hospitals in the NENC. Our interpretation suggests that implementation contexts, in particular structural stigma and growing economic disparity, are the greatest barriers to implementation of evidence-based care in this area. Thus, while some implementation mechanisms can be addressed at a local policy and practice level via improved training and support, system-wide action is needed to enable sustained delivery of preventative alcohol work in these settings.

Goals of Care (GOC) is a longitudinal, multi-setting, and interprofessional practise aiming to guide the use of life-sustaining therapies. We documented the perspectives of different stakeholders regarding their roles in GOC intervention and explored the possibility of implementing an interprofessional approach in a healthcare and social services institution. We interviewed nurses, social workers, and relatives of deceased persons and analyzed the results using an analytical framework based on the 16 mechanisms of the Normalization Process Theory. We identified barriers to implementing a sustainable interprofessional approach to GOC, such as the lack of designated leaders responsible for supporting the day-to-day provision of this rather complex intervention, the difficulty of access to physicians in two of the three care settings under study, and the lack of a robust informational system. We also demonstrated that the GOC intervention is postponed until there is no uncertainty to deal with, i.e., at the end of life. Our study adds to an emerging body of literature criticising the concept of making advance medical directives itself. We advocated for the promotion of tools that would enable lay people to select and empower a supportive decision maker to better represent them in serious illness decision making. [ABSTRACT FROM AUTHOR]

Aim: To identify barriers and facilitators impacting the implementation of a comprehensive transfer program aimed at parents of adolescents with chronic illness in clinical practice. Design: A real‐time, qualitative process evaluation. Methods: Individual interviews were conducted with 10 nurses and seven physicians from paediatric and adult outpatient clinics: Nephrology, hepatology, neurology, and rheumatology. Data were analysed through the lens of normalization process theory. Results: Themes were framed within the theory's four components. (1) Coherence: Healthcare professionals' views on their core tasks and on the parents' role influenced their perception of the program. (2) Cognitive participation: A named key worker, autonomy, and collaboration impacted healthcare professionals' involvement in the program. (3) Collective action: Department prioritization and understanding of the program's aim were key factors in its successful delivery. (4) Reflective monitoring: Participants experienced that the program helped parents during transfer but questioned if the program was needed by all families. Conclusion: We identified three barriers: Healthcare professionals' lack of understanding of the parental role during transfer, top‐down decisions among nurses, and physicians' uncertainty about their role in joint consultations. Facilitators: Healthcare professionals' understanding of the program's purpose and expected effect, the nurses' significant role as named keyworkers, and good collaboration across paediatric and adult departments. Implications for the Profession and/or Patient Care: Implementation strategies should be developed before implementing a transfer program in clinical practice. Impact: Implementing a parental transfer program in clinical practice can be challenging. Therefore, for successful implementation, it is crucial to identify barriers and facilitators.Barriers and facilitators exist at the personal, professional, and organizational levels, and it is important to understand them.The results of this qualitative study could support the implementation of transfer programs in other settings. Reporting Method: Consolidated criteria for reporting qualitative studies (COREQ). Patient or Public Contribution: No patient or public contribution. What does this paper contribute to the wider global clinical community?: Nurses' and physicians' experiences of ownership of the transfer program is essential for successful implementation.Clinics should appoint a named keyworker, preferably a nurse, as the driving force during the implementation of a transfer program.Nurses and physicians should receive training about the purpose, justification, and expected effect of a transfer program before implementation. [ABSTRACT FROM AUTHOR]

Aims Design Methods Results Conclusion Impact Patient or Public Contribution To explore levers and barriers to providing culturally responsive care for general practice nurses (GPNs) using normalization process theory.A self‐administered online cross‐sectional survey.A participatory co‐designed adapted version of the normalization of complex interventions measure (NoMAD) validated tool was distributed to a convenience sample of GPNs between December 2022 and February 2023. The sample comprised of GPNs working in general practice services in Ireland (n = 122). Data were analysed using descriptive and analytical statistics (Pearson correlations) and principles of content analysis. This study was conducted and reported in line with the Consensus‐Based Checklist for Reporting of Survey Studies (CROSS).GPNs in this study indicated their familiarity with, acknowledged the importance of and were committed to, providing culturally responsive care. However, implementing culturally responsive care in daily practice was problematic due to insufficient education and training, scarcity of resources and supports and a lack of organizational leadership. Subsequently, GPNs experience difficulties adapting everyday practices to respond appropriately to the care needs of culturally and linguistically diverse (CaLD) patients.This analysis highlights the necessity of exploring the intricacies of factors that influence capabilities and capacity for providing culturally responsive care. Despite demonstrating awareness of the importance of providing nursing care that responds to the needs of CaLD patients, GPNs do not have full confidence or capacity to integrate culturally responsive care into their daily work practices.Using normalization process theory, this study elucidates for the first time how GPNs in Ireland make sense of, legitimize, enact and sustain culturally responsive care as a routine way of working. It illuminates the multitude of micro‐level (individual), meso‐level (organizational) and macro‐level (structural) factors that require attention for normalizing culturally responsive care in general practice services.The study question was identified in a participatory research prioritization for Irish research about migrant health that involved migrants in the process. [ABSTRACT FROM AUTHOR]

Background: Alcohol-related mortality and morbidity increased during the COVID-19 pandemic in England, with people from lower-socioeconomic groups disproportionately affected. The North East and North Cumbria (NENC) region has high levels of deprivation and the highest rates of alcohol-related harm in England. Consequently, there is an urgent need for the implementation of evidence-based preventative approaches such as identifying people at risk of alcohol harm and providing them with appropriate support. Non-alcohol specialist secondary care clinicians could play a key role in delivering these interventions, but current implementation remains limited. In this study we aimed to explore current practices and challenges around identifying, supporting, and signposting patients with Alcohol Use Disorder (AUD) in secondary care hospitals in the NENC through the accounts of staff in the post COVID-19 context. Methods: Semi-structured qualitative interviews were conducted with 30 non-alcohol specialist staff (10 doctors, 20 nurses) in eight secondary care hospitals across the NENC between June and October 2021. Data were analysed inductively and deductively to identify key codes and themes, with Normalisation Process Theory (NPT) then used to structure the findings. Results: Findings were grouped using the NPT domains 'implementation contexts' and 'implementation mechanisms'. The following implementation contexts were identified as key factors limiting the implementation of alcohol prevention work: poverty which has been exacerbated by COVID-19 and the prioritisation of acute presentations (negotiating capacity); structural stigma (strategic intentions); and relational stigma (reframing organisational logics). Implementation mechanisms identified as barriers were: workforce knowledge and skills (cognitive participation); the perception that other departments and roles were better placed to deliver this preventative work than their own (collective action); and the perceived futility and negative feedback cycle (reflexive monitoring). Conclusions: COVID-19, has generated additional challenges to identifying, supporting, and signposting patients with AUD in secondary care hospitals in the NENC. Our interpretation suggests that implementation contexts, in particular structural stigma and growing economic disparity, are the greatest barriers to implementation of evidence-based care in this area. Thus, while some implementation mechanisms can be addressed at a local policy and practice level via improved training and support, system-wide action is needed to enable sustained delivery of preventative alcohol work in these settings. [ABSTRACT FROM AUTHOR]

Abstract Background There is a growing recognition of multidisciplinary practices as the most rational approach to providing better and more efficient healthcare services. Pharmacists are increasingly integrated into primary care teams, but there is no universal approach to implementing pharmacist services across healthcare settings. In Norway, most pharmacists work in pharmacies, with very few employed outside this traditional setting. The home care workforce is primarily made up of nurses, assistant nurses, and healthcare assistants. General practitioners (GPs) are not based in the same location as home care staff. This study utilized the Normalization Process Theory (NPT) to conduct a process evaluation of the integration of pharmacists in a Norwegian home care setting. Our aim was to identify barriers and facilitators to optimal utilization of pharmacist services within a multidisciplinary team. Methods Semi-structured interviews (n = 9) were conducted with home care unit leaders, ward managers, registered nurses, and pharmacists in Norway, in November 2022-February 2023. Constructs from the NPT were applied to qualitative data. Results Findings from this study pertain to the four constructs of the NPT. Healthcare professionals struggled to conceptualize the pharmacists’ competencies and there were no collectively agreed-upon objectives of the intervention. Consequently, some participants questioned the necessity of pharmacist integration. Further, participants reported conflicting preferences regarding how to best utilize medication-optimizing services in everyday work. A lack of stakeholder empowerment was reported across all participants. Moreover, home care unit leaders and managers reported being uninformed of their roles and responsibilities related to the implementation process. However, the presence of pharmacists and their services were well received in the setting. Moreover, participants reported that pharmacists’ contributions positively impacted the multidisciplinary practice. Conclusion Introducing new work methods into clinical practice is a complex task that demands expertise in implementation. Using the NTP model helped pinpoint factors that affect how pharmacists’ skills are utilized in a home care setting. Insights from this study can inform the development of tailored implementation strategies to improve pharmacist integration in a multidisciplinary team.

Abstract Background Despite recommendations against psychotropic medication in older nursing homes residents with behavioral and psychological symptoms of dementia (BPSD), antidepressants and other psychotropic drugs are still prescribed. We performed a cluster-randomized controlled trial to evaluate the effect of a complex intervention aiming to promote the deprescribing of antidepressants in institutionalized older persons with dementia. To understand the underlying mechanisms of trial outcomes, we conducted a process evaluation exploring the interventions implementation, areas of impact, and contextual factors. The aim of this study was to explore the implementation process and the key factors that promoted and inhibited intervention implementation in the care home setting (Clinicaltrials.gov: NCT04985305. Registered 30 July 2021). Methods Qualitative interviews were conducted between August 2022 and February 2023 with four general practitioners and eight nursing home staff from four associated nursing homes in the Capital Region of Denmark. We coded the interview data according to the four constructs of the Normalization Process Theory (coherence, cognitive participation, collective action, and reflexive monitoring). Results There was a common understanding of the intervention aim. We observed a raised awareness concerning the deprescription of antidepressants among healthcare professionals with good collaboration (coherence). An overall buy-in to a deprescribing mentality was seen (cognitive participation). There were barriers to the GPs and nursing home staff’s use of the intervention elements and how they implemented it, but to some, a common language was created (collective action). Professionals overall valued the idea of deprescribing, but lack of time, high staff turnover, and low education level among nursing home staff hampered the integration (reflexive monitoring). Conclusion Successful implementation seemed to be dependent on the quality of the relationship between the single GP and the single nursing home professional. A common deprescribing mentality promoted the uptake of the intervention. However, several barriers related to lack of resources hindered implementation. It is imperative to adapt complex interventions to the available resources and context.

Background: There is a growing recognition of multidisciplinary practices as the most rational approach to providing better and more efficient healthcare services. Pharmacists are increasingly integrated into primary care teams, but there is no universal approach to implementing pharmacist services across healthcare settings. In Norway, most pharmacists work in pharmacies, with very few employed outside this traditional setting. The home care workforce is primarily made up of nurses, assistant nurses, and healthcare assistants. General practitioners (GPs) are not based in the same location as home care staff. This study utilized the Normalization Process Theory (NPT) to conduct a process evaluation of the integration of pharmacists in a Norwegian home care setting. Our aim was to identify barriers and facilitators to optimal utilization of pharmacist services within a multidisciplinary team. Methods: Semi-structured interviews (n = 9) were conducted with home care unit leaders, ward managers, registered nurses, and pharmacists in Norway, in November 2022-February 2023. Constructs from the NPT were applied to qualitative data. Results: Findings from this study pertain to the four constructs of the NPT. Healthcare professionals struggled to conceptualize the pharmacists' competencies and there were no collectively agreed-upon objectives of the intervention. Consequently, some participants questioned the necessity of pharmacist integration. Further, participants reported conflicting preferences regarding how to best utilize medication-optimizing services in everyday work. A lack of stakeholder empowerment was reported across all participants. Moreover, home care unit leaders and managers reported being uninformed of their roles and responsibilities related to the implementation process. However, the presence of pharmacists and their services were well received in the setting. Moreover, participants reported that pharmacists' contributions positively impacted the multidisciplinary practice. Conclusion: Introducing new work methods into clinical practice is a complex task that demands expertise in implementation. Using the NTP model helped pinpoint factors that affect how pharmacists' skills are utilized in a home care setting. Insights from this study can inform the development of tailored implementation strategies to improve pharmacist integration in a multidisciplinary team. [ABSTRACT FROM AUTHOR]

In Australia, one in two women have experienced sexual harassment in their lifetime and one in five women has experienced sexual violence since the age of 15. Public facing organizations, such as public transport providers, have a role to play in providing safe environments and preventing violence. Our study examined the experiences and views of those working in public transport delivery organizations about the organizational challenges and opportunities to provide safe transport for women. Using Normalization Process Theory (NPT), our analysis of 19 semi-structured in-depth interviews with stakeholders focused on three key areas: making sense of safety of women on public transport; working towards women's safety on public transport; and monitoring the progress of safety initiatives. We found that public transport is delivered by multiple stakeholders, with individual and combined organizational and relational complexity. Participants highlighted the importance of leadership and the need for an overarching strategy for women's safety. Macro-level organizational and environmental barriers to implementing safety initiatives include a lack of proactive, consistent, and collaborative approaches. Differing understandings of what women's safety means can lead to conflicting strategies among organizations, but there are opportunities to develop and integrate enhanced and conceptually consistent training and policies in response to women's safety. At the micro-level, providers recognize the need to prioritize safety for women across public transport. Our findings indicate key opportunities to inform the development of interventions and policies for public transport, and public facing organizations more broadly, to provide for and sustain women's safety. • Complex solutions needed to address sexual assault & harassment against women on public transport. • Solutions require overarching leadership and a collaborative and consistent strategy. • Public transport planning and delivery still requires a gender-lens. [ABSTRACT FROM AUTHOR]

Background: Despite recommendations against psychotropic medication in older nursing homes residents with behavioral and psychological symptoms of dementia (BPSD), antidepressants and other psychotropic drugs are still prescribed. We performed a cluster-randomized controlled trial to evaluate the effect of a complex intervention aiming to promote the deprescribing of antidepressants in institutionalized older persons with dementia. To understand the underlying mechanisms of trial outcomes, we conducted a process evaluation exploring the interventions implementation, areas of impact, and contextual factors. The aim of this study was to explore the implementation process and the key factors that promoted and inhibited intervention implementation in the care home setting (Clinicaltrials.gov: NCT04985305. Registered 30 July 2021). Methods: Qualitative interviews were conducted between August 2022 and February 2023 with four general practitioners and eight nursing home staff from four associated nursing homes in the Capital Region of Denmark. We coded the interview data according to the four constructs of the Normalization Process Theory (coherence, cognitive participation, collective action, and reflexive monitoring). Results: There was a common understanding of the intervention aim. We observed a raised awareness concerning the deprescription of antidepressants among healthcare professionals with good collaboration (coherence). An overall buy-in to a deprescribing mentality was seen (cognitive participation). There were barriers to the GPs and nursing home staff's use of the intervention elements and how they implemented it, but to some, a common language was created (collective action). Professionals overall valued the idea of deprescribing, but lack of time, high staff turnover, and low education level among nursing home staff hampered the integration (reflexive monitoring). Conclusion: Successful implementation seemed to be dependent on the quality of the relationship between the single GP and the single nursing home professional. A common deprescribing mentality promoted the uptake of the intervention. However, several barriers related to lack of resources hindered implementation. It is imperative to adapt complex interventions to the available resources and context. [ABSTRACT FROM AUTHOR]

Background: Insufficient physical activity is a growing public health concern and is closely linked to obesity in both adults and children. Swedish physical activity on prescription (PAP) is effective in increasing physical activity levels in adults, but knowledge about how PAP is used in paediatric healthcare is lacking. Therefore, this study aimed to explore experiences of working with PAP for children with obesity amongst paediatric staff and managers. Methods: Seven focus group discussions with 26 participants from paediatric outpatient clinics in western Sweden were conducted. Data were analysed both inductively and deductively, framed by the Normalization Process Theory's four core constructs: coherence, cognitive participation, collective action, and reflexive monitoring. Results: The PAP work for children with obesity was experienced to be about helping children to become physically active, and less about losing weight. Identified barriers for using PAP were the non-uniform nature of the work and a perceived lack of guidelines. Collaboration with physiotherapists and physical activity organisers outside the organisation was identified as an important facilitator. An important contextual factor for implementing PAP is the collaboration between paediatric clinics and physical activity organisers. In the transition between these stakeholders, maintaining a family-centred approach when working with PAP was experienced as challenging. Conclusions: PAP is a well-known intervention that is inconsistently used for children with obesity. The intervention should include a family-centred approach for this patient group. It also needs to align better with existing collaborations with other healthcare units as well as with new forms of collaboration with physical activity organisers in the community. [ABSTRACT FROM AUTHOR]

Swedish Physical Activity on Prescription (PAP) has been shown to increase physical activity levels, which is known to lead to positive health effects. PAP is being implemented in Swedish healthcare to various extents. However, there is a lack of knowledge about how Swedish general practitioners (GPs) work with PAP and what hinders and facilitates wider implementation. This study aimed to survey GPs' use and views of PAP, identify barriers and facilitators for implementing PAP, and explore associations to gender, practice location, and experience. The study was framed by the Normalization Process Theory. A survey was sent to 463 GPs at 69 different healthcare centres in Region Västra Götaland. Data were analysed using multiple logistic and linear regressions. A total of 143 GPs completed the survey (response rate 31%). Views on PAP were generally positive amongst respondents, but only 27% reported using PAP regularly. The most prominent reported barriers were insufficient training and resources. Positive views and willingness to collaborate in using PAP were identified as facilitators. Responding GPs in Gothenburg used PAP more often (OR 6.4; 95% CI 2.7–14.8) and were significantly more positive to the method than GPs in other areas of the region. GPs with more than 10 years of practice used PAP more often (OR 2.5; 95% CI 1.1–6.0) than less experienced GPs. Few of the investigated variables were associated with gender. The positive views amongst responding GPs are helpful, but more education, training and resources are needed for successful implementation of PAP in Swedish primary health care. Implementation of physical activity on prescription (PAP) in Swedish healthcare has been ongoing for many years, but is implemented to various extents across and within regions. Views on PAP are generally positive, but use is not widespread amongst general practitioners in Region Västra Götaland who responded to the survey. The method is more frequently used in Gothenburg, where the most extensive implementation work has been done, and amongst more experienced general practitioners. Education and training in using PAP need to increase for successful implementation. [ABSTRACT FROM AUTHOR]

Håkan MA Nordin,1,2 Gro Ellen Mathisen,3 Kristine Rørtveit,1,2 Inge Joa,1,4 Jan O Johannessen,1,4 Torleif Ruud,5,6 Miriam Hartveit7,8 1Department of Psychiatry, Stavanger University Hospital, Stavanger, Norway; 2Department of Caring and Ethics, University of Stavanger, Stavanger, Norway; 3Norwegian School of Hotel Management, University of Stavanger, Stavanger, Norway; 4Department of Public Health, University of Stavanger, Stavanger, Norway; 5Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway; 6Institute of Clinical Medicine, University of Oslo, Oslo, Norway; 7Department for Research and Innovation, Helse Fonna Health Trust, Valen, Norway; 8Department of Global Public Health and Primary Care, University of Bergen, Bergen, NorwayCorrespondence: Kristine RørtveitUniversity of Stavanger, Faculty of Health Sciences, Postbox 8600, Stavanger, 4036, Norway, Tel +4790521114, Email kristine.rortveit@uis.no; kristine.rortveit@sus.noBackground: Despite the large amount of leadership and implementation theories and recommendations, healthcare services continue to struggle with efficiently incorporating new knowledge. The questioning of conventional leadership approaches in healthcare organizations prompted us to investigate how frontline leaders comprehend their own implementation intentions and actions, and how these intentions and actions may impact the implementation of clinical guidelines in mental healthcare in Norway.Methods: Employing a theory-driven qualitative design, we conducted nine semi-structured interviews with frontline leaders who had recently led implementation of clinical guidelines for the treatment of psychosis in mental health. We employed Systematic Text Condensation, informed by Normalization Process Theory, to structure and analyze the data and used fidelity scales to measure the degree of implementation and distinguish between leaders’ levels of success in implementation.Results: Frontline leaders in units that achieved high success in implementation described their intentions and actions differently, from those with less success. The former group’s actions aligned more closely with the constructs of the Normalization Process Theory compared to the latter group when describing their actions. Frontline leaders leading units with a high degree of implementation success describe relation-orientation, trust, and providing adaptive space for staff members to take initiative. In contrast, those leading units with less implementation success describe more control and guidance of co-operators and place more emphasize on information and knowledge.Conclusion: Differences in how frontline leaders describe their actions and intentions to achieve clinical guideline implementation suggest that the leadership approach of these frontline leaders is an important factor to consider when planning and conducting implementation. To better understand the implementation process, it is important to pay attention to how frontline leaders customize their leadership approaches to the dynamics of complex organizations, and how they interact with their team and superiors.Plain Language Summary: Despite the large amount of available implementation theories and recommendations, healthcare services continue to struggle with efficiently incorporating new and better practice. The clinicians’ closest leader, the Frontline leader, is considered to be in a unique position to manage and enable implementation in the complex healthcare system. The current study’s aim was to improve our understanding of what these leaders do, and how they operate, to enable the implementation of clinical guidelines. We interviewed nine mental health service leaders in Norway with experience of leading implementation of clinical guideline during the last 3 years. We found a variety of leaders’ intentions and actions regarding their involvement in the process and how they relate to their staff and superiors. Frontline leaders that lead units with high degree of implementation success described actions according to all four constructs of the Normalization Process Theory (Coherence, Cognitive participation, Collective action and Reflexive monitoring), while frontline leaders with less implementation success had more fragmented descriptions. Successful leaders appear to be more relation-oriented compared to those in less successful units. This suggests that leaders should focus on inter-personal dynamics, in addition to more concrete implementation interventions, to succeed.We recommend to take the leadership actions and intentions identified in this study into consideration when planning and evaluating implementation projects and leadership programs, as well as when recruiting frontline leaders.Keywords: complexity leadership theory, frontline leaders’ implementation of clinical guidelines, normalization process theory, implementation fidelity

Abstract Background Standardised use of patient-centred outcome measures (PCOMs) improves aspects of quality of care. Normalization Process Theory (NPT) considers the social (inter-)actions of implementation processes operationalised through four constructs: coherence-building, cognitive participation, collective action and reflexive monitoring. The aim of the study was to identify barriers and enablers for the successful use of PCOMs in specialist palliative home care (SPHC) using NPT, to collect clinically meaningful and reliable data to improve patient outcomes. Methods Qualitative study using semi-structured interviews with palliative care professionals from German SPHC teams who participated in a study using PCOMs. Data were analysed using Framework analysis, and contextualised within NPT. Results Seventeen interviews across five teams were conducted. Some teams already had an understanding of what PCOMs are and how to use them, based on previous experience. In other teams, this understanding developed through the perception of the benefits (coherence). Participation and engagement depended on individuals and was decisive for coherence-building. The attitude of the management level also played a major role (cognitive participation). Integration of PCOMs into everyday clinical practice varied and depended on the manifestation of the first two constructs and other already established routines (collective action). In the context of appraisal, both positive (e.g. focus on patient) and negative aspects (e.g. additional work) of using PCOMs were mentioned (reflexive monitoring). Conclusions Although benefits of using PCOMs were partly recognised, not all teams continued standardised use. Here, not only the social (inter-)actions, but also the influence of the context (working environment) were decisive. Future implementation strategies should consider integrating PCOMs in existing electronic patient records, education sessions supporting coherence-building, internal facilitators/local champions, and ensuring frequent data analyses as it is beneficial and increases the readiness of using PCOMs.

AbstractIntroduction Swedish Physical Activity on Prescription (PAP) has been shown to increase physical activity levels, which is known to lead to positive health effects. PAP is being implemented in Swedish healthcare to various extents. However, there is a lack of knowledge about how Swedish general practitioners (GPs) work with PAP and what hinders and facilitates wider implementation.Aims This study aimed to survey GPs’ use and views of PAP, identify barriers and facilitators for implementing PAP, and explore associations to gender, practice location, and experience.Methods The study was framed by the Normalization Process Theory. A survey was sent to 463 GPs at 69 different healthcare centres in Region Västra Götaland. Data were analysed using multiple logistic and linear regressions.Results A total of 143 GPs completed the survey (response rate 31%). Views on PAP were generally positive amongst respondents, but only 27% reported using PAP regularly. The most prominent reported barriers were insufficient training and resources. Positive views and willingness to collaborate in using PAP were identified as facilitators. Responding GPs in Gothenburg used PAP more often (OR 6.4; 95% CI 2.7–14.8) and were significantly more positive to the method than GPs in other areas of the region. GPs with more than 10 years of practice used PAP more often (OR 2.5; 95% CI 1.1–6.0) than less experienced GPs. Few of the investigated variables were associated with gender.Conclusions The positive views amongst responding GPs are helpful, but more education, training and resources are needed for successful implementation of PAP in Swedish primary health care.

Abstract Background South Africa maintains an integrated health system where syndromic management of sexually transmitted infections (STI) is the standard of care. An estimated 2 million cases of Neisseria gonorrhoeae (N. gonorrhoeae) occur in South Africa every year. Point-of-care diagnostic tests (POCT) may address existing STI control limitations such as overtreatment and missed cases. Subsequently, a rapid lateral flow assay with fluorescence-based detection (NG-LFA) with a prototype reader was developed for N. gonorrhoeae detection showing excellent performance and high usability; however, a better understanding is needed for device implementation and integration into clinics. Methods A qualitative, time-series assessment using 66 in-depth interviews was conducted among 25 trained healthcare workers involved in the implementation of the NG-LFA. Findings were informed by the Normalization Process Theory (NPT) as per relevant contextual (strategic intentions, adaptive execution, and negotiation capacity) and procedural constructs (coherence, cognitive participation, collective action, reflexive monitoring) to examine device implementation within primary healthcare levels. Interviews were audio-recorded, transcribed, and then analyzed using a thematic approach guided by NPT to interpret results. Results Overall, healthcare workers agreed that STI POCT could guide better STI clinical decision-making, with consideration for clinic integration such as space constraints, patient flow, and workload. Perceived NG-LFA benefits included enhanced patient receptivity and STI knowledge. Further, healthcare workers reflected on the suitability of the NG-LFA given current limitations with integrated primary care. Recommendations included sufficient STI education, and appropriate departments for first points of entry for STI screening. Conclusions The collective action and participation by healthcare workers in the implementation of the NG-LFA revealed adaptive execution within the current facility environment including team compositions, facility-staff receptivity, and STI management experiences. User experiences support future clinic service integration, highlighting the importance of further assessing patient-provider communication for STI care, organizational readiness, and identification of relevant departments for STI screening.

Abstract Background Normalization Process Theory (NPT) is an implementation theory that can be used to explain how and why implementation strategies work or not in particular circumstances. We used it to understand the mechanisms that lead to the adoption and routinization of palliative care within hemodialysis centers. Methods We employed a longitudinal, mixed methods approach to comprehensively evaluate the implementation of palliative care practices among ten hemodialysis centers participating in an Institute for Healthcare Improvement Breakthrough- Series learning collaborative. Qualitative methods included longitudinal observations of collaborative activities, and interviews with implementers at the end of the study. We used an inductive and deductive approach to thematic analysis informed by NPT constructs (coherence, cognitive participation, collective action, reflexive monitoring) and implementation outcomes. The NoMAD survey, which measures NPT constructs, was completed by implementers at each hemodialysis center during early and late implementation. Results The four mechanisms posited in NPT had a dynamic and layered relationship during the implementation process. Collaborative participants participated because they believed in the value and legitimacy of palliative care for patients receiving hemodialysis and thus had high levels of cognitive participation at the start. Didactic Learning Sessions were important for building practice coherence, and sense-making was solidified through testing new skills in practice and first-hand observation during coaching visits by an expert. Collective action was hampered by limited time among team members and practical issues such as arranging meetings with patients. Reflexive monitoring of the positive benefit to patient and family experiences was key in shifting mindsets from disease-centric towards a patient-centered model of care. NoMAD survey scores showed modest improvement over time, with collective action having the lowest scores. Conclusions NPT was a useful framework for understanding the implementation of palliative care practices within hemodialysis centers. We found a nonlinear relationship among the mechanisms which is reflected in our model of implementation of palliative care practices through a learning collaborative. These findings suggest that the implementation of complex practices such as palliative care may be more successful through iterative learning and practice opportunities as the mechanisms for change are layered and mutually reinforcing. Trial registration ClinicalTrials.gov, NCT04125537 . Registered 14 October 2019 – Retrospectively registered.

Abstract Background Depression is commonly experienced by people with dementia, and associated with lower quality of life and functional decline. However, access to evidence-based psychological interventions for people with dementia and depression is limited. One potential solution is guided low-intensity behavioral activation. Following the new Medical Research Council Framework, considering factors such as potential barriers and facilitators to implementation is recommended during the development of new interventions. Aims of this study were to: (1) develop an understanding of existing healthcare and community support in the Swedish context for people with dementia and their informal caregivers; and (2) identify barriers and facilitators to intervention uptake informed by Normalization Process Theory. Methods Semi-structured interviews and focus groups were held with healthcare (n = 18) and community (n = 7) stakeholders working with people with dementia and/or informal caregivers. Interview questions were informed by Normalization Process Theory. Data was analysed utilizing a two-step deductive analysis approach using the Normalization Process Theory coding manual, with inductive categories applied to data related to the main mechanisms of the theory, but not captured by its sub-constructs. Results Ten deductive and three inductive categories related to three Normalization Process Theory primary mechanisms (Coherence, Cognitive Participation, and Collective Action) were identified. Identified barriers to intervention uptake included: (1) additional burden for informal caregivers; (2) lack of appropriate workforce to provide guidance; (3) lack of time and financial resources; (4) people with dementia not recognising their diagnosis of dementia and/or a need for support; and (5) stigma. Identified facilitators to intervention uptake included: (1) intervention has potential to fill a large psychological treatment gap in Sweden; (2) objectives and potential benefits understood and agreed by most stakeholders; and (3) some healthcare professionals recognized their potential role in providing intervention guidance. Conclusions Several barriers and facilitators for future implementation, specific to the intervention, individuals and families, as well as professionals, were identified during intervention development. Barriers were mapped into evidence-based implementation strategies, which will be adopted to overcome identified barriers. A feasibility study further examining implementation potential, acceptability and feasibility, alongside clinical, methodological, and procedural uncertainties associated with the intervention will be conducted. Trial registration Not applicable.

Background: South Africa maintains an integrated health system where syndromic management of sexually transmitted infections (STI) is the standard of care. An estimated 2 million cases of Neisseria gonorrhoeae (N. gonorrhoeae) occur in South Africa every year. Point-of-care diagnostic tests (POCT) may address existing STI control limitations such as overtreatment and missed cases. Subsequently, a rapid lateral flow assay with fluorescence-based detection (NG-LFA) with a prototype reader was developed for N. gonorrhoeae detection showing excellent performance and high usability; however, a better understanding is needed for device implementation and integration into clinics. Methods: A qualitative, time-series assessment using 66 in-depth interviews was conducted among 25 trained healthcare workers involved in the implementation of the NG-LFA. Findings were informed by the Normalization Process Theory (NPT) as per relevant contextual (strategic intentions, adaptive execution, and negotiation capacity) and procedural constructs (coherence, cognitive participation, collective action, reflexive monitoring) to examine device implementation within primary healthcare levels. Interviews were audio-recorded, transcribed, and then analyzed using a thematic approach guided by NPT to interpret results. Results: Overall, healthcare workers agreed that STI POCT could guide better STI clinical decision-making, with consideration for clinic integration such as space constraints, patient flow, and workload. Perceived NG-LFA benefits included enhanced patient receptivity and STI knowledge. Further, healthcare workers reflected on the suitability of the NG-LFA given current limitations with integrated primary care. Recommendations included sufficient STI education, and appropriate departments for first points of entry for STI screening. Conclusions: The collective action and participation by healthcare workers in the implementation of the NG-LFA revealed adaptive execution within the current facility environment including team compositions, facility-staff receptivity, and STI management experiences. User experiences support future clinic service integration, highlighting the importance of further assessing patient-provider communication for STI care, organizational readiness, and identification of relevant departments for STI screening. [ABSTRACT FROM AUTHOR]

Background: Standardised use of patient-centred outcome measures (PCOMs) improves aspects of quality of care. Normalization Process Theory (NPT) considers the social (inter-)actions of implementation processes operationalised through four constructs: coherence-building, cognitive participation, collective action and reflexive monitoring. The aim of the study was to identify barriers and enablers for the successful use of PCOMs in specialist palliative home care (SPHC) using NPT, to collect clinically meaningful and reliable data to improve patient outcomes. Methods: Qualitative study using semi-structured interviews with palliative care professionals from German SPHC teams who participated in a study using PCOMs. Data were analysed using Framework analysis, and contextualised within NPT. Results: Seventeen interviews across five teams were conducted. Some teams already had an understanding of what PCOMs are and how to use them, based on previous experience. In other teams, this understanding developed through the perception of the benefits (coherence). Participation and engagement depended on individuals and was decisive for coherence-building. The attitude of the management level also played a major role (cognitive participation). Integration of PCOMs into everyday clinical practice varied and depended on the manifestation of the first two constructs and other already established routines (collective action). In the context of appraisal, both positive (e.g. focus on patient) and negative aspects (e.g. additional work) of using PCOMs were mentioned (reflexive monitoring). Conclusions: Although benefits of using PCOMs were partly recognised, not all teams continued standardised use. Here, not only the social (inter-)actions, but also the influence of the context (working environment) were decisive. Future implementation strategies should consider integrating PCOMs in existing electronic patient records, education sessions supporting coherence-building, internal facilitators/local champions, and ensuring frequent data analyses as it is beneficial and increases the readiness of using PCOMs. [ABSTRACT FROM AUTHOR]

Background: Normalization Process Theory (NPT) is an implementation theory that can be used to explain how and why implementation strategies work or not in particular circumstances. We used it to understand the mechanisms that lead to the adoption and routinization of palliative care within hemodialysis centers. Methods: We employed a longitudinal, mixed methods approach to comprehensively evaluate the implementation of palliative care practices among ten hemodialysis centers participating in an Institute for Healthcare Improvement Breakthrough- Series learning collaborative. Qualitative methods included longitudinal observations of collaborative activities, and interviews with implementers at the end of the study. We used an inductive and deductive approach to thematic analysis informed by NPT constructs (coherence, cognitive participation, collective action, reflexive monitoring) and implementation outcomes. The NoMAD survey, which measures NPT constructs, was completed by implementers at each hemodialysis center during early and late implementation. Results: The four mechanisms posited in NPT had a dynamic and layered relationship during the implementation process. Collaborative participants participated because they believed in the value and legitimacy of palliative care for patients receiving hemodialysis and thus had high levels of cognitive participation at the start. Didactic Learning Sessions were important for building practice coherence, and sense-making was solidified through testing new skills in practice and first-hand observation during coaching visits by an expert. Collective action was hampered by limited time among team members and practical issues such as arranging meetings with patients. Reflexive monitoring of the positive benefit to patient and family experiences was key in shifting mindsets from disease-centric towards a patient-centered model of care. NoMAD survey scores showed modest improvement over time, with collective action having the lowest scores. Conclusions: NPT was a useful framework for understanding the implementation of palliative care practices within hemodialysis centers. We found a nonlinear relationship among the mechanisms which is reflected in our model of implementation of palliative care practices through a learning collaborative. These findings suggest that the implementation of complex practices such as palliative care may be more successful through iterative learning and practice opportunities as the mechanisms for change are layered and mutually reinforcing. Trial registration: ClinicalTrials.gov, NCT04125537. Registered 14 October 2019 – Retrospectively registered. [ABSTRACT FROM AUTHOR]

Background: Depression is commonly experienced by people with dementia, and associated with lower quality of life and functional decline. However, access to evidence-based psychological interventions for people with dementia and depression is limited. One potential solution is guided low-intensity behavioral activation. Following the new Medical Research Council Framework, considering factors such as potential barriers and facilitators to implementation is recommended during the development of new interventions. Aims of this study were to: (1) develop an understanding of existing healthcare and community support in the Swedish context for people with dementia and their informal caregivers; and (2) identify barriers and facilitators to intervention uptake informed by Normalization Process Theory. Methods: Semi-structured interviews and focus groups were held with healthcare (n = 18) and community (n = 7) stakeholders working with people with dementia and/or informal caregivers. Interview questions were informed by Normalization Process Theory. Data was analysed utilizing a two-step deductive analysis approach using the Normalization Process Theory coding manual, with inductive categories applied to data related to the main mechanisms of the theory, but not captured by its sub-constructs. Results: Twelve deductive and three inductive categories related to three Normalization Process Theory primary mechanisms (Coherence, Cognitive Participation, and Collective Action) were identified. Identified barriers to intervention uptake included: (1) additional burden for informal caregivers; (2) lack of appropriate workforce to provide guidance; (3) lack of time and financial resources; (4) people with dementia not recognising their diagnosis of dementia and/or a need for support; and (5) stigma. Identified facilitators to intervention uptake included: (1) intervention has potential to fill a large psychological treatment gap in Sweden; (2) objectives and potential benefits understood and agreed by most stakeholders; and (3) some healthcare professionals recognized their potential role in providing intervention guidance. Conclusions: Several barriers and facilitators for future implementation, specific to the intervention, individuals and families, as well as professionals, were identified during intervention development. Barriers were mapped into evidence-based implementation strategies, which will be adopted to overcome identified barriers. A feasibility study further examining implementation potential, acceptability and feasibility, alongside clinical, methodological, and procedural uncertainties associated with the intervention will be conducted. Trial registration: Not applicable. [ABSTRACT FROM AUTHOR]

Learner agency, or the ability to take control of one's own learning and the learning of others, is a substantial goal of the curricular reform across the world. This can be seen in the implementation of the 2013 curriculum (K13) in Indonesia. However, there has been little evidence regarding the ways that Indonesian teachers have engaged with prescribed innovations. This interpretivist study examined the extent to which curricular innovations have been embedded in classrooms and how far they reveal the quality of their enactments, with particular interest in the identification of pedagogic practices that are associated with the promotion of learner agency. Using rich data from 15 individual semi-structured interviews and filmed classroom observations of three teachers, the study observed learner agency practices, including those associated with promoting peer and self-assessment, learning autonomy, and sharing learning objectives and assessment criteria. However, the implementation of these strategies varied in intensity and was rather artificial, without a strong conceptual underpinning. Drawing on normalization process theory (NPT), this paper argues that the observed teachers' engagement in the promotion of learner agency lacked coherence, cognitive participation, collective action, and evaluation. Reform planners and teachers should understand the nature of successful implementation and consider adopting a framework to analyze and guide their evaluation of how reform should be organized, implemented, and evaluated to ensure effective embedding. [ABSTRACT FROM AUTHOR]

Abstract Background The COVID-19 pandemic brought attention to a need for rapid testing of large populations. Experiences from community-based testing settings show that there can be workload difficulties, logistical challenges and socioeconomic downsides to large scale Polymerase Chain Reaction (PCR) testing. Alternative testing arenas have therefore been considered. Rapid point-of-care (POC) PCR test methods have since been developed and could have potential to surveille viral respiratory infections. It is, however, unknown if PCR testing can be successfully implemented routinely in general practice. The aim of this study was to assess factors that enable and inhibit the implementation of point-of-care PCR testing for acute respiratory tract infection in general practice. Methods Fourteen general practices in the east Zealand area in Denmark were included in the study and given access to POC PCR testing equipment during a flu season. The participating clinics were initially trained in the use of a POC PCR testing device and then spent 6 weeks testing it. We conducted qualitative interviews with general practitioners (GPs) and their staff, before and after the testing period, specifically focusing on their clinical decision-making and internal collaboration in relation to POC PCR testing. We used normalization process theory to design the interview guides and to analyze the data. Results Professionals reported no clinical need for a POC PCR testing device in a non-pandemic clinical setting. Results were delivered faster, but this was only timesaving for the patient and not the GP, who had to perform more tasks. Conclusion In its current form, the added diagnostic value of using POC PCR testing in general practice was not sufficient for the professionals to justify the increased work connected to the usage of the diagnostic procedure in daily practice. Trial registration n/a.

Abstract Implementation science scholars argue that knowing ‘what works’ in public health is insufficient to change practices, without understanding ‘how’, ‘where’ and ‘why’ something works. In the peer reviewed literature on conflict-affected settings, challenges to produce research, make decisions informed by evidence, or deliver services are documented, but what about the understanding of ‘how’, ‘where’ and ‘why’ changes occur? We explored these questions through a scoping review of peer-reviewed literature based on core dimensions of the Extended Normalization Process Theory. We selected papers that provided data on how something might work (who is involved and how?), where (in what organizational arrangements or contexts?) and why (what was done?). We searched the Global Health, Medline, Embase databases. We screened 2054 abstracts and 128 full texts. We included 22 papers (of which 15 related to mental health interventions) and analysed them thematically. We had the results revised critically by co-authors experienced in operational research in conflict-affected settings. Using an implementation science lens, we found that: (a) implementing actors are often engaged after research is produced to discuss feasibility; (b) new interventions or delivery modalities need to be flexible; (c) disruptions affect how research findings can lead to sustained practices; (d) strong leadership and stable resources are crucial for frontline actors; (e) creating a safe learning space to discuss challenges is difficult; (f) feasibility in such settings needs to be balanced. Lastly, communities and frontline actors need to be engaged as early as possible in the research process. We used our findings to adapt the Extended Normalization Process Theory for operational research in settings affected by conflicts. Other theories used by researchers to document the implementation processes need to be studied further.

Background: Studies suggest that preoperative evaluation can be effectively conducted through telehealth. As the COVID-19 pandemic has accelerated digital transformation, we hypothesize that a new telehealth model of care may be feasibly implemented for preoperative evaluation at our institution. This qualitative study seeks to evaluate the attitudes and perception of elective surgery patients and health care providers toward telehealth conducted for preanesthesia evaluation. Methods: At a tertiary women's hospital in Asia, health care providers and elective surgery patients were recruited by convenience and snowball sampling to undergo one-on-one semistructured interviews regarding a new telehealth model of care for preanesthesia evaluation, under-pinned by the Normalization Process Theory. Data were analyzed, coded, and consolidated into themes using the framework analysis method by a team of four researchers from diverse backgrounds. Results: Twenty-five interviews were conducted among 10 patients and 15 health care participants. Ninety-five codes were identified, consolidated into four themes that connect to guide the implementation of a new telehealth pathway for preoperative care, mapped to the Normalization Process Theory. The themes pertain to advantages of telehealth workflow (coherence), requisites for new telehealth workflow (coherence, collective action), barriers to implementation (cognitive participation, collective action), and enablers of implementation (cognitive participation, collective action). All participants were receptive to telehealth, but health care participants expressed concern about the impact of additional tasks on current clinical workload. Training in videoconferencing was deemed essential by both patients and health care providers. Conclusions: The study has provided insights into levels of coherence and cognitive participation among patients and health care providers. The telehealth workflow should be redesigned, considering systems' constraints and stakeholders' needs. Greater buy-in is needed to gain health care providers' commitment for collective action. Clinicaltrials.gov identifier: NCT05781789

Background: People living in settings affected by conflicts face insecurity and live in fragmented social systems. Conducting research in these settings is essential, however integrating results into practices is complex. Implementation science tools are not used often in such environments. In this paper we explore how a convenience sample of interviewees experienced implementation in these settings, through the lens of the adapted Extended Normalization Process Theory (a-ENPT). Methods: We conducted in-depth interviews with 26 participants (donors, academics, and humanitarian actors). We assessed what key issues interviewees met and how they negotiated them. We combined an inductive thematic analysis to identify implementation issues, and we applied the a-ENPT deductively to question power imbalances, engaging a group of humanitarian actors as co-authors along the way. Results: The main challenges met by interviewees related to a) engaging frontline actors to produce knowledge; b) discussing the results critically; c) integrating research results in constrained learning spaces; and d) managing contextual instabilities in settings affected by conflicts. Interviewees negotiated these constraints through an early involvement of frontline actors, an institutional support, a meaningful engagement of communities, and balanced partnerships. Based on these findings we propose a tool to anticipate the power imbalances embedded in the implementation of research results in settings affected by conflicts, rooted in the a-ENPT constructs. Conclusion: We identified mechanisms that allowed for the negotiation of important challenges and power imbalances, through an implementation science tool. Further research should focus on the perspectives of communities affected themselves.

BackgroundThere is growing demand for developmental and behavioral pediatric services including autism evaluation and care management. Clinician trainings have been found to result in an increase of knowledge and attitudes. This study utilizes Normalization Process theory (NPT) to evaluate a clinician training program and its effects on practice.MethodsThe year-long virtual training program about autism screening and care management included didactic portions and case presentations. Focus groups and interviews were conducted with primary care clinicians (n = 10) from community health centers (n = 6) across an urban area five months post-training. Transcripts were deductively coded using NPT to uncover barriers to implementation of autism screening and care, benefits of the training program, and areas for future training.ResultsParticipants were motivated by the benefits of expanding and improving support for autistic patients but noted this effort requires effective collaboration within a complex network of care providers including clinicians, insurance agencies, and therapy providers. Although there were support that participants could provide to families there were still barriers including availability of behavior therapy and insufficient staffing. Overall, participants positively viewed the training and reported implementing new strategies into practice.ConclusionDespite the small sample size, application of NPT allowed for assessment of both training delivery and implementation of strategies, and identification of recommendations for future training and practice sustainability. Follow-up focus groups explored participants' practice five months post-program. Variations in participants' baseline experience and context at follow-up to enable application of skills should be considered when using NPT to evaluate clinician trainings.

Abstract: Sustained vaccination coverage of domestic dog populations can interrupt rabies transmission. However, challenges remain including low dog owner participation, high operational costs associated with current (centralized and annually delivered (pulse)) approaches and high dog population turnover. To address these challenges an alternative (community-based continuous mass dog vaccination (CBC-MDV)) approach was designed. We investigated the potential for successful normalization of CBC-MDV into routine practice within the context of local communities and the veterinary system of Tanzania Methods: In a process evaluation of a pilot implementation of CBC-MDV, we conducted in-depth interviews with implementers and community leaders (n = 24), focus group discussion with implementers and community members (n = 12), and non-participant observation (n = 157 h) of delivery of the intervention components. We analyzed these data thematically drawing on the normalization process theory, to assess factors affecting implementation and integration. Main findings: Implementers and community members clearly understood the values and benefits of the CBC-MDV, regarding it as an improvement over the pulse strategy. They had a clear understanding of what was required to enact CBC-MDV and considered their own involvement to be legitimate. The approach fitted well into routine schedules of implementers and the context (infrastructure, skill sets and policy). Implementers and community members positively appraised CBC-MDV in terms of its perceived impact on rabies and recommended its use across the country. Implementers and community members further believed that vaccinating dogs free of charge was critical and made community mobilization easier. However, providing feedback to communities and involving them in evaluating outcomes of vaccination campaigns were reported to have not been done. Local politics was cited as a barrier to collaboration between implementers and community leaders. Conclusion: This work suggests that CBC-MDV has the potential to be integrated and sustained in the context of Tanzania. Involving communities in design, delivery and monitoring of CBC-MDV activities could contribute to improving and sustaining its outcomes.

Background: The COVID-19 pandemic brought attention to a need for rapid testing of large populations. Experiences from community-based testing settings show that there can be workload difficulties, logistical challenges and socioeconomic downsides to large scale Polymerase Chain Reaction (PCR) testing. Alternative testing arenas have therefore been considered. Rapid point-of-care (POC) PCR test methods have since been developed and could have potential to surveille viral respiratory infections. It is, however, unknown if PCR testing can be successfully implemented routinely in general practice. The aim of this study was to assess factors that enable and inhibit the implementation of point-of-care PCR testing for acute respiratory tract infection in general practice. Methods: Fourteen general practices in the east Zealand area in Denmark were included in the study and given access to POC PCR testing equipment during a flu season. The participating clinics were initially trained in the use of a POC PCR testing device and then spent 6 weeks testing it. We conducted qualitative interviews with general practitioners (GPs) and their staff, before and after the testing period, specifically focusing on their clinical decision-making and internal collaboration in relation to POC PCR testing. We used normalization process theory to design the interview guides and to analyze the data. Results: Professionals reported no clinical need for a POC PCR testing device in a non-pandemic clinical setting. Results were delivered faster, but this was only timesaving for the patient and not the GP, who had to perform more tasks. Conclusion: In its current form, the added diagnostic value of using POC PCR testing in general practice was not sufficient for the professionals to justify the increased work connected to the usage of the diagnostic procedure in daily practice. Trial registration: n/a. [ABSTRACT FROM AUTHOR]

Aim: In the context of widening societal diversity, culturally and linguistically diverse patients continue to experience inequities in healthcare access and deficiencies in standards of nursing care. Re‐framing culturally responsive care as a complex intervention spanning multiple interacting factors at micro, meso and macro levels is an essential prerequisite for addressing knowledge translation gaps into everyday nursing practice. To this end, this paper proposes and explicates the potential of applying synergistic participatory implementation methodologies for developing effective implementation strategies with impact at individual and wider structural levels. Design: Discussion Paper. Data Sources: A co‐design case study is presented as an example of combining normalization process theory and participatory learning and action to investigate and support the implementation of culturally responsive care in general practice nursing. Implications for Nursing: Enacting culturally responsive health care is inherently complex in that it is influenced by multiple interacting factors. Viewing culturally responsive care as a complex intervention and incorporating a synergistic participatory implementation science approach offers possibilities for addressing the documented shortcomings in the implementation of culturally responsive nursing care. Conclusion: There is a need to move away from conventional approaches to conceptualizing and generating evidence on culturally responsive care. Incorporating participatory implementation methodologies can provide a new lens to investigate and support whole system implementation strategies. Impact: The combination of participatory and implementation methodologies is both theoretically and empirically informed. Engaging stakeholders in the co‐design and co‐production of evidence and solutions to long standing problems has the potential to increase the likelihood of influencing iterative and sustainable implementation and changes to clinical practice and systems. Patient or Public Contribution: This work is part of a wider programme of participatory health research on migrant health, partnering with a non‐governmental organization that supports migrants. [ABSTRACT FROM AUTHOR]

Introduction: Health partnerships in global health aim to build capacity by strengthening training and education. Health psychology has an important role to play, as traditionally health partnerships focus upon increasing capability such as increasing knowledge but do not tackle opportunity and motivation. The Change Exchange recruits applied psychologist volunteers to utilize health psychology in global health partnerships, which is a novel approach. This study aimed to understand the experiences of applied psychologist volunteers working in health partnerships and how such interventions were implemented. Methods: Semi‐structured interviews were carried out. Interviews were analysed using inductive thematic analysis to explore the translation and implementation of health psychology in health partnerships. A deductive approach was then taken using the higher level constructs of the Normalization Process Theory to inform and interpret the themes into recommendations. Results: Fifteen applied psychologists, all of whom were from the UK and had volunteered in health partnerships between the UK and low‐ to middle‐income countries participated. Key themes and sub‐themes were identified: (1) The challenges of the application of behavioural science within the health partnerships, (2) Building relationships within the health partnership, (3) Exploring the communal and individual effort carried out within the health partnership and (4) Reflecting on the work carried out within the health partnership. Discussion: Barriers exist in regards to the implementation of health psychology in health partnerships but capacity building is possible. Recommendations suggest, future work should establish clear roles for applied psychologists in health partnerships and critical evaluation of current psychological models, methods and measures for use outside of Western, Educated, Industrialized, Rich and Democratic societies. [ABSTRACT FROM AUTHOR]

This qualitative study investigates the effects of the COVID-19 pandemic on drug treatment courts through the lens of court team members. We conducted semi-structured interviews, guided by Normalization Process Theory, to learn how transitioning to remote operations impacted courts, clients, and practices. Team members gave mixed reviews of the utilization of remote technology for drug treatment court processes, citing the advantages of increased flexibility and accessibility alongside concerns about client accountability. Additionally, there was disagreement on whether remote technology promoted or hindered communication between the clients and the judge. Interviewees also endorsed the idea of keeping the remote option post-pandemic for specific categories of clients. [ABSTRACT FROM AUTHOR]

Purpose – At the outbreak of the COVID-19 pandemic, the absence of pharmaceutical agents meant that policy institutions had to intervene by providing nonpharmaceutical interventions (NPIs). To satisfy this need, the World Health Organization (WHO) issued policy guidelines, such as NPIs, and the government of Pakistan released its own policy document that included social distancing (SD) as a containment measure. This study explores the policy actors and their role in implementing SD as an NPI in the context of the COVID-19 pandemic. Design/methodology/approach – The study adopted the constructs of Normalization Process Theory (NPT) to explore the implementation of SD as a complex and novel healthcare intervention under a qualitative study design. Data were collected through document analysis and interviews, and analysed under framework analysis protocols. Findings – The intervention actors (IAs), including healthcare providers, district management agents, and staff from other departments, were active in implementation in the local context. It was observed that healthcare providers integrated SD into their professional lives through a higher level of collective action and reflexive monitoring. However, the results suggest that more coherence and cognitive participation are required for integration. Originality/value – This novel research offers original and exclusive scenario narratives that satisfy the recent calls of the neo-implementation paradigm, and provides suggestions for managing the implementation impediments during the pandemic. The paper fills the implementation literature gap by exploring the normalisation process and designing a contextual framework for developing countries to implement guidelines for pandemics and healthcare crises.

Implementation science scholars argue that knowing 'what works' in public health is insufficient to change practices, without understanding 'how', 'where' and 'why' something works. In the peer reviewed literature on conflict-affected settings, challenges to produce research, make decisions informed by evidence, or deliver services are documented, but what about the understanding of 'how', 'where' and 'why' changes occur? We explored these questions through a scoping review of peer-reviewed literature based on core dimensions of the Extended Normalization Process Theory. We selected papers that provided data on how something might work (who is involved and how?), where (in what organizational arrangements or contexts?) and why (what was done?). We searched the Global Health, Medline, Embase databases. We screened 2054 abstracts and 128 full texts. We included 22 papers (of which 15 related to mental health interventions) and analysed them thematically. We had the results revised critically by co-authors experienced in operational research in conflict-affected settings. Using an implementation science lens, we found that: (a) implementing actors are often engaged after research is produced to discuss feasibility; (b) new interventions or delivery modalities need to be flexible; (c) disruptions affect how research findings can lead to sustained practices; (d) strong leadership and stable resources are crucial for frontline actors; (e) creating a safe learning space to discuss challenges is difficult; (f) feasibility in such settings needs to be balanced. Lastly, communities and frontline actors need to be engaged as early as possible in the research process. We used our findings to adapt the Extended Normalization Process Theory for operational research in settings affected by conflicts. Other theories used by researchers to document the implementation processes need to be studied further. [ABSTRACT FROM AUTHOR]

Abstract Background The Normalization MeAsure Development (NoMAD) is a brief quantitative tool based on the Normalization Process Theory (NPT), which can measure the implementation process of new technologies and complex interventions. The aim of our study was to translate and culturally adapt the NoMAD into Chinese, and to evaluate the psychometric properties of the Chinese version of NoMAD. Methods According to the NoMAD translation guideline, we undertook forward translation, backward translation, and compared these translations to get a satisfactory result, then we performed cognitive interviews to achieve cross-culture adaptation. And the psychometric properties of the final version were evaluated among clinical nurses who used the pressure injuries management system via WeChat mini-program at a tertiary hospital in northwestern China. Results A total of 258 nurses were enrolled in our study, and the response rate was 92.1%. The Cronbach’s alpha of four dimensions were as follow: Coherence (0.768), Cognitive Participation (0.904), Collective Action (0.820), and Reflexive Monitoring (0.808). The overall internal consistency was 0.941. The confirmatory factor analysis results showed a good fit for its theoretical structure (CFI = 0.924, TLI = 0.910, RMSEA = 0.0079, SRMSR = 0.046, χ2/df = 2.61). The item-level content validity index ranged from 0.857 to 1, and the scale-level content validity index was 0.95. There were positive correlations between four constructs scores and three general normalization scores. Conclusions The Chinese version of NoMAD is a reliable and valid tool to evaluate the implementation process of innovations.

Abstract Background The COVID-19 pandemic has seen unprecedented growth in the use of interactive technologies in care facilities for social contact between residents and their close contacts due to the need for social distancing. As the pandemic is transitioning into a new phase, there is a need to critically examine the new practices associated with technology usage. Objective Our analysis is based on a case study of how a care facility in western Norway adopted a novel technology called KOMP. We empirically investigate the stability of practices with KOMP for maintaining social communication between residents and their relatives and consider whether these practices are likely to last beyond the pandemic. We draw on normalization process theory (NPT) to interpret our findings and critically examine how stable embedding of new technologies for social communication occurs under extraordinary circumstances. Methods We conducted a case study based on participant observation and interviews, and the data were analyzed through inductive thematic analysis. Participants are health care professionals from a public care facility in western Norway. Results Four major themes emerged from the data. The first revolved around the pressing need for communications between residents and relatives with a suitable tool. Second, staff showed engagement through motivation to learn and adapt the technology in their practices. A third theme centered on how staff and the organization could work effectively to embed KOMP in daily practice. Our fourth theme suggested that the professionals continuously assessed their own use of the technology. Conclusion From the perspective of NPT, practices with KOMP have been partially embedded by developing a shared understanding, engaging through cognitive participation, working collectively with staff and the organization, and reflexively monitoring the benefits of using KOMP. However, staff engagement with the technology was continuously threatened by factors related to diverging staff preferences, the burden of facilitating KOMP for residents with impaired cognitive and physical abilities, issues of privacy and ethics, and the technical skills of the residents’ relatives. Our analysis suggests that caring practices via KOMP have become relatively stable despite barriers to engagement and are therefore likely to persist beyond the pandemic.

Abstract Background Healthcare accreditation is a widely implemented tool used to enhance the quality of care and underpin quality control. However, research is sparse on the accreditation process in general practice. The aim of this study was to explore how team-based implementation activities preceding accreditation were associated with self-perceived improvements in emergency preparedness (preparedness for urgent disease and cardiac arrest) and handling of prescription renewals in Danish general practice. Methods GPs (general practitioners) completed a questionnaire exploring practice-team activities conducted to implement two specific accreditation standards and the related improvements as perceived by the GPs. The following implementation activities were selected, inspired by Normalization Process Theory: Common understanding (obtaining a common understanding of the purpose of implementing changes according to the accreditation standard), key person (assigning a key person responsible for working with the standard), and easy integration (finding it easy to integrate changes into existing working procedures). Data were analysed with logistic regression, and adjusted analyses included practice type, number of GP partners, number of staff, training site for junior GPs and administrative region. Results The total response rate was 74% (n = 920). Around 80% of the clinics reported having conducted team-based implementation activities. Almost half of the clinics (48%) reported perceived improvements in the emergency preparedness, and 30% reported perceived improvements in the handling of prescription renewals. Obtaining a common understanding was found to have a strong, significant association with perceived improvements in the emergency preparedness (OR = 5.07 (3.06–8.40)) and handling of prescription renewals (OR = 3.66 (2.07–6.46)). Easy integration of changes was also significantly associated with improvements in both emergency preparedness (OR = 1.88 (1.24–2.85)) and handling of prescription renewals (OR = 2.34 (1.44–3.79)), whereas assigning a key person was only significantly associated with improved emergency preparedness (OR = 1.95 (1.19–3.19)). Conclusion Clinical quality initiatives that involve collaboration within a practice team are more likely to cause improvements if specific team-based implementation activities are conducted. It is particularly important to facilitate a common understanding of the purpose of the initiative. Therefore, external support for quality initiatives aiming at the practice level in general practice should facilitate such team-based activities.

Purpose: The current literature on operationalizing and implementing recovery-oriented inpatient care in diverse settings remains limited. The present study systematically examined factors affecting the implementation of one aspect of recovery-oriented care in a large and diverse national sample of Veterans Health Administration (VHA) inpatient mental health units. Method: VHA inpatient mental health units were scored on the Recovery-Oriented Acute Inpatient scale (RAIN). Sites scoring either one standard deviation above (n = 8; i.e., high-scoring sites) or one standard deviation below (n = 5; i.e., low-scoring sites) the mean on the RAIN factor of inpatient treatment planning subscale were included for additional analyses (N = 13). We used a qualitative approach known as emergent thematic analysis to assess the implementation of inpatient treatment planning elements (e.g., goal setting, shared decision-making) from qualitative interviews, observation notes, and chart reviews collected for the 13 sites. The analysis was guided by Normalization Process Theory. Results: The eleven themes that emerged across the elements of recovery-oriented inpatient treatment planning mostly represented commonalities across sites, such as a shared treatment philosophy of acute care. However, five themes emerged as "differentiators" that distinguished high- and low-scoring sites and included veteran input, elicitation of recovery goals, the value of group programming, and the purpose of family involvement. Conclusion: Findings provide insight into contextual factors and processes that impacted the implementation of recovery-oriented treatment planning at these VHA inpatient mental health units. To further facilitate the implementation of recovery-oriented inpatient treatment planning elements, future research should examine staff's collective understanding of recovery-oriented inpatient care. [ABSTRACT FROM AUTHOR]

Abstract Background Normalization process theory (NPT) has been widely used to better understand how new interventions are implemented and embedded. The NoMAD (Normalization Measurement Development questionnaire) is a 23-item NPT instrument based on NPT. As the NoMAD is a relatively new instrument, the objectives of this paper are: to describe the experience of implementing the NoMAD, to describe it being used as a feedback mechanism to gain insight into the normalization process of a complex health intervention, and to further explore the psychometric properties of the instrument. Methods Health TAPESTRY was implemented in six Family Health Teams (total of seven sites) across Ontario. Healthcare team members at each site were invited to complete the NoMAD, and three general questions about normalization, six times over a 12-month period. Each site was then provided a visual traffic light summary (TLS) reflecting the implementation of the Health TAPESTRY. The internal consistency of each sub-scale and validity of the NoMAD were assessed. Learnings from the implementation of the NoMAD and subsequent feedback mechanism (TLS) are reported descriptively. Results In total, 56 diverse health care team members from six implementation sites completed the NoMAD. Each used it at least once during the 12-month study period. The implementation of the NoMAD and TLS was time consuming to do with multiple collection (and feedback) points. Most (60%) internal consistency values of the four subscales (pooled across site) across each collection point were satisfactory. All correlations were positive, and most (86%) were statistically significant among NoMAD subscales. All but one correlation between the NoMAD subscales and the general questions were positive, and most (72%) were significant. Generally, scores on the subscales were higher at 12-month than baseline, albeit did not follow a linear pattern of change across implementation. Generally, scores were higher for experienced sites compared to first-time implementors. Conclusion Our experience would suggest fewer collection points; three timepoints spaced out by several months are adequate, if repeated administration of the NoMAD is used for feedback loops. We provide additional evidence of the psychometric properties of the NoMAD. Trial Registration Registered at ClinicalTrials.gov: NCT03397836 .