Frontiers in health services最新文献

Introduction: Inpatient falls are serious adverse events that contribute to functional decline and adverse outcomes. Overconfidence in mobility, and reluctance to seek assistance, are often difficult for staff to detect in the absence of a structured tool. The Multidimensional Falls Efficacy Scale (MdFES) was developed to assess patients' confidence across fall prevention, recovery, and self-protection domains. This pilot implementation feasibility study evaluated the early adoption of the MdFES in a community hospital, using the Proctor Implementation Outcomes framework to examine patient and nurse perspectives.

Methods: A mixed-methods pilot was conducted in Singapore community hospitals involving 90 patients and 32 nurses. Quantitative data were collected across multiple implementation outcomes-including acceptability, appropriateness, feasibility, cost, and fidelity-using structured questionnaires, with results reported as mean ± SD. Qualitative data from open-ended responses were thematically analysed to identify barriers and facilitators to MdFES implementation.

Results: Patients reported high acceptability [Acceptability of Intervention Measure (AIM)] = 17.48 ± 2.66) and appropriateness [Intervention Appropriateness Measure (IAM)] = 17.54 ± 2.75), with 80% agreeing with their MdFES results and an average completion time of 3.12 ± 2.23 min, indicating low perceived burden. In contrast, nurses reported moderate acceptability (AIM = 12.72 ± 2.11), appropriateness (IAM = 13.19 ± 3.17), and feasibility [Feasibility of Intervention Measure (FIM)] = 13.47 ± 2.66), citing language barriers, cognitive limitations, and workflow constraints as key challenges. Fidelity was affected, with frequent rewording and translation required. Qualitative themes highlighted the need for translated versions, simplified wording, and workflow integration.

Conclusion: This pilot feasibility study demonstrates that the MdFES is acceptable and meaningful to patients, while revealing modifiable feasibility challenges for nurses. These early findings provide essential insights to guide workflow adaptations, stakeholder engagement, and contextual modifications required before proceeding to a larger-scale, multi-centre implementation study.

In many rural communities, traditional and biomedical health systems operate side by side, yet the comparative roles of traditional birth attendants and community health workers in perinatal care remain poorly understood. This study examines the variations in the influence of Accredited Social Health Activists (ASHAs) and traditional birth attendants (locally known as Dais) on maternal and newborn health behaviors in rural Bihar, India. We employed a mixed-methods design. Qualitative data included 40 focus group discussions, 50 key informant interviews, and six weeks of focused ethnographic observation of both ASHAs and Dais guided by rapid ethnography principles. Quantitative data were collected through a multi-stage cluster random survey of 1,166 recent mothers and 400 ASHAs, designed to ensure representation across Bihar's major linguistic regions. Logistic regression with backward selection (validated through sensitivity analyses and alternate specifications) estimated the influence of each provider on perinatal behaviors, with multicollinearity assessed using variance inflation factors. Findings revealed distinct temporal and functional roles: ASHAs were most active during pregnancy and labor, significantly increasing the odds of antenatal visits and institutional delivery, while Dais exerted greater influence postpartum, promoting traditional practices such as newborn massage. Synergistic effects emerged in breastfeeding initiation when both providers were involved, while conflicting guidance appeared in cord care. Families often created hybrid care models that blended biomedical recommendations with ritual practices. Overall, the coexistence of ASHAs and Dais suggests complementarity rather than simple competition, though patterns varied across settings. The study focuses on behaviors rather than health outcomes, and we acknowledge that this scope, along with ethical considerations of working with overlapping provider systems, shapes interpretation. Tailored strategies that foster respectful collaboration-such as joint training and coordinated outreach-may improve the uptake and cultural acceptability of maternal and newborn health programs in rural contexts.

Introduction: Multidisciplinary school mental health (SMH) teams play a key role in delivering mental health services to children. However, poor workflow, inefficient communication, and limited resources, compromise SMH service delivery. Despite robust literature demonstrating the efficacy of team science interventions, such as the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), research on these interventions with SMH teams is limited.

Methods: We conducted qualitative interviews with SMH team members, teachers, and school administrators who had participated in a hybrid effectiveness-implementation trial of TeamSTEPPS. Participants identified barriers and facilitators to implementation of the adapted TeamSTEPPS intervention, which were then organized according to the Consolidated Framework for Implementation Research (CFIR). An Implementation Research Logic Model was developed, aligning implementation determinants with implementation strategies and proposed mechanisms by which the strategies impact outcomes.

Results: Barriers to the successful implementation of the adapted TeamSTEPPS intervention included a lack of financing and resources, the intervention not being a relative priority, mission misalignment, poor work infrastructure to support, unmotivated innovation recipients and leaders, and insufficient planning. Proposed implementation strategies included providing dynamic training for leadership and SMH team members, centralizing technical assistance, development and distribution of educational materials, and ongoing consultation about implementation supports/when challenges arose, developing local policies that support implementation, establishing mandates for change, pruning competing initiatives, and providing reminders of strategies to school personnel. Proposed implementation outcomes (e.g., acceptability, feasibility), service outcomes (e.g., Observation of use of TeamSTEPPS strategies, Perceptions of teaming, Attitudes toward teamwork), and "client outcomes" (e.g., student service use, absences, suspensions, grade promotion) were also identified.

Discussion: Lessons from the implementation process and recommendations for future directions are highlighted to inform the delivery and sustainment of team science interventions, such as TeamSTEPPS, for use with SMH teams.

Vision health is a critical yet often overlooked component of comprehensive primary care, particularly for underserved populations. Patient access to eye care services enhances workplace productivity, household income, and employment opportunities, ultimately supporting economic growth, poverty reduction, and food security. Community Health Centers (CHC) collectively serve over 32 million patients annually and are uniquely positioned to address disparities in eye care access. Yet only 26% of CHCs offer vision care services, and only 2.9% of people who access CHC services receive eye care. Addressing this gap requires a strategic, systems-level approach to implementation. This perspective proposes an integrated framework to guide the sustainable and equitable integration of eye care providers, including optometrists and ophthalmologists, into Community Health Centers (CHCs). Drawing on and uniting the Consolidated Framework for Implementation Research (CFIR), the National Institute on Minority Health and Health Disparities (NIMHD) Research Framework, and the National Association of Community Health Centers' (NACHC) Value Transformation Framework (VTF), we outline a multi-level strategy that addresses implementation readiness, equity, and sustainability. This integrated framework is intended to inform implementation research and policy development aimed at making on-site eye care via an optometrist or ophthalmologist a mandated service in CHCs nationwide. In doing so, we offer an actionable game plan for CHC leaders, healthcare administrators, and public health advocates to expand access to comprehensive eye care in underserved communities.

In Jordan, a Low- Middle-Income Country (LMIC) in the Eastern Mediterranean Region (EMR), tobacco use rates are among the highest globally. These alarming rates impose a huge economic and health burden and are exacerbated by cultural norms, societal misperceptions, and insufficient policy implementation. The tobacco epidemic is a multidimensional and complex one requiring multiple complementary solutions. One such solution is the availing of tobacco dependence treatment (TDT) services. However, establishing and maintaining TDT services can be challenging in resource-challenged countries. In this Policy and Practice Paper, we conducted a comprehensive critical analysis of Jordan's experience in initiating, expanding and maintaining TDT services, with the intention of providing insight which other LMICs seeking to establish TDT services can find useful. Our analysis is guided by the Consolidated Framework for Implementation Research (CFIR). Specifically, information was collected through both a desk review of the available evidence, and through expert insight from six healthcare practitioners directly involved in the establishment and/or implementation of TDT in Jordan. A CFIR assessment template was used to document the evidence and gather expert insights across the five CFIR domains (Innovation Domain, Outer Setting, Inner Setting, Individuals Domain, and Implementation Process Domain). Lessons learned and recommendations also were generated within each CFIR domain. Our findings, while presented in the context of Jordan as an LMIC, can be of use to other countries and settings with similar limited resources that will need to consider the adaptability and complexity of TDT, the broader policy and environmental setting within which TDT will be established, the physical and practice settings hosting TDT services, the potential stakeholders to engage in TDT establishment, and the changing implementation challenges faced when sustaining TDT services in an LMIC. Thus, our review can assist resource-limited countries planning or preparing to implement TDT services.

Background: Adaptive implementation strategies tailor support to setting needs rather than applying a uniform approach. These strategies improve efficiency and fit, yet practical guidance on identifying decision points and tailoring variables is limited. This study collected end-user and partner input to specify decision points and tailoring variables for an adaptive implementation strategy.

Methods: This study focused on the evidence-based nutrition program, Together, We Inspire Smart Eating (WISE). End users and implementation partners with prior experience in WISE were recruited in two states to participate in semi-structured interviews or focus groups designed to elicit feedback to specify an adaptive implementation strategy for WISE.

Results: Qualitative input supported three crucial decisions for an adaptive implementation strategy: (1) low-intensity support, the starting point for all sites, will include leadership commitments, local champions, an implementation blueprint, classroom reminders, and task-focused facilitation at the site level; (2) assessment of response to low-intensity support will occur in October (Month 3) of the school year; and (3) sites not responding by Month 3 will receive holistic facilitation and tailored educational materials at the teacher level. Participants emphasized the universal need for facilitation at all sites, with struggling sites requiring more. They also identified tailoring variables: sites with fewer than 60% of classrooms achieving fidelity would require high-intensity support.

Conclusions: This study illustrates a process for using feedback from end users and partners to define key elements of an adaptive implementation strategy. Our approach holds significant potential to specify strategies for scaling health-related evidence.

Background: Appropriate communication with patients is increasingly crucial in a growing elderly population to prevent both over- and undertreatment. Advance care planning (ACP) is recognized as a valuable communication process for patients, their relatives and healthcare professionals that facilitates future care and medical decision-making. Despite its importance, the uptake remains low, particularly among frail, older patients in hospitals.

Methods: This qualitative substudy is nested within a cluster randomized controlled trial. Data collection involved eight semi-structured interviews conducted in acute geriatric hospital units receiving our implementation support program, along with informal data from interactions with the units during the implementation process. The aim was to explore healthcare professionals' perspectives on the barriers and facilitators to ACP implementation and their experiences with the implementation support program. A semi-structured interview guide was used. The data was analyzed using content analysis.

Results: Factors influencing ACP implementation were identified at three levels: a) the organizational level, b) the national level, and c) the clinical level. Participants recognized the critical role of timing, context, and patients' capacity. However, there was meaningful opportunities for ACP conversations in acute geriatric units. Overall, the experiences underscored the complex interplay of individual motivation and interest, organizational support, prioritization, available time and resources, and systemic factors that influence the integration of ACP into clinical practice, as well as the fact that research can act as both a barrier and a facilitator in implementation efforts.

Discussion: This study illustrates the significant challenges in implementing ACP in acute hospital care. Despite a generally positive perception of ACP, its implementation was hindered by barriers such as overwhelming workload, production-oriented healthcare, the biomedical model, and lack of prioritization. These factors creates a cycle where short-term demands overshadow preventive and patient-centered interventions, limiting their perceived and documented benefits. Breaking this cycle will likely require targeted investment in the implementation of complex interventions.

Trial registration: ClinicalTrials.gov, Identifier NCT05681585.

Objective: This study provides the first empirical evaluation of Taiwan's Hospital-at-Home (HaH) pilot program, launched in 2024 under the National Health Insurance system. The aim was to examine the clinical effectiveness, safety, and economic feasibility of HaH in managing acute infections, including pneumonia, urinary tract infections (UTIs), and soft tissue infections (STIs), among older adults living in long-term care facilities.

Methods: A prospective, matched-controlled study was conducted from July 2024 to June 2025 across seven nursing homes. Sixty residents aged 65 years or older who received HaH care were matched in a 1:2 ratio with 120 hospitalized patients by age, sex, and diagnosis. HaH services were delivered by a single interdisciplinary team. Primary outcomes included care duration, medical costs (USD), emergency department (ED) revisits, readmissions, and mortality. Secondary outcomes were complication rates. Statistical analyses used Chi-square tests, t-tests, and Mann-Whitney U tests, with odds ratios and 95% confidence intervals reported. A p-value < 0.05 was considered significant.

Results: HaH patients had significantly shorter care episodes compared with hospitalized patients (6.6 ± 1.5 vs. 11.8 ± 6.0 days, p < 0.001) and lower medical costs across all diagnoses. For STIs, costs were reduced by 65.1% (USD 979 vs. 2,805, p < 0.001), while UTIs and pneumonia showed savings of 46.0% and 45.5%, respectively. Overall clinical outcomes, including ED revisits, readmissions, and mortality, were similar between groups. In the STI subgroup, HaH patients had a significantly lower 14-day ED revisit rate (7.4% vs. 27.8%, odds ratio 0.21, 95% confidence interval 0.04-0.99, p = 0.04). HaH patients also experienced fewer hospital-acquired complications, particularly gastrointestinal and neurological events.

Conclusion: The findings demonstrate that HaH is a safe, effective, and cost-efficient alternative to hospitalization for acute infections in institutionalized older adults. By reducing care duration and costs without compromising clinical outcomes, HaH offers a patient-centered model that can ease healthcare system pressures in rapidly aging societies. These results support further expansion of HaH in Taiwan and encourage additional longitudinal studies to confirm long-term benefits and broader health system impacts.

Background: A significant proportion of patients with chronic obstructive pulmonary disease (COPD) continue smoking after diagnosis, contributing to increased symptom burden, more frequent exacerbations and poorer long-term outcomes. Hospitalisation due to COPD exacerbation may serve as a "window of opportunity" for delivering smoking cessation support.

Aim: This pilot study evaluated the feasibility of integrating structured smoking cessation support into routine inpatient care for patients hospitalised with a COPD exacerbation.

Methods: We followed 45 patients admitted for COPD exacerbation who reported active smoking at baseline. Smoking status and COPD symptoms (COPD Assessment Test, CAT) were evaluated at baseline, 1 month and 3 months after discharge. Comparisons were made between participants with smoking and non-smoking status at 1 month follow-up, and across three groups at 3 months: sustained non-smoking, sustained smoking and smoking relapse.

Results: At 1 month, 30 patients (66.7%) reported abstinence, and 19 (42.2%) remained abstinent at 3 months. Improvements in mean CAT scores were observed over time, from 22.9 (95% CI = 20.0-25.7) at baseline to 13.9 (CI = 11.4-16.3) at 1 month and 12.9 (CI = 10.1-15.6) at 3 months. A trend towards lower CAT scores were observed for participants with non-smoking status at follow-up, compared with those who were smoking. We observed, that those who sustained non-smoking at follow-up were older, had higher baseline expectations of quitting and reported greater confidence in their ability to stop. However, those who relapsed at three months were the oldest. Being without a partner appeared more common among sustained smoking at follow-up.

Conclusion: Smoking cessation support initiated during COPD hospitalisation was feasible and the majority of patients reported short-term abstinence and meaningful reductions in symptom burden. Age, expectations and confidence appeared to affect cessation trajectories, but should be explored further in larger, controlled trials and implementation setups.

Background: Evidence-based practice means making decisions based on evidence which takes account of experiences, values and preferences of employees and users. Fragmentation of services, technological limitations, lack of workforce, cultural resistance, resource constraints and distance between academia and practice can make the utilisation of evidence in health and social care services challenging. This study aimed to provide new insights into the development and implementation of a model for research support for decision-makers in municipal healthcare.

Methods: We used a qualitative design to explore stakeholders' experiences with development and implementation of the model for research support. We included minutes from several meetings and evaluation forms from the participating municipalities, ranging from the start of the project in January 2021 to the end of the project in January 2024. We conducted a thematic analysis, and the textual data were coded into categories and mapped according to the constructs of the consolidated framework for implementation (CFIR).

Results: The stakeholders in the municipalities expressed need for a support model to apply research in prioritising, planning and decision making. There were barriers to implementing the model due to complex and broad research questions. The researchers needed to navigate between methodological thoroughness and practical usability. The participants from the municipalities reported lack of structure, funding, competence and incentives to apply the evidence. They also struggled with dissemination and implementation of the results from the research summaries. Facilitating factors were political and administrative commitment, availability of research findings in plain language, a learning-by-doing approach through meetings and seminars working on real-world municipal challenges, and a structured collaboration between municipality employees and academics.

Conclusions: The study indicates that research support for decision-makers in the application of systematic reviews can be useful for evidence-based decision-making in municipal healthcare. However, implementing the model is resource-demanding, considering the use of time and personnel, both from the municipalities' and research institutions' point of view. Future research is needed to assess the effectiveness of the research-based support model towards better decision-making in municipalities and improvedpatient care.