Staff perspectives on the barriers and facilitators to exercise implementation in inpatient mental health services: A qualitative study

Exercise has multiple benefits for the physical and mental health of people with severe mental health problems (SMI). However, people with SMI engage in significantly less exercise than the general population and there is an evidence-practice gap regarding the implementation of exercise in clinical services. Mental health staff in inpatient services are well placed to support people with SMI to exercise, yet little is known about staff perspectives on exercise facilitation in inpatient care. This study aimed to explore staff views on role for exercise for people with SMI and the barriers and facilitators to exercise implementation in inpatient services. Qualitative semi-structured interviews were conducted with 25 clinicians working in inpatient mental health settings. Interview topics included the role for exercise in inpatient services, staff roles in relation to exercise, the barriers and facilitators to patients’ engagement in exercise, and promotion of exercise. Interview data were analysed using Thematic Analysis. Four key themes were developed: (i) perceived patient factors, (ii) exercise in the context of relationships, (iii) the ward context, and (iv) the therapeutic role for exercise. Clinicians readily recognised the benefits of service users engaging in exercise, though identified a number of individual, systemic, and organisational barriers to exercise implementation in inpatient services. Organisational prioritisation of exercise and support for staff to develop their skills and confidence in exercise facilitation is required. Enhancing the legitimacy of exercise as a multi-beneficial intervention for people with SMI is essential. Further recommendations for services based on the study findings are provided.     

Helping and hindering: perceptions of enablers and barriers to collaboration within a rural South Australian mental health network

Objective: To evaluate clinicians’ perceptions of what helps and hinders the delivery of mental health care across a service network in a rural setting. Design: Qualitative, semistructured interviews were conducted with 10 individuals who work in one rural mental health care service network. Setting: A regional centre in rural South Australia involving representatives of the mental health team, general practice, hospital, community health and nongovernment organisations. Results: Clinicians’ perceptions of barriers and enablers to working within their mental health care network were explored. Participants showed a strong shared commitment to effective mental health care delivery and a good understanding of the services that each offers. Interview data suggested that working relationships between local services could be perceived as stronger when a personal or historical element is recognisable. Similarly, the notion of familiarity and community involvement were perceived as facilitators in this network. A perceived barrier for participants was the failure to attract staff with mental health experience, leading to dependence upon the dedication and commitment of existing service providers. Conclusions: Collaboration is especially necessary in rural areas, where access to health care services is known to be difficult. The informality of relationships between service providers was shown to be the main facilitator in the network. This is both a strength as it promotes the communication between services and service providers that is essential for successful collaboration, yet is also a threat to the sustainability of the network based on the difficulties of staff recruitment and retention to rural settings.     

Feasibility and acceptability of opportunistic screening to detect atrial fibrillation in Aboriginal adults

Objective : Examine the feasibility and acceptability of an electrocardiogram (ECG) attached to a mobile phone (iECG) screening device for atrial fibrillation (AF) in Aboriginal Controlled Community Health Services (ACCHS) and other community settings. Methods : Semi‐structured interviews were conducted with ACCHS staff in urban, rural and remote communities in three Australian states/territories. Quantitative and qualitative questions identified the enabling factors and barriers for staff and Aboriginal patients' receptiveness to the device. Mean quantitative scores and their standard deviation were calculated in Microsoft Excel and qualitative questions were thematically analysed. Results : Eighteen interviews were conducted with 23 staff across 11 ACCHS. Quantitative data found staff were confident in providing iECG screening and managing the referral pathway, and thought the process was beneficial for patients. Qualitative data highlighted the usefulness of the device to undertake opportunistic screening and acceptability in routine practice, and provided opportunities to engage patients in education around AF. Conclusion : The iECG device was well accepted within ACCHSs and was feasible to use to screen for AF among Aboriginal patients. Implications for public health : The device can be used in clinical and community settings to screen Aboriginal people for atrial fibrillation to help reduce rates of stroke and other cardiovascular diseases.     

Improving Adolescent Perceptions of Barriers and Facilitators to Sexual and Reproductive Health Services Through Sexual Health Education

PurposeThis study examines whether comprehensive sexual health education that provides information on clinical services can change adolescents’ perceptions of barriers, facilitators, and intention to use services and whether changes in perceptions differ by participant characteristics.MethodsAdolescent participants in a statewide sexual health education program in California were surveyed at baseline and at exit about their perceptions of barriers, facilitators, and intention to use clinical services. Linked baseline and exit surveys (n = 7,460) assessed change in perceptions after program completion. Logistic regression analyses that accounted for the clustered data structure assessed associations between participant characteristics and improvement in perceptions.ResultsAfter the program, there were significant reductions in two perceived barriers (worry about cost and judgment by staff), but there were also small but significant increases in perceptions of two barriers (worry about confidentiality of services and test results). There were significant increases in all three perceived facilitators and intention to use sexual and reproductive health services, which rose from 90.6% at baseline to 96.2% at exit. Younger youth were more likely than older youth to show improvement in all perceived facilitators and intentions. Girls and Black youth were more likely than boys and Hispanic youth to show improvement in two facilitators (knowing what to expect and access). No sociodemographic characteristics were consistently associated with reductions in perceived barriers.DiscussionComprehensive sexual health education that addresses adolescents’ questions and concerns regarding clinical services can help to reduce perceived barriers, increase facilitators, and increase intention to use services if needed.     

Barriers and facilitators of shared decision making in acutely ill inpatients with schizophrenia—Qualitative findings from the intervention group of a randomised‐controlled trial

BackgroundShared decision making (SDM) is appreciated as a promising model of communication between clinicians and patients. However, in acute mental health settings, its implementation is still unsatisfactory.ObjectiveThe aim of this study is to examine barriers and facilitators of SDM with acutely ill inpatients with schizophrenia.DesignA qualitative interview study was performed.Setting and ParticipantsThe analysis is based on interviews with participants (patients and staff members) of the intervention group of the randomised‐controlled SDM^PLUS trial that demonstrated a significant improvement of SDM measures for patients with schizophrenia on acute psychiatric wards.Main Variables StudiedInterviews addressed treatment decisions made during the current inpatient stay. The interviews were analysed using qualitative content analysis.ResultsA total of 40 interviews were analysed and 131 treatment decisions were identified. According to the interviewees, SDM had taken place in 29% of the decisions, whereas 59% of the decisions were made without SDM. In 16%, a clear judgement could not be made. Barriers and facilitators of SDM were categorised into patient factors, clinician factors, setting factors and others. Clinicians mostly reported patient factors (e.g., symptoms) as barriers towards SDM, which were not mirrored on the patients'' side. Facilitators included patient as well as clinician behaviour during consultations.ConclusionEven in the context of a successful SDM intervention, the implementation of SDM for patients in the very acute stages of schizophrenia is often not possible. However, strong facilitators for SDM have also been identified, which should be used for further implementation of SDM.Patient or Public ContributionDuring the development of the study protocol, meetings with user representatives were held.     

Targeting preventive home visits to older adults in disadvantaged communities: Perspectives of professionals

This study explored the implementation of multidimensional preventive home visits targeted to older adults living in a disadvantaged community in Denmark. The intervention was adapted to include the following key components: involvement of community members in recruitment processes; a combination of individual and group-based dissemination; adaptation of materials to overcome language barriers; and diversity-sensitivity training for professionals. The study took place over 12 months between August 2016 and August 2017 and used various data sources: registry-based data, participant observations, combined with individual and focus group interviews with the target population (n = 22) and relevant health care professionals (n = 8). Here, we report on findings pertaining to implementation barriers and facilitators as seen from the perspective of professionals. Socioeconomic vulnerability was prominent, and uptake of health care services was low, indicating under-utilisation. Implementation facilitators and barriers were identified including potentials in nurturing local partnerships and proximity during recruitment; overcoming language barriers; offering diversity-sensitivity training for professionals; and a need for a more multidisciplinary, comprehensive scope of preventive visits for diverse older adults in disadvantaged communities. Thus, more focus on participatory, comprehensive and community-based health promotion are needed to ensure healthy ageing in the context of social inequality and ethnic diversity.     

Effect of Fortification with Multiple Micronutrient Powder on the Prevention and Treatment of Iron Deficiency and Anaemia in Brazilian Children: A Randomized Clinical Trial

Fortification with multiple micronutrient powder has been proposed as a public health intervention able to reduce micronutrient deficiencies in children. Our objective was to compare the effectiveness of fortification with multiple micronutrient powder with drug supplementation in the prevention and treatment of iron deficiency and anaemia. This was a cluster trial with anemic and non-anaemic children between six and 42 months old, in randomization data. Non anaemic children received fortification with multiple micronutrient powder or standard drug supplementation of ferrous sulfate associated with folic acid in a prevention dose. Anaemic children who were randomized to receive multiple micronutrient powder also received the recommended iron complementation for anaemia treatment. A total of 162 children were evaluated. The prevalence of anaemia decreased from 13.58 to 1.85%. Iron deficiency decreased from 21.74% to 7.89% (by serum ferritin) and iron deficiency decreased from 66.81 to 38.27% (by soluble transferrin receptor). No difference was identified between interventions for hemoglobin (p = 0.142), serum ferritin (p = 0.288), and soluble transferrin receptor (p = 0.156). Fortification with multiple micronutrient powder was effective in preventing iron deficiency and anaemia in children aged six to 48 months. In anaemic children; it was necessary to supplement the dose of multiple micronutrient powder with ferrous sulfate.     

Health service providers' perceptions of barriers to tuberculosis care in Russia

The Russian Federation has witnessed a marked rise in rates of tuberculosis (TB) over the past decade. Public health TB control institutions remain broadly modelled along pre-1990 lines despite substantial programmes of investment and advocacy in implementing the World Health Organization's 'Directly Observed Treatment--short course' (DOTS) strategy. In 2002, we undertook a qualitative study to explore health care providers' perceptions of existing barriers to access to TB services in Samara Oblast in Russia. Six focus group discussions were conducted with physicians and nurses from facilities in urban and rural areas. Data were analyzed using a framework approach for applied policy research. Barriers to access to care were identified in interconnected areas: barriers associated with the health care system, care process barriers, barriers related to wider contextual issues, and barriers associated with patients' personal characteristics and behaviour. In the health care system, insufficient funding was identified as an underlying problem resulting in a decrease in screening coverage, low salaries, staff shortages, irregularities in drug supplies and outdated infrastructure. Suboptimal collaboration with general health services and social services limits opportunities for care and social support to patients. Worsening socioeconomic conditions were seen both as a cause of TB and a major obstacle to access to care. Behavioural characteristics were identified as an important barrier to effective care and treatment, and health staff favoured compulsory treatment for 'noncompliant' patients and involvement of the police in defaulter tracing. TB was profoundly associated with stigma and this resulted in delays in accessing care and barriers to ensuring treatment success.     

Tackling health inequalities through partnership working: Learning from a realistic evaluation

UK government health policy now strongly supports local partnership working as a key mechanism for tackling health inequalities. There is, however, still a lack of evidence based operational guidance for the development of local partnerships in tackling inequalities in health, as well as continuing evidence of the deep-rooted political, organizational and cultural barriers to partnership working. This paper reports on the evaluation of a two year Health Education Authority programme of demonstration projects designed to test five different models of partnership working in tackling health inequalities. The evaluation drew on Pettigrew et al.'s (1992) concepts of receptive and non-receptive contexts for change as well as the 'realistic evaluation' of Pawson & Tilley (1997). Data were collected using a range of qualitative methods including semi-structured interviews with key stakeholders and non-participant observation. Six key themes were identified from the case studies: shared strategic vision, leadership and management, relations and local ownership, accountability, organizational readiness and responsiveness to a changing environment. The importance of understanding how project mechanisms worked in the context of national and local policy change is emphasized, and lessons are identified for UK Health Improvement Programmes, Health Action Zones and Primary Care Groups.     

Identifying the determinants of tuberculosis control in resource-poor countries: insights from a qualitative study in The Gambia

Despite the availability of effective treatment, tuberculosis (TB) remains a major cause of death from an infectious disease in the world, particularly in resource-poor countries. Among the chief reasons for this are deficiencies in case tracing and in adherence to treatment. In order to investigate the contribution of non-biological factors to these deficiencies, we carried out a qualitative study in The Gambia, West Africa, from October 2000 to March 2001. The methods used were focus group discussions, interviews, participant and non-participant observation, and case histories. Four domains were distinctively investigated: the TB patients, the community, the health care providers (including programme staff), and the donors and policy makers. Analysis of the data from all these sources indicated the contribution of a wide range of socio-anthropological factors which influence the success or otherwise of the TB control programme in The Gambia, i.e. gender, urban/rural residence, recourse to traditional healers, adherence to national health policies, knowledge about TB, migration, and socio-economic factors. It is concluded that all these factors must be taken into account in formulating interventions to improve detection of TB cases and patient adherence to treatment within the framework of the national TB control programmes, and proposals have been made for targeted interventions.     

Using systems thinking to understand how the South West - School Health Research Network can improve adolescent health and well-being: A qualitative process evaluation

Schools offer a valuable setting to promote good health and mental well-being amongst young people. Schools are complex systems and therefore systems interventions are needed to improve pupil health and well-being. This paper presents a qualitative process evaluation of the South West- School Health Research Network, a systems level intervention. The evaluation is based on interviews with school staff, local authorities and wider stakeholders. Given the complexity of England's educational system there is a need to intervene and monitor health at multiple levels and to ensure close partnership working to effectively improve adolescent health through schools.     

Barriers and Facilitators to Implementation of an Occupational Health Guideline Aimed at Preventing Weight Gain Among Employees in the Netherlands

OBJECTIVE:: To assess barriers and facilitators to implementation of an occupational health guideline aimed at preventing weight gain. METHODS:: Barriers and facilitators to implementation were assessed among 14 occupational physicians (OPs) and employers and analyzed following a systematic approach using Atlas.ti. RESULTS:: Barriers and facilitators mentioned by OPs and employers were related to the sociopolitical context, organization, OP, and guideline. Recommendations include the formation of a linkage group, collaboration with other experts, formation of peer support groups, and communicating benefits of investments, expectations, and ethical considerations. Results of this study recommend incorporating these barriers and facilitators in the guideline, including strategies about how to overcome barriers and stimulate facilitators. CONCLUSIONS:: The identified barriers and facilitators can be used to increase the chance of successful implementation of the final guideline into occupational health practices throughout the Netherlands.     

Barriers and facilitators of implementing a collaborative HPV vaccine program in an incarcerated population: A case study

BackgroundMen and women in county jails make up a population that is difficult to reach with traditional preventive health interventions. Collaborations between local health departments and county jails represent an opportunity to enhance public health by reaching a vulnerable population with services like vaccinations. The objective of this study was to coordinate planning and implementation of a collaborative program between a local health department (HD) and a county jail to offer human papillomavirus (HPV) vaccinations to adolescents (ages 10–17) and young adults (ages 18–26) in the jail and to identify facilitators and barriers to inform future program development.MethodsA county-municipal jail and a local HD in Kansas participated. A case study method was employed based on data collected from a focus group, telephone interviews, and site observations, September 2016 to December 2017. Data were coded using codes roughly drawn from the consolidated framework for implementation research (CFIR). Codes were then consolidated into themes related to barriers and facilitators.ResultsNo adults were vaccinated; two juveniles were vaccinated. Barriers to a collaborative program to offer HPV vaccine to young adults arose in two areas: constrained resources and divergent organizational cultures and priorities. Barriers to offering HPV vaccinations to juveniles in the jail included parental consent and the unpredictable, often brief duration of juvenile detentions. A shared commitment to offering HPV vaccination services by leaders and staff in the two agencies was a key facilitator.ConclusionFinding ways to leverage leadership and staff buy-in and address specific barriers of constrained resources and divergent culture and priorities merits close attention, since partnerships between jails and local HD have potential to increase HPV vaccination rates in an overlooked population and advance public health.     

Experiences of Māori of Aotearoa New Zealand's public health system: a systematic review of two decades of published qualitative research

Objective: This paper aims to synthesise the broader perspectives of Māori patients and their whānau (extended family, family group) of their treatment within the public health system. Our research question was ‘What are the experiences of Māori in the public health and/or hospital system in Aotearoa New Zealand?’ Methods: A systematic search using PRISMA protocols and reflexive typology organised around the categories of Māori, public healthcare and qualitative research identified 14 papers that covered all three categories. We undertook a qualitative metasynthesis on these papers using a critical community psychology approach. Results: Māori patients and whānau from the included papers mention both barriers and facilitators to health. We categorised barriers as organisational structures, staff interactions and practical considerations. Facilitators were categorised as the provision of whānau support in the form of practical assistance, emotional care and health system navigation. Conclusions: For many Māori, the existing public health system is experienced as hostile and alienating. Whānau members provide support to mitigate this, but it comes as a cost to whānau. Implications for public health: Public health providers must find ways to ensure that Māori consistently experience positive, high‐quality healthcare interactions that support Māori ways of being.     

Pregnancy experiences of women in rural Romania: understanding ethnic and socioeconomic disparities

Women in rural Romania face significant health disadvantages. This qualitative pilot study describes the structural disadvantage experienced during pregnancy by women in rural Romania, focusing on the lived experiences of Roma women. We explore how women in rural communities experience pregnancy, their interactions with the healthcare system, and the role that ethnic and social factors play in pregnancy and childbearing. We conducted 42 semi-structured interviews with health and other professionals, seven narrative interviews with Roma and non-Roma women and a focus group with Roma women. Data were analysed using thematic analysis. We identified intersectional factors associated with women’s pregnancy experiences: women perceiving pregnancy as both unplanned and wanted, joyful, and normal; women’s and professionals’ differing prenatal care perceptions; transport and cost related barriers to care; socioeconomic and ethnic discrimination; and facilitators to care such as social support, having a health mediator and having a doctor. Talking directly with professionals and Roma and non-Roma women helped us understand these many factors, how they are interconnected, and how we can work towards improving the pregnancy experiences of Roma women in rural Romania.     

Treating acute mental illness in rural general hospitals: Necessity or choice?

OBJECTIVE: To identify reasons why rural general practitioners (GPs) treat a large proportion of patients with a primary psychiatric diagnosis in general beds of their local hospitals, and the barriers encountered when providing this treatment. DESIGN: A postal questionnaire was developed and distributed to a sample of rural GPs, asking about the treatment of patients with an acute mental illness in their local hospital. RESULTS: The majority of GPs agreed that they treat the acutely mentally ill in general beds of their local hospital due to lack of availability of, and inability to gain access to, mental health beds in the larger centres; and also to enable ongoing family involvement and continuity of care. Distance factors were identified as least significant. Barriers to providing care to this group of patients included a perceived lack of support by consultant psychiatrists, confidentiality issues, lack of community mental health workers to provide assistance, aggression levels of patients, inappropriate local hospital setting, and lack of confidence of GPs and general hospital nursing staff. CONCLUSION: Addressing these barriers is necessary if rural Australians are to receive a quality of care that is equal to that received by those located in metropolitan Australia. Continuing research in this area is crucial.     

Mental health support for youth offending teams: a qualitative study

The objective of the present study was to examine the views of professionals working in youth offending teams (YOTs) on a new model for providing mental health service support within the context of an interagency setting. Focus groups were used and data were analysed according to the constant comparative method. The setting consisted of two YOTs, one in an inner-city area and the other in a rural/semi-urban area, where primary mental health workers operate at the interface between YOTs and the specialist child and adolescent mental health services. Seventeen YOT professionals participated in four focus groups. Four themes were identified: previous experiences of specialist mental health services; issues of interagency working; the role of the primary mental health worker within the YOT; and recommendations for the future. Overall, the clinical component of the role (assessment and intervention), and the accessibility and responsiveness of the mental health staff were consistently valued, while there were mixed responses on role definitions within the team, consultation and training. It is concluded that mental health service provision through primary mental health workers is a useful model for interagency partnerships for high-risk client groups with multiple and complex mental health needs.     

Home-based care: barriers and facilitators to expanded personal support worker roles in Ontario,Canada

ABSTRACT

To accommodate the increasing demand for home care in Ontario, Canada, some care tasks traditionally performed by regulated health professionals are being transferred to personal support workers (PSW). However, this expansion of PSW roles is not uniform across the province. Between December 2014 and April 2015, barriers and facilitators to expansion of PSW roles in home care were explored in a series of 13 focus groups. Home care staff identified seven categories of factors affecting the expansion of PSW roles in home care including: communication and documentation; organization and structures of care; attitudes and perceptions of the expanding PSW role; adequate staffing; education, training and support; PSW role clarity and variation in practices, policies, and procedures. Addressing barriers and promoting facilitators at the funder and employer levels will enable the provision of safe, effective, and equitable care by PSWs.