Factors impacting sustainability of community health worker programming in rural Uganda: a qualitative study

BackgroundDespite significant global progress towards decreased child mortality in past decades, maternal and child mortality continues to be high, especially in sub Saharan Africa. Most of these deaths are preventable with known interventions. Community health workers (CHWs) are well-positioned to promote these life-saving interventions; however, sustaining CHW programs remains a challenge.MethodsA sustainability-focused qualitative evaluation, was done between July and August 2018 in 2 rural districts in southwest Uganda. Using semi-structured interview tools, we conducted 6 Focus Group discussions (FGDs) with CHWs and 17 in-depth interviews (IDIs) with various district stakeholders to gain insights into factors affecting sustainability of a district-wide maternal, newborn and child health (MNCH)-oriented CHW intervention. Data was managed using NVivo software (version 12) with themes using thematic analysis.ResultsIdentified factors impacting CHW program sustainability included ‘health system effectiveness’ (availability of supplies, medicines and services and availability of facility health providers), CHW program-related factors'' (CHW selection and training, CHW recognition), ‘community attitudes and beliefs’ and ‘stakeholder engagement’.ConclusionTo sustain CHW programs in rural Uganda and globally, planners, policymakers and funders should maximize community engagement in establishing CHW networks and strengthen accountability, supply chains and linkages with communities and health facilities     

An evaluation of a peer supervision pilot project among community health workers in rural Uganda

BackgroundLiving Goods operates a Community Health Worker (CHW) program in 19 districts of Uganda, where CHWs are supervised by full time Community Health Supervisors. This model is effective, but expensive. Evidence indicates that peer supervision can be a substitute and cheaper model for CHW supervision. We describe our experience and outcomes while implementing peer supervision among CHWs in Mayuge districtObjectives1. To compare health services delivery outcomes between the two supervision models. 2. To compare costs of the two supervision models..MethodsInternal organizational records from January to December 2019 were reviewed. Focus group discussions and in-depth interviews with participating CHWs were also conducted. Qualitative analysis was performed using thematic content analysis. Quantitative data was summarized to generate averages, percentages and graphs.FindingsCHWs under the peer supervision performed better than those under standard supervision against all key performance indicators. The total cost to maintain the peer supervision model for 1 year was USD $176 per CHW versus USD $273 among CHWs under the standard supervision model. Peer supervision thus resulted in overall cost savings of 36%. There was lower attrition among CHWs under peer supervision compared to standard supervision (10% versus 17%).ConclusionsPeer supervision is a feasible and more affordable model of supervising CHWs.     

Evaluating the use of mobile phone technology to enhance cardiovascular disease screening by community health workers

BackgroundPrimary prevention of cardiovascular disease (CVD),by identifying individuals at risk is a well-established, but costly strategy when based on measurements that depend on laboratory analyses. A non-laboratory, paper-based CVD risk assessment chart tool has previously been developed to make screening more affordable in developing countries. Task shifting to community health workers (CHWs) is being investigated to further scale CVD risk screening. This study aimed to develop a mobile phone CVD risk assessment application and to evaluate its impact on CHW training and the duration of screening for CVD in the community by CHWs.MethodsA feature phone application was developed using the open source online platform, CommCare^©. CHWs (n = 24) were trained to use both paper-based and mobile phone CVD risk assessment tools. They were randomly allocated to using one of the risk tools to screen 10–20 community members and then crossed over to screen the same number, using the alternate risk tool. The impact on CHW training time, screening time and margin of error in calculating risk scores was recorded. A focus group discussion evaluated experiences of CHWs using the two tools.ResultsThe training time was 12.3 h for the paper-based chart tool and 3 h for the mobile phone application. 537 people were screened. The mean screening time was 36 min (SD = 12.6) using the paper-base chart tool and 21 min (SD = 8.71) using the mobile phone application, p = <0.0001. Incorrect calculations (4.3% of average systolic BP measurements, 10.4% of BMI and 3.8% of CVD risk score) were found when using the paper-based chart tool while all the mobile phone calculations were correct. Qualitative findings from the focus group discussion corresponded with the findings of the pilot study.ConclusionThe reduction in CHW training time, CVD risk screening time, lack of errors in calculation of a CVD risk score and end user satisfaction when using a mobile phone application, has implications in terms of adoption and sustainability of this primary prevention strategy to identify people with high CVD risk who can be referred for appropriate diagnoses and treatment.     

Increasing knowledge of cardiovascular risk factors among African Americans by use of community health workers: the ABCD community intervention pilot project

African Americans have higher rates of cardiovascular disease (CVD) and poorer outcomes compared to others. The American Diabetes Association and the National Diabetes Education Program have promoted use of the ABC approach (glycated hemoglobin A1c, blood pressure, cholesterol) for identifying and controlling the leading indicators of CVD risk. In the present study, researchers added a D factor, for depression, because this disorder is common and also predictive of CVD risk and of control of diabetes. Particularly among low-income African Americans, depression is frequently not targeted or treated. The current study tests the effectiveness of recruiting African Americans in churches and training community health workers (CHWs) to educate their peers about CVD and risk reduction. For the intervention group, CHWs participated in a 16-hour training session and delivered a 6-week tailored educational program with counseling sessions and demonstrations. The control group received a weekly lecture by clinical experts. The CHW active-learning intervention was more effective than lectures by clinical experts in increasing the knowledge of CVD risk. The only significant difference in clinical measures reflected a worsening of HbA1c levels in the control group; the CHW intervention group showed a slight improvement. Participants also learned self-management skills, such as taking blood pressure, measuring glucose, and reading labels. Nevertheless, more longitudinal research and a larger sample size are needed to confirm the impact of CHWs in community settings to change factors associated with CVD risk.     

Development and evaluation of a genomics training program for community health workers in Texas

PurposeGenomics services have the potential to reduce incidence and mortality of diseases by providing individualized, family health history (FHH)-based prevention strategies to clients. These services may benefit from the involvement of community health workers (CHWs) in the provision of FHH-based genomics education and services, as CHWs are frontline public health workers and lay health educators, who share similar ethnicities, languages, socioeconomic statuses, and life experiences with the communities they serve. We developed, implemented, and evaluated the FHH-based genomics training program for CHWs.MethodsThis theory- and evidence-based FHH-focused genomics curriculum was developed by an interdisciplinary team. Full-day workshops in English and Spanish were delivered to 145 Texas CHWs (91.6% were Hispanic/black). Preworkshop, postworkshop, and 3-month follow-up data were collected.ResultsCHWs significantly improved their attitudes, intention, self-efficacy, and knowledge regarding adopting FHH-based genomics into their practice after the workshops. At 3-month follow-up, these scores remained higher, and there was a significant increase in CHWs’ genomics practices.ConclusionThis FHH-based genomics training successfully educated Texas CHWs, and the outcomes were promising. Dissemination of training to CHWs in and outside of Texas is needed to promote better access to and delivery of personalized genomics services for the lay and underserved communities.     

Using path analysis to model the process of change in HbA1c among African Americans and Latinos in a community health worker diabetes intervention

ObjectiveTo examine which components of a culturally tailored community health worker (CHW) intervention improved glycemic control and intermediate outcomes among Latina/o and African American participants with diabetes.MethodsThe sample included 326 African American and Latina/o adults with type 2 diabetes in Detroit, MI. CHWs provided interactive group diabetes self-management classes and home visits, and accompanied clients to a clinic visit during the 6-month intervention period. We used path analysis to model the processes by which each intervention component affected change in diabetes self-efficacy, diabetes-related distress, knowledge of diabetes management, and HbA1c.ResultsThe group-based healthy lifestyle component was significantly associated with improved knowledge. The group-based self-management section was significantly associated with reduced diabetes-related distress. Intervention class attendance was positively associated with self-efficacy. Diabetes self-management mediated the reductions in HbA1c associated with reductions in diabetes distress.ConclusionsPath analysis allowed each potential pathway of change in the intervention to be simultaneously analyzed to identify which aspects of the CHW intervention contributed to changes in diabetes-related behaviors and outcomes among African Americans and Latinas/os.Practice Implications: Findings reinforce the importance of interactive group sessions in efforts to improve diabetes management and outcomes among Latina/o and African American adults with diabetes.     

A multi-site community randomized trial of community health workers to provide counseling and support for patients newly entering HIV care in rural Ethiopia: study design and baseline implementation

Background: Although HIV therapy is delivered to millions globally, treatment default (especially soon after entering care) remains a challenge. Community health workers (CHWs) can provide many services for people with HIV, including in rural and resource-limited settings.

Objectives: We designed and implemented a 32 site community randomized trial throughout southern Ethiopia to assess an intervention using CHWs to improve retention in HIV care.

Methods: Sixteen district hospital and 16 local health center HIV clinics were randomized 1:1 to be intervention or control sites. From each site, we enrolled adults newly entering HIV care. Participants at intervention sites were assigned a CHW who provided: HIV and health education; counseling and social support; and facilitated communication with HIV clinics. All participants are followed through three years with annual health surveys, plus HIV clinic record abstraction including clinic visit dates. CHWs record operational data about their client contacts.

Results: 1799 HIV patients meeting inclusion criteria were enrolled and randomized: 59% were female, median age = 32 years, median CD4 + count = 263 cells/mm³, and 41% were WHO Stage III or IV. A major enrollment challenge was fewer new HIV patients initiating care at participating sites due to shortage of HIV test kits. At intervention sites, 71 CHWs were hired, trained and assigned to clients. In meeting with clients, CHWs needed to accommodate to various challenges, including HIV stigma, distance, and clients lacking cell phones.

Conclusions: This randomized community HIV trial using CHWs in a resource-limited setting was successfully launched, but required flexibility to adapt to unforeseen challenges.     

Perspectives of older people engaging in nurse-led cardiovascular prevention programmes: a qualitative study in primary care in the Netherlands

BackgroundCardiovascular prevention programmes are increasingly being offered to older people. To achieve the proposed benefits, adherence is crucial. Understanding the reasons for adherence and non-adherence can improve preventive care.AimTo gain insight into what motivates older people living in the community to partake in a cardiovascular prevention programme, and reasons for subsequent continuation or withdrawal.MethodSemi-structured interviews were conducted with a purposive sample of 15 participants (aged 76–82 years). Interviews were audiorecorded and analysed by two independent researchers using a thematic approach. Participants were asked about their motivation for participating in the programme, along with the facilitators and barriers to continue doing so.ResultsResponders reported that regular check-ups offered a feeling of safety, control, or being looked after, and were an important motivator for participation. For successful continuation, a personal relationship with the nurse and a coaching approach were both essential; the lack of these, along with frequent changes of nursing staff, were considered to be barriers. Participants considered general preventive advice unnecessary or patronising, but practical support was appreciated.ConclusionTo successfully engage older people in long-term, preventive consultations, the approach of the healthcare provider is crucial. Key elements are to offer regular check-ups, use a coaching approach and to build a personal relationship with the patient.     

Women's attitudes towards receiving family planning services from community health workers in rural Western Kenya

BackgroundKenya ranks among the countries in Africa with high fertility rates. In order to reverse the trends in high fertility rates, there is need to increase uptake of family planning services particularly by use of community health workers (CHWs) in providing these services in rural areas.ObjectiveTo describe the perceptions of women towards family planning service provision by CHWs in four rural districts of Western Kenya. It is based on baseline survey data from a three-year, rural community-based family planning project funded by The David and Lucile Packard Foundation.MethodsA cross-sectional baseline survey was conducted in Western Kenya. The data presented is part of a broader the broader survey . A survey questionnaire was administered to 1,997 women (15–49 years) but only 963 cases were valid for our analyses.ResultsThe findings revealed that only a third of the respondents exhibited high approval for Family Planning services from CHWs. Only four out of the thirteen variables explored showed significance on attitudes towards family planning services from CHWs. These are age, level of education, knowledge about family planning benefits and districts.ConclusionWomen''s perception towards family planning services delivered by CHWs in Western region in Kenya is quite low. To improve the demand and supply for family planning services in this region, there is need to invest a substantial amount of effort into sensitization of women on the relevance of CHWs in providing family planning services.     

Intensity of exposure to a patient activation intervention and patient engagement in medical visit communication

ObjectiveWe examined associations between intensity of exposure to a community health worker (CHW) delivered communication activation intervention targeting low-income patients with hypertension.MethodsWe analyzed question-asking behaviors of patients assigned to the intervention arms (n = 140) in a randomized controlled trial. Intensity of exposure to the intervention was operationalized as the duration of face-to-face coaching and number of protocol-specified topics discussed. Mixed effects models characterized the relationship between intensity of exposure and patients’ communication in a subsequent medical visit.ResultsThe number of topics discussed during the coaching session was positively associated with patients’ asking psychosocial-related questions during their visit. The duration of the coaching session was positively associated with patients’ use of communication engagement strategies to facilitate their participation in the visit dialogue. Exposure to a physician trained in patient-centered communication did not influence these relationships.ConclusionsA dose-response relationship was observed between exposure to a CHW- delivered communication activation intervention and patient-provider communication.Practice implicationsThis study supports the use of CHWs in activating patients toward greater communication in the therapeutic exchange.     

Barriers and Facilitators Faced by Athletic Trainers Implementing National Athletic Trainers' Association Inter-Association Task Force Preseason Heat-Acclimatization Guidelines in US High School Football Players

ContextThe aim of the National Athletic Trainers'' Association Inter-Association Task Force (NATA-IATF) preseason heat-acclimatization guidelines was to acclimatize high school athletes to the environment during the first 2 weeks of the preseason and reduce the risk of exertional heat illness.ObjectiveTo identify barriers and facilitators that high school athletic trainers (ATs) encountered when implementing the NATA-IATF guidelines.DesignQualitative study.SettingIndividual phone interviews with all participants.Patients or Other ParticipantsThirty-three ATs (16 men, 17 women; age = 36.0 ± 12.0 years, athletic training experience = 12.9 ± 10.5 years) representing 19 states (4 with state mandates) were interviewed before data saturation was achieved. Participants were purposefully sampled from a larger investigation based on stratification of US Census region and preidentified high school compliance with the NATA-IATF guidelines.Main Outcome Measure(s)A cross-sectional, semistructured phone interview (6 steps) was conducted with each participant and then transcribed verbatim. A 7-person research team (5 coders, 2 auditors) coded the data into themes and categories, focusing on consensus of data placement to reduce bias and ensure accuracy.ResultsFacilitators and barriers that influenced successful guideline implementation were (1) perceived stakeholder access, (2) perceived stakeholder role, (3) capability and capacity, (4) school culture, (5) logistical support, (6) resources, (7) physical environment, and (8) consistency of the guidelines. Overall, participants discussed facilitators and barriers within each category based on their experiences and circumstances.ConclusionsAthletic trainers faced numerous concerns regarding compliance with the NATA-IATF preseason heat-acclimatization guidelines. Multiple levels of influence should be targeted to improve implementation. These include intrapersonal factors by giving ATs the education and self-efficacy to support advocacy for implementation, interpersonal components by establishing strong collaborative networks for change, community and environmental factors by optimizing school culture and community resources for implementation, and policy aspects by establishing consistent guidelines across all bodies.     

An evaluation of the facilitator training to implement ‘Taking charge of my life and health’, a peer-led group program to promote self-care and patient empowerment in Veteran participants

ObjectiveWe developed a peer-led group program for Veterans called Taking Charge of My Life and Health (TCMLH) that emphasizes patient education, goal setting, shared decision making, and whole person care. Our aim was to conduct an evaluation of a facilitator training course to deliver TCMLH in VA sites.MethodsRepeated measures ANOVA models were used to examine change over three timepoints (pre-test, post-test, and two-month follow-up) in outcomes of attitudes, knowledge, skills, and self-efficacy related to patient empowerment, skills acquisition, self-care strategies, and curriculum facilitation. Qualitative data analysis of participant feedback was used to identify potential training adaptations and barriers to TCMLH delivery.ResultsOur sample comprised 70 trainees who completed all three assessments. Participants reported high levels of training satisfaction, quality, and utility, and sustained improvements in knowledge of Whole Health, self-efficacy for group facilitation, and self-efficacy for using Whole Health concepts and tools. Implementation barriers included challenges related to group management and site logistics.ConclusionThe facilitator training course improved knowledge and self-efficacy associated with successful peer-led program delivery and identified opportunities to improve the training course and TCMLH dissemination.Practice Implications: Findings provide insights on the design and implementation of training models to support peer-led programs.     

Midwives' challenges in the management of postpartum haemorrhage at rural PHC facilities of Limpopo province,South Africa: an explorative study

BackgroundPostpartum haemorrhage is one of the causes of the rise in maternal mortality. Midwives'' experiences related to postpartum haemorrhage (PPH) management remain unexplored, especially in Limpopo. The purpose of the study was to explore the challenges experienced by midwives in the management of women with PPH.MethodsQualitative research was conducted to explore the challenges experienced by midwives in the management of women with PPH. Midwives were sampled purposefully. Unstructured interviews were conducted on 18 midwives working at primary health care facilities. Data were analysed after data saturation.ResultsAfter data analysis, one theme emerged “challenges experienced by midwives managing women with PPH” and five subthemes, including: “difficulty experienced resulting in feelings of frustrations and confusion and lack of time and shortage of human resource inhibits guidelines consultation”.ConclusionThe study findings revealed that midwives experienced difficulty when managing women with postpartum haemorrhage. For successful implementation of maternal health care guidelines, midwives should be capacitated through training, supported and supervised in order to execute PPH management with ease.     

The First Systematic Gastroscopy Training Program for Surgeons in Korea

BackgroundEndoscopic evaluation of the stomach is essential for preoperative planning and post-surgical surveillance for various diseases of the stomach, including malignancy. The gastroscopy education program for surgeons is currently in its infancy and is not systematically organized in Korea. This study aimed to introduce the first systematic gastroscopy education program for surgeons in Korea.MethodsThe gastroscopy education program entitled “Gastroscopy School for Surgeons (GSS)” comprised of theoretical education, dry lab hands-on training, and clinical practice. All participants were beginners without any gastroscopy experience. Clinical practice started after the completion of the theoretical and dry lab training. The gastroscopy practices utilized simple luminal observation, biopsy, localization using clips or dye injection, and limited therapeutic gastroscopy. The educational performances and surveys from 33 participants were analyzed.ResultsThe participants consisted of surgical residents, general surgeons, gastrointestinal-specialized surgeons, and physicians. Participants performed a total of 2,272 gastroscopies, 2,008 of which were post-gastrectomy cases. Currently, of the 33 participants, 7 (21.2%) of the participants performed gastroscopy regularly, and 7 (21.2%) occasionally. According to the self-reported survey, one participant assessed their current gastroscopic technique to be at the expert level, and 25 (75.8%) at a proficient level. All participants considered gastroscopy education for surgeons to be necessary, and 28 (84.8%) stated that systematic education is not currently provided in Korea.ConclusionWe introduced the first systematic gastroscopy education program for surgeons in Korea, namely the GSS, which is practical and meets clinical needs. More training centers are needed to expand gastroscopy training among Korean surgeons.     

Co-creation and collaboration: A promising approach towards successful implementation. Experience from an integrated communication and mental health skills training programme for Japanese General Practice

IntroductionThis paper describes the co-creation and delivery of an integrated training programme in communication and depression assessment & management for Japanese GPs.MethodsExperts in communication and depression from EACH and WONCA developed a framework and filled it with content. Through iterative discussions with the Japanese participants and experts during delivery, the training was further adjusted to match local needs. It included didactic and experiential training methods with an emphasis on practicing and feedback. A “train-the-trainer” component helped participants develop their own trainer skills to enhance dissemination of the training in Japan.ResultsSix Japanese GPs participated in two one week training-modules in May and November 2018. To aid implementation participants received online supervision on depression management and on teaching between the two modules and after the second module. Evaluation of the content of the training, the teaching methods and the participatory approach was positive. More than two years after the training, many elements of the training continue to be used in daily practice with the GPs teaching communication as well as depression management skills.ConclusionThe method of co-creation is promising. Research is needed to confirm that it is effective in transfer to clinical practice.     

Characteristics and Distribution of Surgical Diseases in North Korean Research Papers Published between 2006 and 2017

BackgroundLittle is known about the surgical discipline in North Korea from the perspective of the outside world. This study aimed to examine the disease entities covered by articles published in the major medical journal in North Korea, “Surgery.”MethodsContent and frequency analyses of 2,132 articles published in “Surgery” from 2006 to 2017 were conducted. Two medical doctors who majored in surgery and anesthesiology perused the articles and compiled the diseases being elucidated in each article. The diseases described in each article were stratified into 13 surgical subspecialties.ResultsArticles from “Surgery,” similar to articles from the Western surgical community, also covered a wide variety of surgical diseases from different subspecialties, and the number of publications continued to grow consistently. Moreover, a number of studies focused on the fields of orthopedics and general surgery dealing with benign diseases. Some articles focused on minimally invasive surgeries using laparoscopy.ConclusionThe studies published in the North Korean journal “Surgery” encompass various clinical areas, but their quality is unclear.     

The role of tablets in accessing information throughout undergraduate medical education in Botswana

BackgroundMobile learning (mLearning) uses wireless networks and mobile devices to expand physician trainees’ and healthcare providers’ access to and exchange of medical information. Opportunities to increase implementation and expand use of mobile devices to support health care information access and delivery in Africa are vast, but the rapid growth of mLearning has caused project implementation to outpace objective measurement of impact. This study makes a contribution to the existing body of literature regarding mLearning implementation in Africa through its focus on the use of smart devices (tablets) in undergraduate medical education and medical students’ perceptions of the effects on their learning environment.Materials and methodsThe population of this prospective mixed-methods study consisted of 82 undergraduate medical students (45 third year and 37 fourth year) at the University of Botswana Faculty of Medicine. They received tablets in the earliest phase of the mLearning project implementation (between November 2012 and January 2013), when they were in the third and fourth year of their medical training. Usage of the tablets was assessed both quantitatively and qualitatively, through both application usage tracking and focus groups.ResultsBased on application usage data and coding and analysis of focus group discussions, undergraduate medical students indicated that tablets were useful in their medical education, allowing them continual access to information and opportunities for communication. Participants noted that the primary barrier to use of tablets was the lack of mobile cellular Internet beyond the Wi-Fi zones at the training sites. Moreover, participants offered suggestions for improvements to the implementation process.ConclusionsEven in resource-limited settings where Internet access can be unreliable and intermittent, the adoption of tablets can have benefits to medical education by providing consistent access to extensive and current medical information resources. This study highlights the value of clinical resources with offline functionality, with or without consistent access to the Internet. There is also the potential for optimizing the use of tablets through improved training and technical support.     

Barriers to uptake of cervical cancer screening among women in Nigeria: a systematic review

BackgroundCervical cancer is the second most frequent cancer and cause of cancer-related deaths among women in Nigeria. The Visual inspection with acetic acid and cryotherapy “see and treat” screening approach is a feasible and effective method that can be implemented in low resource settings like Nigeria; however, screening utilization is still low.ObjectiveThis systematic review aims at offering a comprehensive synthesis of studies that assessed the barriers preventing women from utilizing cervical cancer screening services in Nigeria.MethodsElectronic data search was performed on PubMed, Cochrane Library, EMbase, Directory of Open Access Journals, Google Scholar, and ScienceDirect, and quality assessment was conducted for the included studies. Data were extracted independently by two authors and thematically analysed for barriers to cervical cancer screening utilization.ResultsFifteen studies, consisting of 9,995 women aged 15 and above published between 2007 and 2020, were included. Frequently reported barriers to cervical screening include lack of knowledge of cervical cancer and screening, health service factors, screening is unnecessary, fear of outcome and procedure, and financial constraints.ConclusionLack of adequate information about cervical cancer is a significant hindrance to screening; this factor is strongly associated with the numerous misconceptions and negative perceptions. The study highlights the need for further assessment of the sociodemographic determinants of cervical cancer screening uptake in Nigeria. Preventive strategies should be targeted at improving the dissemination of valid information, reducing the knowledge gap among women, and addressing the financial and health service factors.     

Implementing the NICE guideline for schizophrenia recommendations for psychological therapies: a qualitative analysis of the attitudes of CMHT staff

Objectives. Despite national guidelines recommending cognitive–behavioural therapy (CBT) and family intervention (FI) in the treatment of schizophrenia, levels of implementation in routine care remain low. The present study investigates attitudinal factors amongst community mental health team (CMHT) staff affecting guideline implementation. Design. CMHTs were audited to measure the capacity and delivery of CBT and FI, and semi‐structured interviews were conducted with staff from the teams. Methods. Four CMHTs were audited, and five care coordinators from each team were interviewed. A purposive approach to sampling was used to represent the range of professional training of care coordinating staff. Data were analysed using thematic content analysis. Results. Positive views towards guidelines were evident, although tempered by specific implementation issues. Employing simple psychological interventions and approaches as part of the care coordinating role also emerged as highly valued by staff. Severe workload, time pressure and the need for specialist staff were crucial barriers to implementation. Pessimistic views of recovery for clients with psychosis were also apparent and may affect implementation. Conclusions. Staff attitudes and knowledge are an important area of research when examining guideline implementation and require further study. Key themes that have emerged could inform future training agendas and should be considered when developing guideline implementation strategies for the updated 2009 guidelines. Copyright © 2010 John Wiley & Sons, Ltd. Key Practitioner Message: ? There continues to be limited access to psychological therapies for those with a diagnosis of schizophrenia—barriers relate to staff attitudes and knowledge as well as training, resources and organization of services. ? A rolling programme of training is required to ensure all clinical staff have a broad understanding of recommended psychological therapies and are competent to discuss these interventions with patients and carers. ? Services require access to staff with both the appropriate competencies and dedicated time to deliver CBT for psychosis and FI and ongoing supervision of this work. ? Services should regularly and objectively audit eligibility for interventions and offers, uptake and outcome of therapy.