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1.  Barriers and facilitators to implementing continuous quality improvement programs in colonoscopy services: a mixed methods systematic review 
Endoscopy International Open  2015;4(2):E118-E133.
Background and aim: Continuous quality improvement (CQI) programs may result in quality of care and outcome improvement. However, the implementation of such programs has proven to be very challenging. This mixed methods systematic review identifies barriers and facilitators pertaining to the implementation of CQI programs in colonoscopy services and how they relate to endoscopists, nurses, managers, and patients.
Methods: We developed a search strategy adapted to 15 databases. Studies had to report on the implementation of a CQI intervention and identified barriers or facilitators relating to any of the four groups of actors directly concerned by the provision of colonoscopies. The quality of the selected studies was assessed and findings were extracted, categorized, and synthesized using a generic extraction grid customized through an iterative process.
Results: We extracted 99 findings from the 15 selected publications. Although involving all actors is the most cited factor, the literature mainly focuses on the facilitators and barriers associated with the endoscopists’ perspective. The most reported facilitators to CQI implementation are perception of feasibility, adoption of a formative approach, training and education, confidentiality, and assessing a limited number of quality indicators. Receptive attitudes, a sense of ownership and perceptions of positive impacts also facilitate the implementation. Finally, an organizational environment conducive to quality improvement has to be inclusive of all user groups, explicitly supportive, and provide appropriate resources.
Conclusion: Our findings corroborate the current models of adoption of innovations. However, a significant knowledge gap remains with respect to barriers and facilitators pertaining to nurses, patients, and managers.
PMCID: PMC4751006  PMID: 26878037
2.  Using a Modified Technology Acceptance Model to Evaluate Healthcare Professionals' Adoption of a New Telemonitoring System 
Objective: To examine the factors that could influence the decision of healthcare professionals to use a telemonitoring system. Materials and Methods: A questionnaire, based on the Technology Acceptance Model (TAM), was developed. A panel of experts in technology assessment evaluated the face and content validity of the instrument. Two hundred and thirty-four questionnaires were distributed among nurses and doctors of the cardiology, pulmonology, and internal medicine departments of a tertiary hospital. Cronbach alpha was calculated to measure the internal consistency of the questionnaire items. Construct validity was evaluated using interitem correlation analysis. Logistic regression analysis was performed to test the theoretical model. Adjusted odds ratios (ORs) and their 95% confidence intervals (CIs) were computed. Results: A response rate of 39.7% was achieved. With the exception of one theoretical construct (Habit) that corresponds to behaviors that become automatized, Cronbach alpha values were acceptably high for the remaining constructs. Theoretical variables were well correlated with each other and with the dependent variable. The original TAM was good at predicting telemonitoring usage intention, Perceived Usefulness being the only significant predictor (OR: 5.28, 95% CI: 2.12–13.11). The model was still significant and more powerful when the other theoretical variables were added. However, the only significant predictor in the modified model was Facilitators (OR: 4.96, 95% CI: 1.59–15.55). Conclusion: The TAM is a good predictive model of healthcare professionals' intention to use telemonitoring. However, the perception of facilitators is the most important variable to consider for increasing doctors' and nurses' intention to use the new technology.
PMCID: PMC3270047  PMID: 22082108
home health monitoring; telemedicine; telehealth
3.  The Influence of a Wound Care Teleassistance Service on Nursing Practice: A Case Study in Quebec 
Telemedicine Journal and e-Health  2014;20(6):593-600.
Background: Although telehealth is a promising solution for healthcare professionals who work in remote and rural regions, the influence of specific telehealth applications on the nursing workforce remains unknown. This case study aimed to explore the potential influence of a teleassistance service in wound care (the acronym in French is TASP) on nursing practices and on nurse retention in peripheral areas. Materials and Methods: We carried out an exploratory single case study based on 16 semistructured interviews with two promoters of TASP, five nursing managers, and nine nurses from three levels of expertise associated with this service. Results: According to participants, the main positive influences of TASP were observed in quality of care, professional autonomy, professional development, and decrease of professional isolation. Participants mentioned increased workload associated with global patient data collection at first consultation as a negative effect of TASP. Finally, three possible effects of TASP on nurse retention were identified: none or minimal, imprecise, or mostly positive. Conclusions: This case study highlights the positive influence of TASP on several dimensions of nursing practice, in addition to its essential role in improving the quality of care. However, it is important to consider that the service cannot be considered as a solution to or replacement for the shortage of nurses.
PMCID: PMC4038993  PMID: 24694008
information and communication technologies; nursing practice; nurse retention; wound care; home health monitoring; telemedicine
4.  Barriers and facilitators to implementing electronic prescription: a systematic review of user groups’ perceptions 
We conducted a systematic review identifying users groups’ perceptions of barriers and facilitators to implementing electronic prescription (e-prescribing) in primary care.
We included studies following these criteria: presence of an empirical design, focus on the users’ experience of e-prescribing implementation, conducted in primary care, and providing data on barriers and facilitators to e-prescribing implementation. We used the Donabedian logical model of healthcare quality (adapted by Barber et al) to analyze our findings.
We found 34 publications (related to 28 individual studies) eligible to be included in this review. These studies identified a total of 594 elements as barriers or facilitators to e-prescribing implementation. Most user groups perceived that e-prescribing was facilitated by design and technical concerns, interoperability, content appropriate for the users, attitude towards e-prescribing, productivity, and available resources.
This review highlights the importance of technical and organizational support for the successful implementation of e-prescribing systems. It also shows that the same factor can be seen as a barrier or a facilitator depending on the project's own circumstances. Moreover, a factor can change in nature, from a barrier to a facilitator and vice versa, in the process of e-prescribing implementation.
This review summarizes current knowledge on factors related to e-prescribing implementation in primary care that could support decision makers in their design of effective implementation strategies. Finally, future studies should emphasize on the perceptions of other user groups, such as pharmacists, managers, vendors, and patients, who remain neglected in the literature.
PMCID: PMC3994867  PMID: 24130232
Electronic Prescribing; Systematic Review; Implementation Factors; Users' Perceptions; Primary Care
5.  E-Health, another mechanism to recruit and retain healthcare professionals in remote areas: lessons learned from EQUI-ResHuS project in Mali 
The aim of this study was to evaluate the perceived influence of telehealth on recruitment and retention of healthcare professionals in remote areas in Mali.
After 15 months of diagnosis imaging training and telehealth activities at four project sites in remote Mali, between May 2011 and August 2012, a 75-item questionnaire was administered to healthcare professionals to assess the various factors related to Information and Communication Technologies (ICT), especially telehealth, and their influence on health personnel recruitment and retention. Questions assessing perceived impact of telehealth on recruitment and retention of healthcare professionals were rated on a five-point Likert scale. Dependent variables were perceived influence of ICT on recruitment and retention and independent variables were access to ICT, ICT training, ICT use, perceived benefits and drawbacks of telehealth, and perceived barriers to recruitment and retention. A multiple linear regression was performed to identify variables explaining the respondents’ perceptions regarding telehealth influence on recruitment and retention.
Data analysis showed that professionals in remote areas have very positive perceptions of telehealth in general. Many benefits of telehealth for recruitment and retention were highlighted, with perceived benefits of ICT (p = 0.0478), perceived effects of telehealth on recruitment (p = 0.0018), telehealth training (0.0338) and information on telehealth (0.0073) being the strongest motivators for recruitment, while the perceived effects of telehealth on retention (p = 0.0018) was the only factor significantly associated with retention.
Based on our study results, telehealth could represent a mechanism for recruiting and retaining health professionals in remote areas and could reduce the isolation of these professionals through networking opportunities.
Electronic supplementary material
The online version of this article (doi:10.1186/s12911-014-0120-8) contains supplementary material, which is available to authorized users.
PMCID: PMC4305223  PMID: 25539841
6.  Applying Theory to Understand and Modify Nurse Intention to Adhere to Recommendations regarding the Use of Filter Needles: An Intervention Mapping Approach 
Nursing Research and Practice  2014;2014:356153.
The manipulation of glass ampoules involves risk of particle contamination of parenteral medication, and the use of filter needles has often been recommended in order to reduce the number of particles in these solutions. This study aims to develop a theory-based intervention to increase nurse intention to use filter needles according to clinical guideline recommendations produced by a large university medical centre in Quebec (Canada). Using the Intervention Mapping framework, we first identified the psychosocial determinants of nurse intention to use filter needles according to these recommendations. Second, we developed and implemented an intervention targeting nurses from five care units in order to increase their intention to adhere to recommendations on the use of filter needles. We also assessed nurse satisfaction with the intervention. In total, 270 nurses received the intervention and 169 completed the posttest questionnaire. The two determinants of intention, that is, attitude and perceived behavioral control, were significantly higher after the intervention, but only perceived behavioral control remained a predictor of intention. In general, nurses were highly satisfied with the intervention. This study provides support for the use of Intervention Mapping to develop, implement, and evaluate theory-based interventions in order to improve healthcare professional adherence to clinical recommendations.
PMCID: PMC4121269  PMID: 25120927
7.  Systematic Review of Factors Influencing the Adoption of Information and Communication Technologies by Healthcare Professionals 
Journal of medical systems  2010;36(1):241-277.
This systematic review of mixed methods studies focuses on factors that can facilitate or limit the implementation of information and communication technologies (ICTs) in clinical settings. Systematic searches of relevant bibliographic databases identified studies about interventions promoting ICT adoption by healthcare professionals. Content analysis was performed by two reviewers using a specific grid. One hundred and one (101) studies were included in the review. Perception of the benefits of the innovation (system usefulness) was the most common facilitating factor, followed by ease of use. Issues regarding design, technical concerns, familiarity with ICT, and time were the most frequent limiting factors identified. Our results suggest strategies that could effectively promote the successful adoption of ICT in healthcare professional practices.
PMCID: PMC4011799  PMID: 20703721 CAMSID: cams382
Systematic review; Adoption factors; Information and communication technologies (ICTs); ICT adoption by healthcare professionals
8.  A Systematic Review of the Key Indicators for Assessing Telehomecare Cost-Effectiveness 
Telehomecare is considered one of the most successful applications of telehealth. However, despite increasing evidence of telehomecare benefits, the diffusion of these services is still limited. Decision-makers need strong evidence in order to expand the development of telehomecare to various populations, regions, and health conditions. The objective of this review is to provide a basis for decision-making by identifying common indicators from the literature on telehomecare. A comprehensive review of the literature on the cost-effectiveness of telehomecare was conducted in specialized bibliographic databases. A total of 23 studies met the inclusion criteria. First, selected studies were analyzed to identify and classify the indicators that better addressed the cost-effectiveness impacts of telehomecare projects. Then, a synthesis of the evidence was done by exploring the relative cost-effectiveness of telehomecare applications. The analyses show that there is fair evidence of cost-effectiveness for many telehomecare applications. However, the heterogeneity among cost-effectiveness indicators in the applications reviewed and the methodological limitations of the studies impede the possibility of generalizing the findings. This suggests the need for a set of common indicators that could be applied for assessing the cost-effectiveness of telehomecare projects. This review provides knowledge on the indicators available for assessing cost-effectiveness in telehomecare projects. It appears that the specific context in which the projects take place, meaning different patients, environments, technologies, and healthcare systems, should be taken into account when selecting indicators for assessing telehomecare cost-effectiveness.
PMCID: PMC4005790  PMID: 19035798 CAMSID: cams378
telehomecare; cost-effectiveness; literature review
9.  Interventions for promoting information and communication technologies adoption in healthcare professionals 
Information and communication technologies (ICT) are defined as digital and analogue technologies that facilitate the capturing, processing, storage and exchange of information via electronic communication. ICTs have the potential to improve information management, access to health services, quality of care, continuity of services, and cost containment. Knowledge is lacking on conditions for successful ICT integration into practice.
To carry out a systematic review of the effectiveness of interventions to promote the adoption of ICT by healthcare professionals.
Search methods
Specific strategies, defined with the help of an information specialist, were used to search the Cochrane Effective Practice and Organisation of Care Group (EPOC) register and additional relevant databases. We considered studies published from January 1990 until October 2007.
Selection criteria
Randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before/after studies (CBAs), and interrupted time series (ITS) that reported objectively measured outcomes concerning the effect of interventions to promote adoption of ICT in healthcare professionals’ practices.
Data collection and analysis
Two reviewers independently assessed each potentially relevant study for inclusion. We resolved discrepancies by discussion or a third reviewer. Two teams of two reviewers independently extracted data and assessed the quality of included studies. A meta-analysis of study outcomes was not possible, given the small number of included studies and the heterogeneity of intervention and outcomes measures. We conducted qualitative analyses, and have presented the results in a narrative format.
Main results
Ten studies met the inclusion criteria. Nine of them were RCTs. All studies involved physicians as participants (including postgraduate trainees), and one study also included other participants. Only two studies measured patient outcomes. Searching skills and/or frequency of use of electronic databases, mainly MEDLINE, were targeted in eight studies. Use of Internet for audit and feedback, and email for provider-patient communication, were targeted in two studies. Four studies showed small to moderate positive effects of the intervention on ICT adoption. Four studies were unable to demonstrate significant positive effects, and the two others showed mixed effects. No studies looked at the long-term effect or sustainability of the intervention.
Authors’ conclusions
There is very limited evidence on effective interventions promoting the adoption of ICTs by healthcare professionals. Small effects have been reported for interventions targeting the use of electronic databases and digital libraries. The effectiveness of interventions to promote ICT adoption in healthcare settings remains uncertain, and more well designed trials are needed.
PMCID: PMC3973635  PMID: 19160265 CAMSID: cams377
Databases, Bibliographic [utilization]; Health Personnel [*statistics & numerical data]; Information Storage and Retrieval [*utilization]; Professional Practice [*statistics & numerical data]; Randomized Controlled Trials as Topic
10.  Out-of-pocket expenditure and its determinants in the context of private healthcare sector expansion in sub-Saharan Africa urban cities: evidence from household survey in Ouagadougou, Burkina Faso 
BMC Research Notes  2016;9:34.
Conventional wisdom suggests that out-of-pocket (OOP) expenditure reduces healthcare utilization. However, little is known about the expenditure borne in urban settings with the current development of the private health sector in sub-Saharan Africa. In an effort to update knowledge on medical expenditure, this study investigated the level and determinants of OOP among individuals reporting illness or injury in Ouagadougou, Burkina Faso and who either self-treated or received healthcare in either a private or public facility.
A cross-sectional study was conducted with a representative sample of 1017 households (5638 individuals) between August and November 2011. Descriptive statistics and multivariate techniques including generalized estimating equations were used to analyze the data.
Among the surveyed sample, 29.6 % (n = 1666) persons reported a sickness or injury. Public providers were the single most important providers of care (36.3 %), whereas private and informal providers (i.e.: self-treatment, traditional healers) accounted for 29.8 and 34.0 %, respectively. Almost universally (96 %), households paid directly for care OOP. The average expenditure per episode of illness was 8404XOF (17.4USD) (median 3750XOF (7.8USD). The total expenditure was higher for those receiving care in private facilities compared to public ones [14,613.3XOF (30.3USD) vs. 8544.1XOF (17.7USD); p < 0.001], and the insured patients’ bill almost tripled uninsured (p < 0.001). Finally, medication was the most expensive component of expenditure in both public and private facilities with a mean of 8022.1XOF (16.7USD) and 12,270.5 (25.5USD), respectively.
OOP was the principal payment mechanism of households. A significant difference in OOP was found between public and private provider users. Considering the importance of private healthcare in Burkina Faso, regulatory oversight is necessary. Furthermore, an extensive protection policy to shield households from catastrophic health expenditure is required.
PMCID: PMC4721044  PMID: 26795567
Burkina Faso; Urban; Healthcare utilization; For-profit; Not-for-profit; Public; Expenditure; Out-of-pocket expenditure
11.  Evaluation of a Web-based tailored intervention (TAVIE en santé) to support people living with HIV in the adoption of health promoting behaviours: an online randomized controlled trial protocol 
BMC Public Health  2015;15:1042.
Long-term use of antiretroviral therapy, normal aging, and presence of certain risk factors are associated with metabolic disorders that predispose persons living with HIV to diabetes and cardiovascular diseases. The emergence and progression of these disorders can be prevented by adopting healthy behaviours. Based on the theory of planned behaviour, the Web-based tailored intervention TAVIE en santé was developed. The aim of this study is to evaluate the effectiveness of TAVIE en santé in order to support people living with HIV in the adoption of health promoting behaviours.
An online randomized controlled trial with parallel-groups will be conducted across Canada. To participate in this study, people living with HIV must be: ≥ 18 years, able to read/understand French or English, have access to the Internet. A convenience sample of 750 participants will be randomly assigned either to an experimental group (TAVIE en santé, n = 375) or to a control group (websites, n = 375) (1:1 allocation ratio). The TAVIE en santé intervention is composed of seven interactive computer sessions, lasting between 5 and 10 min. The sessions, hosted by a virtual nurse, aim to develop and strengthen skills required for behaviour change. The control group will receive a validated list of five predetermined conventional health-related Websites. The adoption of health behaviour (smoking cessation or physical activity or healthy eating) is the principal outcome. Cognitions (intention, attitude, perceived behavioral control) are the secondary outcomes. Health indicators will also be assessed. All outcomes will be measured with a self-administered online questionnaire and collected three times: at baseline, 3 and 6 months after. The principal analyses will focus on differences between the two trial groups using Intention-to-Treat analysis.
This study will yield new results about the efficacy of Web-based tailored health behaviours change interventions in the context of chronic disease. The TAVIE en santé intervention could constitute an accessible complementary service in support of existing specialized services to support people living with HIV adopt health behaviors.
Trial registration
NCT02378766, assigned on March 3th 2015.
PMCID: PMC4603806  PMID: 26458508
Online randomized control trial; Web-based tailored intervention; People living with HIV; Smoking cessation; Physical activity; Healthy eating; Intention; Attitude; Perceived control; Theory of planned behaviour
12.  Impacts of information and communication technologies on nursing care: an overview of systematic reviews (protocol) 
Systematic Reviews  2015;4:75.
Information and communication technologies (ICTs) used in the health sector have well-known advantages. They can promote patient-centered healthcare, improve quality of care, and educate health professionals and patients. However, implementation of ICTs remains difficult and involves changes at different levels: patients, healthcare providers, and healthcare organizations. Nurses constitute the largest health provider group of the healthcare workforce. The use of ICTs by nurses can have impacts in their practice. The main objective of this review of systematic reviews is to systematically summarize the best evidence regarding the effects of ICTs on nursing care.
We will include all types of reviews that aim to evaluate the influence of ICTs used by nurses on nursing care. We will consider four types of ICTs used by nurses as a way to provide healthcare: management systems, communication systems, information systems, and computerized decision support systems. We will exclude nursing management systems, educational systems, and telephone systems. The following types of comparisons will be carried out: ICT in comparison with usual care/practice, ICT compared to any other ICT, and ICT versus other types of interventions. The primary outcomes will include nurses’ practice environment, nursing processes/scope of nursing practice, nurses’ professional satisfaction as well as nursing sensitive outcomes, such as patient safety, comfort, and quality of life related to care, empowerment, functional status, satisfaction, and patient experience. Secondary outcomes will include satisfaction with ICT from the nurses and patients’ perspective. Reviews published in English, French, or Spanish from 1 January 1995 will be considered. Two reviewers will independently screen the title and abstract of the papers in order to assess their eligibility and extract the following information: characteristics of the population and setting, type of interventions (e.g., type of ICTs and service provided), comparisons, outcomes, and review limitations. Any disagreements will be resolved by discussion and consensus involving the two reviewers or will involve a third review author, if needed.
This overview is an interesting starting point from which to compare and contrast findings of separate reviews regarding the positive and negative effects of ICTs on nursing care.
Systematic review registration
PROSPERO CRD42014014762.
PMCID: PMC4449960  PMID: 26002726
Information and communication technology; e-Health; Telehealth; Nursing practice; Nursing care; Nursing sensitive outcomes; Overview
13.  An integrated strategy of knowledge application for optimal e-health implementation: A multi-method study protocol 
E-health is increasingly valued for supporting: 1) access to quality health care services for all citizens; 2) information flow and exchange; 3) integrated health care services and 4) interprofessional collaboration. Nevertheless, several questions remain on the factors allowing an optimal integration of e-health in health care policies, organisations and practices. An evidence-based integrated strategy would maximise the efficacy and efficiency of e-health implementation. However, decisions regarding e-health applications are usually not evidence-based, which can lead to a sub-optimal use of these technologies. This study aims at understanding factors influencing the application of scientific knowledge for an optimal implementation of e-health in the health care system.
A three-year multi-method study is being conducted in the Province of Quebec (Canada). Decision-making at each decisional level (political, organisational and clinical) are analysed based on specific approaches. At the political level, critical incidents analysis is being used. This method will identify how decisions regarding the implementation of e-health could be influenced or not by scientific knowledge. Then, interviews with key-decision-makers will look at how knowledge was actually used to support their decisions, and what factors influenced its use. At the organisational level, e-health projects are being analysed as case studies in order to explore the use of scientific knowledge to support decision-making during the implementation of the technology. Interviews with promoters, managers and clinicians will be carried out in order to identify factors influencing the production and application of scientific knowledge. At the clinical level, questionnaires are being distributed to clinicians involved in e-health projects in order to analyse factors influencing knowledge application in their decision-making. Finally, a triangulation of the results will be done using mixed methodologies to allow a transversal analysis of the results at each of the decisional levels.
This study will identify factors influencing the use of scientific evidence and other types of knowledge by decision-makers involved in planning, financing, implementing and evaluating e-health projects.
These results will be highly relevant to inform decision-makers who wish to optimise the implementation of e-health in the Quebec health care system. This study is extremely relevant given the context of major transformations in the health care system where e-health becomes a must.
PMCID: PMC2390530  PMID: 18435853
14.  Advancing theories, models and measurement for an interprofessional approach to shared decision making in primary care: a study protocol 
Shared decision-making (SDM) is defined as a process by which a healthcare choice is made by practitioners together with the patient. Although many diagnostic and therapeutic processes in primary care integrate more than one type of health professional, most SDM conceptual models and theories appear to be limited to the patient-physician dyad. The objectives of this study are to develop a conceptual model and propose a set of measurement tools for enhancing an interprofessional approach to SDM in primary healthcare.
An inventory of SDM conceptual models, theories and measurement tools will be created. Models will be critically assessed and compared according to their strengths, limitations, acknowledgement of interprofessional roles in the process of SDM and relevance to primary care. Based on the theory analysis, a conceptual model and a set of measurements tools that could be used to enhance an interprofessional approach to SDM in primary healthcare will be proposed and pilot-tested with key stakeholders and primary healthcare teams.
This study protocol is informative for researchers and clinicians interested in designing and/or conducting future studies and educating health professionals to improve how primary healthcare teams foster active participation of patients in making health decisions using a more coordinated approach.
PMCID: PMC2265696  PMID: 18173848
15.  Exploring Women’s Beliefs and Perceptions About Healthy Eating Blogs: A Qualitative Study 
Chronic diseases are the leading cause of death (63%) worldwide. A key behavioral risk factor is unhealthy eating. New strategies must be identified and evaluated to improve dietary habits. Social media, such as blogs, represent a unique opportunity for improving knowledge translation in health care through interactive communication between health consumers and health professionals. Despite the proliferation of food and lifestyle blogs, no research has been devoted to understanding potential blog readers’ perceptions of healthy eating blogs written by dietitians.
To identify women’s salient beliefs and perceptions regarding the use of healthy eating blogs written by dietitians promoting the improvement of their dietary habits.
We conducted a qualitative study with female Internet users living in the Quebec City, QC, area with suboptimal dietary habits. First, the women explored 4 existing healthy eating blogs written in French by qualified dietitians. At a focus group 2-4 weeks later, they were asked to discuss their experience and perceptions. Focus group participants were grouped by age (18-34, 35-54, and 55-75 years) and by their use of social media (users/nonusers). Using a questionnaire based on the Theory of Planned Behavior, participants were asked to identify salient beliefs underlying their attitudes (advantages/disadvantages), subjective norms (what people important to them would think), and perceptions of control (facilitators/barriers) regarding the use of a healthy eating blog written by a dietitian to improve dietary habits. Discussion groups were audiotaped, transcribed verbatim, coded, and a deductive content analysis was performed independently by 2 individuals using the NVivo software (version 10).
All participants (N=33) were Caucasian women aged between 22 to 73 year. Main advantages perceived of using healthy eating blogs written by a dietitian were that they provided useful recipe ideas, improved lifestyle, were a credible source of information, and allowed interaction with a dietitian. Disadvantages included increased time spent on the Internet and guilt if recommendations were not followed. Important people who would approve were family, colleagues, and friends. Important people who could disapprove were family and doctors. Main facilitators were visually attractive blogs, receiving an email notification about new posts, and finding new information on the blog. Main barriers were too much text, advertising on the blog, and lack of time.
The women in this study valued the credibility of healthy eating blogs written by dietitians and the contact with dietitians they provided. Identifying salient beliefs underlying women’s perceptions of using such blogs provides an empirically supported basis for the design of knowledge translation interventions to help prevent chronic diseases.
PMCID: PMC4407018  PMID: 25858777
blog; health behavior; nutrition; qualitative research; social media; knowledge translation
16.  Implementation and Evaluation of a Wiki Involving Multiple Stakeholders Including Patients in the Promotion of Best Practices in Trauma Care: The WikiTrauma Interrupted Time Series Protocol 
JMIR Research Protocols  2015;4(1):e21.
Trauma is the most common cause of mortality among people between the ages of 1 and 45 years, costing Canadians 19.8 billion dollars a year (2004 data), yet half of all patients with major traumatic injuries do not receive evidence-based care, and significant regional variation in the quality of care across Canada exists. Accordingly, our goal is to lead a research project in which stakeholders themselves will adapt evidence-based trauma care knowledge tools to their own varied institutional contexts and cultures. We will do this by developing and assessing the combined impact of WikiTrauma, a free collaborative database of clinical decision support tools, and Wiki101, a training course teaching participants how to use WikiTrauma. WikiTrauma has the potential to ensure that all stakeholders (eg, patients, clinicians, and decision makers) can all contribute to, and benefit from, evidence-based clinical knowledge about trauma care that is tailored to their own needs and clinical setting.
Our main objective will be to study the combined effect of WikiTrauma and Wiki101 on the quality of care in four trauma centers in Quebec.
First, we will pilot-test the wiki with potential users to create a version ready to test in practice. A rapid, iterative prototyping process with 15 health professionals from nonparticipating centers will allow us to identify and resolve usability issues prior to finalizing the definitive version for the interrupted time series. Second, we will conduct an interrupted time series to measure the impact of our combined intervention on the quality of care in four trauma centers that will be selected—one level I, one level II, and two level III centers. Participants will be health care professionals working in the selected trauma centers. Also, five patient representatives will be recruited to participate in the creation of knowledge tools destined for their use (eg, handouts). All participants will be invited to complete the Wiki101 training and then use, and contribute to, WikiTrauma for 12 months. The primary outcome will be the change over time of a validated, composite, performance indicator score based on 15 process performance indicators found in the Quebec Trauma Registry.
This project was funded in November 2014 by the Canadian Medical Protective Association. We expect to start this trial in early 2015 and preliminary results should be available in June 2016. Two trauma centers have already agreed to participate and two more will be recruited in the next months.
We expect that this study will add important and unique evidence about the effectiveness, safety, and cost savings of using collaborative platforms to adapt knowledge implementation tools across jurisdictions.
PMCID: PMC4376233  PMID: 25699546
interrupted time series; wiki; quality improvement; knowledge translation; trauma care; stakeholder engagement; adapting knowledge tools
17.  Development of a Fully Automated, Web-Based, Tailored Intervention Promoting Regular Physical Activity Among Insufficiently Active Adults With Type 2 Diabetes: Integrating the I-Change Model, Self-Determination Theory, and Motivational Interviewing Components 
JMIR Research Protocols  2015;4(1):e25.
Type 2 diabetes is a major challenge for Canadian public health authorities, and regular physical activity is a key factor in the management of this disease. Given that fewer than half of people with type 2 diabetes in Canada are sufficiently active to meet the recommendations, effective programs targeting the adoption of regular physical activity (PA) are in demand for this population. Many researchers argue that Web-based, tailored interventions targeting PA are a promising and effective avenue for sedentary populations like Canadians with type 2 diabetes, but few have described the detailed development of this kind of intervention.
This paper aims to describe the systematic development of the Web-based, tailored intervention, Diabète en Forme, promoting regular aerobic PA among adult Canadian francophones with type 2 diabetes. This paper can be used as a reference for health professionals interested in developing similar interventions. We also explored the integration of theoretical components derived from the I-Change Model, Self-Determination Theory, and Motivational Interviewing, which is a potential path for enhancing the effectiveness of tailored interventions on PA adoption and maintenance.
The intervention development was based on the program-planning model for tailored interventions of Kreuter et al. An additional step was added to the model to evaluate the intervention’s usability prior to the implementation phase. An 8-week intervention was developed. The key components of the intervention include a self-monitoring tool for PA behavior, a weekly action planning tool, and eight tailored motivational sessions based on attitude, self-efficacy, intention, type of motivation, PA behavior, and other constructs and techniques. Usability evaluation, a step added to the program-planning model, helped to make several improvements to the intervention prior to the implementation phase.
The intervention development cost was about CDN $59,700 and took approximately 54 full-time weeks. The intervention officially started on September 29, 2014. Out of 2300 potential participants targeted for the tailored intervention, approximately 530 people visited the website, 170 people completed the registration process, and 83 corresponded to the selection criteria and were enrolled in the intervention.
Usability evaluation is an essential step in the development of a Web-based tailored intervention in order to make pre-implementation improvements. The effectiveness and relevance of the theoretical framework used for the intervention will be analyzed following the process and impact evaluation. Implications for future research are discussed.
PMCID: PMC4376153  PMID: 25691346
physical activity; tailoring; computer-tailoring; type 2 diabetes mellitus; eHealth; World Wide Web; Internet; motivational interviewing; self determination; I-Change Model; behavior modification
18.  A Systematic Review of Instruments to Assess Organizational Readiness for Knowledge Translation in Health Care 
PLoS ONE  2014;9(12):e114338.
The translation of research into practices has been incomplete. Organizational readiness for change (ORC) is a potential facilitator of effective knowledge translation (KT). However we know little about the best way to assess ORC. Therefore, we sought to systematically review ORC measurement instruments.
We searched for published studies in bibliographic databases (Pubmed, Embase, CINAHL, PsychINFO, Web of Science, etc.) up to November 1st, 2012. We included publications that developed ORC measures and/or empirically assessed ORC using an instrument at the organizational level in the health care context. We excluded articles if they did not refer specifically to ORC, did not concern the health care domain or were limited to individual-level change readiness. We focused on identifying the psychometric properties of instruments that were developed to assess readiness in an organization prior to implementing KT interventions in health care. We used the Standards for Educational and Psychological Testing to assess the psychometric properties of identified ORC measurement instruments.
We found 26 eligible instruments described in 39 publications. According to the Standards for Educational and Psychological Testing, 18 (69%) of a total of 26 measurement instruments presented both validity and reliability criteria. The Texas Christian University –ORC (TCU-ORC) scale reported the highest instrument validity with a score of 4 out of 4. Only one instrument, namely the Modified Texas Christian University – Director version (TCU-ORC-D), reported a reliability score of 2 out of 3. No information was provided regarding the reliability and validity of five (19%) instruments.
Our findings indicate that there are few valid and reliable ORC measurement instruments that could be applied to KT in the health care sector. The TCU-ORC instrument presents the best evidence in terms of validity testing. Future studies using this instrument could provide more knowledge on its relevance to diverse clinical contexts.
PMCID: PMC4256226  PMID: 25474622
19.  Organizational readiness for knowledge translation in chronic care: a Delphi study 
Health-care organizations need to be ready prior to implement evidence-based interventions. In this study, we sought to achieve consensus on a framework to assess the readiness of health-care organizations to implement evidence-based interventions in the context of chronic care.
We conducted a web-based modified Delphi study between March and May 2013. We contacted 76 potentially eligible international experts working in the fields of organizational readiness (OR), knowledge translation (KT), and chronic care to comment upon the 76 elements resulting from our proposed conceptual map. This conceptual map was based on a systematic review of the existing frameworks of Organizational Readiness for Change (ORC) in health-care. We developed a conceptual map that proposed a set of core concepts and their associated 17 dimensions and 59 sub-dimensions. Experts rated their agreement concerning the applicability and importance of ORC elements on a 5-point Likert scale, where 1 indicates total disagreement and 5 indicates total agreement. Two rounds were needed to get a consensus from the experts. Consensus was a priori defined as strong (≥75%) or moderate (60-74%). Simple descriptive statistics was used.
In total, 14 participants completed the first round and 10 completed the two rounds. Panel members reached consensus on the applicability and importance of 6 out of 17 dimensions and 28 out of 59 sub-dimensions to assess OR for KT in the context of chronic care. A strong level of consensus (≥75%) was attained on the Organizational contextual factors, Leadership/participation, Organizational support, and Motivation dimensions. The Organizational climate for change and Change content dimensions reached a moderate consensus (60-74%). Experts also reached consensus on 28 out of 59 sub-dimensions to assess OR for KT. Twenty-one sub-dimensions reached a strong consensus (≥75%) and seven a moderate consensus (60-74%).
This study results provided the most important and applicable dimensions and sub-dimensions for assessing OR-KT in the context of chronic care. They can be used to guide the design of an assessment tool to improve knowledge translation in the field of chronic care.
PMCID: PMC4226850  PMID: 25380653
Organizational readiness; Delphi study; Knowledge translation; Chronic care; Measurement
20.  Effects and repercussions of local/hospital-based health technology assessment (HTA): a systematic review 
Systematic Reviews  2014;3:129.
Health technology assessment (HTA) is increasingly performed at the local or hospital level where the costs, impacts, and benefits of health technologies can be directly assessed. Although local/hospital-based HTA has been implemented for more than two decades in some jurisdictions, little is known about its effects and impact on hospital budget, clinical practices, and patient outcomes. We conducted a mixed-methods systematic review that aimed to synthesize current evidence regarding the effects and impact of local/hospital-based HTA.
We identified articles through PubMed and Embase and by citation tracking of included studies. We selected qualitative, quantitative, or mixed-methods studies with empirical data about the effects or impact of local/hospital-based HTA on decision-making, budget, or perceptions of stakeholders. We extracted the following information from included studies: country, methodological approach, and use of conceptual framework; local/hospital HTA approach and activities described; reported effects and impacts of local/hospital-based HTA; factors facilitating/hampering the use of hospital-based HTA recommendations; and perceptions of stakeholders concerning local/hospital HTA. Due to the great heterogeneity among studies, we conducted a narrative synthesis of their results.
A total of 18 studies met the inclusion criteria. We reported the results according to the four approaches for performing HTA proposed by the Hospital Based HTA Interest Sub-Group: ambassador model, mini-HTA, internal committee, and HTA unit. Results showed that each of these approaches for performing HTA corresponds to specific needs and structures and has its strengths and limitations. Overall, studies showed positive impacts related to local/hospital-based HTA on hospital decisions and budgets, as well as positive perceptions from managers and clinicians.
Local/hospital-based HTA could influence decision-making on several aspects. It is difficult to evaluate the real impacts of local HTA at the different levels of health care given the relatively small number of evaluations with quantitative data and the lack of clear comparators. Further research is necessary to explore the conditions under which local/hospital-based HTA results and recommendations can impact hospital policies, clinical decisions, and quality of care and optimize the use of scarce resources.
PMCID: PMC4218945  PMID: 25352182
Health technology assessment; Local/hospital-based HTA; Impact of HTA activities; Hospital budget; Perceptions of stakeholders; HTA units; Internal committee; Mini-HTA; Ambassador model
21.  A cross-sectional survey of supports for evidence-informed decision-making in healthcare organisations: a research protocol 
This protocol builds on the development of a) a framework that identified the various supports (i.e. positions, activities, interventions) that a healthcare organisation or health system can implement for evidence-informed decision-making (EIDM) and b) a qualitative study that showed the current mix of supports that some Canadian healthcare organisations have in place and the ones that are perceived to facilitate the use of research evidence in decision-making. Based on these findings, we developed a web survey to collect cross-sectional data about the specific supports that regional health authorities and hospitals in two Canadian provinces (Ontario and Quebec) have in place to facilitate EIDM.
This paper describes the methods for a cross-sectional web survey among 32 regional health authorities and 253 hospitals in the provinces of Quebec and Ontario (Canada) to collect data on the current mix of organisational supports that these organisations have in place to facilitate evidence-informed decision-making. The data will be obtained through a two-step survey design: a 10-min survey among CEOs to identify key units and individuals in regard to our objectives (step 1) and a 20-min survey among managers of the key units identified in step 1 to collect information about the activities performed by their unit regarding the acquisition, assessment, adaptation and/or dissemination of research evidence in decision-making (step 2). The study will target three types of informants: CEOs, library/documentation centre managers and all other key managers whose unit is involved in the acquisition, assessment, adaptation/packaging and/or dissemination of research evidence in decision-making. We developed an innovative data collection system to increase the likelihood that only the best-informed respondent available answers each survey question. The reporting of the results will be done using descriptive statistics of supports by organisation type and by province.
This study will be the first to collect and report large-scale cross-sectional data on the current mix of supports health system organisations in the two most populous Canadian provinces have in place for evidence-informed decision-making. The study will also provide useful information to researchers on how to collect organisation-level data with reduced risk of self-reporting bias.
PMCID: PMC4197221  PMID: 25294109
Health systems; Knowledge translation; Research evidence; Cross-sectional study
22.  Development and Validation of Questionnaires Exploring Health Care Professionals' Intention to Use Wiki-Based Reminders to Promote Best Practices in Trauma 
JMIR Research Protocols  2014;3(4):e50.
Little is known about factors influencing professionals’ use of wikis.
We developed and validated two questionnaires to assess health care professionals’ intention to use wiki-based reminders for the management of trauma patients.
We developed questionnaires for emergency physicians (EPs) and allied health professions (AHPs) based on the Theory of Planned Behavior and adapted them to the salient beliefs of each, identified in an earlier study. Items measured demographics and direct and indirect theoretical constructs. We piloted the questionnaires with 2 focus groups (5 EPs and 5 AHPs) to identify problems of wording and length. Based on feedback, we adjusted the wording and combined certain items. A new convenience sample of 25 EPs and 26 AHPs then performed a test-retest of the questionnaires at a 2-week interval. We assessed internal consistency using Cronbach alpha coefficients and temporal stability of items with an agreement intraclass correlation coefficient (ICC).
Five EPs and 5 AHPs (3 nurses, 1 respiratory therapist, and 1 pharmacist) formed 2 focus groups; 25 EPs and 26 AHPs (12 nurses, 7 respiratory therapists, and 7 pharmacists) completed the test and retest. The EP questionnaire test-retest scores for consistency (Cronbach alpha) and stability (ICC) were intention (test: Cronbach alpha=.94; retest: Cronbach alpha=.98; ICC=.89), attitude (.74, .72, .70), subjective norm (.79, .78, .75), perceived behavioral control (.67, .65, .66), attitudinal beliefs (.94, .86, .60), normative beliefs (.83, .87, .79), and control beliefs barriers (.58, .67, .78) and facilitators (.97, .85, .30). The AHP questionnaire scores for consistency and stability were: intention (test Cronbach alpha=.69, retest Cronbach alpha=.81, ICC=.48), attitude (.85, .87, .83), subjective norm (.47, .82, .62), perceived behavioral control (.55, .62, .60), attitudinal beliefs (.92, .91, .82), normative beliefs (.85, .90, .74), and control beliefs barriers (.58, .55, .66) and facilitators (.72, .94, –.05). To improve the psychometric properties of both questionnaires, we reformulated poorly consistent or unstable items.
Our new theory-based questionnaires to measure health care professionals’ intention to use wiki-based reminders have adequate validity and reliability for use in large surveys. In the long run, they can be used to develop a theory-based implementation intervention for a wiki promoting best practices in trauma care.
PMCID: PMC4213801  PMID: 25281856
knowledge translation; wiki; collaborative writing applications; decision support tools; health informatics; Theory of Planned Behavior; trauma care; traumatic brain injury; interprofessional collaboration
23.  A qualitative study on clinicians’ perceptions about the implementation of a population risk stratification tool in primary care practice of the Basque Health Service 
BMC Family Practice  2014;15:150.
A prospective Population Risk Stratification (PRS) tool was first introduced in the public Basque Health Service in 2011, at the level of its several Primary Care (PC) practices. This paper aims at exploring the new tool’s implementation process, as experienced by its potential adopters/users, ie. PC clinicians (doctors and nurses). Findings could help guide future PRS implementation strategies.
Three focus groups exploring clinicians’ opinions and experiences related to the PRS tool and its implementation in their daily practice were conducted. A purposive sample of 12 General Practitioners and 11 PC nurses participated in the groups. Discussions were digitally recorded, transcribed verbatim and analysed by two independent researchers using thematic analysis based on Graham et al.’s Knowledge Translation Theory.
Exploring PC clinicians’ experience with the new PRS tool, allowed us to identify certain elements working as barriers and facilitators in its implementation process. This series of closely interrelated elements, which emerged as relevant in building up the complex implementation process of the new tool, as experienced by the clinicians, can be grouped into four domains: 1) clinicians’ characteristics as potential adopters, 2) clinicians’ perceptions of their practice settings where PRS is to implemented, 3) clinicians’ perceptions of the tool, and 4) the implementation strategy used by the PRS promoter.
Lessons from the implementation process under study point at the need to frame the implementation of a new PRS tool within a wider strategy encouraging PC clinicians to orientate their daily practice towards a population health approach. The PRS tool could also improve the perceived utility by its potential adopters, by bringing it closer to the clinicians’ needs and practice, and allowing it to become context-sensitive. This would require clinicians being involved from the earliest phases of conceptualisation, design and implementation of the new tool, and mounting efforts to improve communication between clinicians and tool promoters.
Graham et al.’s Knowledge Translation Theory proved a suitable framework to explore the implementation process of a new PRS tool in the public Basque Health Service’s PC practice, and hence to identify implementation barriers and facilitators as experienced by the clinicians.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2296-15-150) contains supplementary material, which is available to authorized users.
PMCID: PMC4165939  PMID: 25200276
Stratification; Population health management; Primary care; Implementation; Knowledge translation; Predictive risk models
24.  Online training course on critical appraisal for nurses: adaptation and assessment 
BMC Medical Education  2014;14:136.
Research is an essential activity for improving quality and efficiency in healthcare. The objective of this study was to train nurses from the public Basque Health Service (Osakidetza) in critical appraisal, promoting continuous training and the use of research in clinical practice.
This was a prospective pre-post test study. The InfoCritique course on critical appraisal was translated and adapted. A sample of 50 nurses and 3 tutors was recruited. Educational strategies and assessment instruments were established for the course. A course website was created that contained contact details of the teaching team and coordinator, as well as a course handbook and videos introducing the course. Assessment comprised the administration of questionnaires before and after the course, in order to explore the main intervention outcomes: knowledge acquired and self-learning readiness. Satisfaction was also measured at the end of the course.
Of the 50 health professionals recruited, 3 did not complete the course for personal or work-related reasons. The mean score on the pre-course knowledge questionnaire was 70.5 out of 100, with a standard deviation of 11.96. In general, participants’ performance on the knowledge questionnaire improved after the course, as reflected in the notable increase of the mean score, to 86.6, with a standard deviation of 10.00. Further, analyses confirmed statistically significant differences between pre- and post-course results (p < 0.001). With regard to self-learning readiness, after the course, participants reported a greater readiness and ability for self-directed learning. Lastly, in terms of level of satisfaction with the course, the mean score was 7 out of 10.
Participants significantly improved their knowledge score and self-directed learning readiness after the educational intervention, and they were overall satisfied with the course. For the health system and nursing professionals, this type of course has the potential to provide methodological tools for research, promote a research culture, and encourage critical thinking for evidence-based decision making.
PMCID: PMC4107575  PMID: 24996951
Evidence-based practice; Critical appraisal; Nursing; E-learning
25.  Involving patient in the early stages of health technology assessment (HTA): a study protocol 
Public and patient involvement in the different stages of the health technology assessment (HTA) process is increasingly encouraged. The selection of topics for assessment, which includes identifying and prioritizing HTA questions, is a constant challenge for HTA agencies because the number of technologies requiring an assessment exceeds the resources available. Public and patient involvement in these early stages of HTA could make assessments more relevant and acceptable to them. Involving them in the development of the assessment plan is also crucial to optimize their influence and impact on HTA research. The project objectives are: 1) setting up interventions to promote patient participation in three stages of the HTA process: identification of HTA topics, prioritization, and development of the assessment plan of the topic prioritized; and 2) assessing the impact of patient participation on the relevance of the topics suggested, the prioritization process, and the assessment plan from the point of view of patients and other groups involved in HTA.
Patients and their representatives living in the catchment area of the HTA Roundtable of Université Laval’s Integrated University Health Network (covering six health regions of the Province of Quebec, Canada) will be involved in the following HTA activities: 1) identification of potential HTA topics in the field of cancer; 2) revision of vignettes developed to inform the prioritization of topics; 3) participation in deliberation sessions for prioritizing HTA topics; and 4) development of the assessment plan of the topic prioritized. The research team will coordinate the implementation of these activities and will evaluate the process and outcomes of patient involvement through semi-structured interviews with representatives of the different stakeholder groups, structured observations, and document analysis, mainly involving the comparison of votes and topics suggested by various stakeholder groups.
This project is designed as an integrated approach to knowledge translation and will be conducted through a close collaboration between researchers and knowledge users at all stages of the project. In response to the needs expressed by HTA producers, the knowledge produced will be directly useful in guiding practices regarding patient involvement in the early phases of HTA.
PMCID: PMC4072844  PMID: 24950739
Public and patient participation; Research priorities; Health technology assessment; Public involvement; Knowledge translation

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