seven researchers, including three Aboriginal researchers, from a range of disciplinary backgrounds (health economics, pharmacy, nursing and public health) who were not involved in the implementation of the trial conducted the interviews. Most interviews were conducted face-to- face, with a small number conducted by telephone for logistic reasons. Interviews were professionally tran- scribed and coded by two research- ers (H L and L M) using NVivo 9 (QSR International). Twelve transcripts were selected (six patients and six health care providers — pharma- cists, GPs, nurses and Aboriginalhealth workers [AHWs]) and were coded independently by the two researchers. These researchers iden- tified the major themes arising from these 12 interviews and developed an initial coding framework. Insights gained by the research team about the context of the interviews and the local setting were documented and used to aid interpretation. The cod- ing framework was then discussed and refined by a multidisciplinary group comprising the study investi- gators and the interview team. This included two ACCHS clinicians who were site principal investigators on the trial. The two researchers then coded the remaining interviews and made minor, iterative changes to code definitions.
We analyzed the data using a modified grounded theory  approach informed by Proctor and colleagues’ conceptualization of implementation outcomes . Two project staff members conducted analyses. First, they cre- ated an initial code list based on a preliminary reading of randomly selected transcripts from each participant group. Codes were reviewed and modified during regular meetings between the two project staff members during the process. There were few disagreements regarding the codes. Where disagreements occurred, they were resolved with discussion. Once the two coders had identified a list of primary and secondary codes, they shared the codes and text examples from various transcripts for context with the other members of the research team who further refined the codes. The final coding scheme consisted of four main code families: perceived barriers and facilitators to implementing the WHC; patient barriers; clinical or provider barriers; and operational (or structural) barriers to women seeking treatment or clinicians providing ser- vices in general. The current manuscript describes the first code family, perceived barriers and facilitators to imple- menting the WHC.
Environmental factors, including time pressure, insuffi- cient staff (lack of staff, staff turnover), lack of space and equipment, and organizational constraints (insufficient support from the organizational/senior management) emerged as the most frequently cited barriers to imple- mentation of the KT interventions during the trial as well as the recommendations. In a recent study describ- ing the factors influencing the implementation of stroke clinical practice guidelines among speech pathologists, Hadely and colleagues  also reported that factors within the work environment were barriers to imple- mentation. Specifically, the main barriers included lack of time, education, treatment resources, and standardized assessments to carry out guideline implementation . Environmental/work factors as barriers (and facilitators) to guideline implementation have been reported consist- ently in literature – in the treatment of persons post-stroke as well as other chronic conditions [6, 11, 37, 39, 40]. In the current study, one of the main findings was that envir- onmental factors were seldom noted as facilitators to the implementation of the recommended treatments and/or KT interventions. It should also be highlighted that some of these environmental factors were mitigated by team fac- tors/facilitation. Thus, a main message from our research is that in the absence of more organizational resources (time, money), team factors can be leveraged to overcome such deficits. For example, a high level of staff turnover was noted across the rehabilitation centers; however, if strong leadership/management support was present at the rehabilitation center, this person often ensured that new staff knew the procedures/responsibilities associated with the trial. Horne  similarly noted that leaders and even the larger hospital administrative culture could act as key mediators between the environmental fac- tors (time, money, equipment) and the implementa- tion of recommendations.
Outcome measures have been developed to facilitate clinical practice and are widely used in audit and research to enable out- comes to be measured systematically. Outcome measures usually comprise ques- tionnaires or checklists completed by ser- vice users or health professionals. They assess effectiveness and outcomes of treat- ments and interventions (Bowling, 1997a; Salek et al, 2002) and help guide patient care. For example, by assessing the patient’s symptom control and quality of life, and providing evidence to improve the quality of services (Hearn and Higginson, 1997). As healthcare organizations conduct clini- cal audits and further develop individual- ized care plans, for example, as outlined in The NHS Plan (DoH, 2000), outcome measures are becoming established and integral to clinical practice.
Evidence-based medicine (EBM) is defined as the inte- gration of clinical expertise with evidence from re- search  to improve the efficiency, quality and outcomes of patient care by ensuring that treatment recommendations are based on the best available clin- ical evidence. The attempted mobilisation of research evidence into practice in the UK has traditionally oc- curred through the dissemination of clinical guidelines into the National Health Service (NHS) such as those produced by the National Institute for Health and Care Excellence (NICE)  and the Scottish Intercollegiate Guidelines Network (SIGN) . A key remit for these policy makers is to ensure the full implementation of clinical guidelines . The actual level of implementa- tion has been, and can be, further examined using trad- itional experimental methods, for example, to provide a rate of uptake or impact through educational strategies or audit . Several systematic reviews on universal guideline implementation have been conducted but provide limited insight on how to choose implementa- tion strategies that address implementation problems [6–9]. This type of research typically demonstrates lim- ited success of guideline implementation and evidence- based knowledge into clinical practice, particularly in community care services [6, 10–14]. To move beyond this and explore how and why clinical guidelines strug- gle to achieve full uptake and use within surgery, we need to go beyond traditional views and experimental methods to examine the barriers and facilitators of im- plementation in real-life NHS practice. These barriers and facilitators could be multifactorial, linked to indi- vidual, organisational or contextual influences, which act on the guideline implementation process [6–9] but could also directly stem from the professional work of surgeons.
Clinical networks have been established in many coun- tries such as the UK [28, 29], France [30, 31], Canada , Australia [33, 34] and the US , and have shown success in breaching traditional professional boundaries, increasing compliance rates with evidence-based guide- lines and have reported positive impacts on quality of care and patients outcomes . These networks repre- sent a shift away from the traditional hierarchical and bureaucratic systems of healthcare services, to one that fosters multidisciplinary collaboration, integration of ser- vices, and improved models of care where clinicians are engaged and committed to their development . The NCPs’ foundation is based upon this clinical network model. The exact composition and typology of each clin- ical network depends on the purpose and the focus of the network (e.g., a disease construct such as cancer care or a network to improve the functionality of primary and secondary care across multiple conditions) . Clinical networks within the NCPs included representa- tion from clinical stakeholders such as physicians, and allied healthcare professionals such as nursing. Recently, there has been a move towards co-production of healthservices by including patients, families and even the gen- eral public within networks to design and reform the health service [37, 38]. The structure of the NCPs out- lined allowed for inclusion of patients as part of the Clinical Advisory Group.
The professional context provides some explanation for the implementation patterns. Some providers did not see themselves as responsible for informing women of the 60- hour stay option and, in fact, were surprised that women had knowledge of the policy and would exercise this option. They reflected a view of LOS as a clinical decision and one that is most appropriately made by mothers and practitioners rather than by policy makers. Providers were quick to point out that if they assessed a mother as being in need of more time in hospital, then she stayed longer. They saw part of their role as one of professional advocacy for patient services when they believed it necessary. Apply- ing the policy would have meant giving up this discretion- ary professional activity. The association of longer stay with women who fall into traditional "high risk catego- ries" suggests that discretionary offers were still being made and that the professional context modified organi- zational context in terms of implementation.
Health care delivery in Estonia is provided by family doctors and their teams at primary care level and spe- cialist services in outpatient and in-patient settings. The providers are contracted and services are purchased by the Estonian Health Insurance Fund, a mandatory social health insurance system covering approximately 95% of the population . Numerous reforms have been intro- duced [2,3] and increased attention has been paid to quality of care, including usage of clinical guidelines . The Estonian Health Insurance Fund (EHIF), in collab- oration with other stakeholders, has launched a nation- wide effort to further develop and implement evidence- based clinical practice guidelines. Until 2011, several institutions and health professional organizations in Es- tonia supported or developed national clinical practice guidelines. Although the first handbook for preparing guidelines was approved in 2004 , there has been vari- ation in the format and quality of guidelines commis- sioned by EHIF. Over 90 guidelines in areas such as family medicine, cardiology, neurology, and oncology have been developed and are available on the public website for health care workers ( http :// www . ravijuhend . ee / ravijuhendikasutajale / ravijuhendite - andmebaas /), 40 of them prepared since 2003 following the first hand- book for guideline preparation, steered by Estonian Health Insurance Fund, and additional 50 guidelines pre- pared using different approaches: initiatives by the med- ical associations, individual providers/specialties, interest groups and medical journals.
A salient Inner Setting constraint in PROVEN and comparable studies relates to such contextual barriers, i.e., limited resources (inadequate staffing, significant turnover, competing work demands, and intensive time pressure) [7, 25, 26, 31–34]. In PROVEN, perceived lack of sufficient implementation time coincided even with perceptions of the intervention as brief. Indeed, while some Champions described PROVEN’s videos as com- patible with usual clinical workflows, a critical element for ACP intervention effectiveness in fast-paced health care settings , others described easy workflow inte- gration as hindered by time constraints. The intransigent nature of resource barriers in NHs will remain a chal- lenge for future PCTs in this setting. This challenge may be best addressed by designing interventions that are as parsimonious as feasible  and engaging NH adminis- trators and direct care staff in developing implementa- tion strategy in its earliest stages [26, 35]. Designating multiple collaborating Champions who could represent different disciplines may be another solution.
In order to improve recruitment methods, a quality assessment project was initiated to collect data on recruitment methods, results, and challenges. This data was collected from a convenience sample of five different primary care healthservices research studies conducted between 2004 and 2010 by investigators at the Élisabeth Bruyère Research Institute, University of Ottawa, Canada. All five projects received approval from the institutional Bruyère Continuing Care Research Ethics Board. The projects were all initiated as part of a major national effort to improve primary care and, thus, took place dur- ing periods of significant primary care reform. A Princi- pal Investigator for each project was approached and six individuals, three Principal Investigators and three Pro- ject Coordinators, who were not part of the quality assessment project team, had a semi-structured interview with EG-D about recruitment methods used, results, challenges encountered and innovative practices used. A Project Coordinator for each study completed a short survey on recruitment methods, results, and challenges. See Additional file 1 for an outline of the survey topics, which guided the semi-structured interviews. See Table 1 for a brief description of each project.
step previously coded data were re-coded using the revised definitions. Three team members [DM, JK, VE] independently coded one transcript to test the defini- tions. At step two, coding pairs independently coded each of the 11 transcripts, using paper versions to manually code. Content analysis  was used analyze the content of transcripts and apply CFIR codes. Coding pairs re- solved coding differences, followed by a team meeting to discuss discrepancies and agree on revised operational definitions. The transcripts were then imported into the CFIR NVivo Project Template  and the codes applied. In step three, three transcripts (one from each phase) were selected and code reports generated from NVivo with all the data segments for each code, organized by CFIR domain. These collated data were reviewed inde- pendently by all team members for consistency in appli- cation of the codes, followed by meetings to resolve disagreements, further refine definitions, and review in- stances of double-coding with the aim of applying only one code where possible. In step four, all team members independently reviewed the coding in the remaining eight transcripts to ensure that final definitions were applied. In step five, an inductive analysis was conducted to iden- tify implementationbarriers and facilitators. Rigor was supported by the longitudinal data collection, prolonged stakeholder engagement, triangulation of data from mul- tiple sources and stakeholders, documentation of all communication with participants, and iterative team- based coding and analysis [31, 36].
Phone: 250.213.4441 Fax: 250.213.4445 Urgent Short Term
Assessment and Treatment (USTAT) USTAT provides short-term individual psychotherapy for patients in high risk of harm. With this service, clients are assigned to a primary therapist who does an initial assessment and establishes treatment goals. A team of psychiatrists is available as needed for consultation and follow-up. Referrals are made through Mental Health and Addictions Intake and can be faxed to: 250.213-4401.
Sexual health promotion aims to leverage change at individual, community and policy levels to support positive notions of sexual health inclusive of gender, race, religion and ethnicity . It was upon this premise that an Aboriginal sexual health promotion initiative was developed. Smart and Deadly was a community-led initiative to develop sexual health promotion resources with young Aboriginal people in north-eastern Victoria, Australia. A regional community forum and subsequent ‘yarn-ups’ (community discussions) to consider sexual health issues for young people were conducted in 2010–2011 and resulted in the formation of a local working group, with majority Aboriginal membership. Extensive consultation with Elders and Aboriginal workers followed. The initiative had three specific objectives: (1) to design, implement and evaluate a local sexual health promotion initiative with young rural Aboriginal people and their families, using the principles of Aboriginalhealth promotion practice; (2) to support young rural Aboriginal people to develop their own creative sexuality education resources; (3) to produce an audio-visual training resource for non-Aboriginal rural health workers engaging with Aboriginal communities.
community and family, influencing attitudes and opin- ions in the larger community may be an important first step before patient recruitment. In our study, both Chin- ese and Malay women expressed a lack of knowledge about the purpose and processes of clinical trials and in- adequacy about making decisions. Patient education may need to be more intense and address literacy as well as cultural barriers to improve recruitment. Trust in their own (but not in other unknown) physicians was a dom- inant theme among participants, which suggests that re- cruitment might be more successful if conducted through the patients’ own primary care physicians and oncologists. Our findings suggest that researchers need to pay more attention to both individual and community cultural factors when considering recruitment strategies or training recruiters.
When positive, the effects of PA appear to be only modest and short-term. One reason being that imple- mentation and adherence to workplace PA has proven difficult [17–19]. As an example, the mean level of regu- lar adherence was 61% across nine RCTs conducted in Denmark, ranging from 31% to 86% . Baily et al. sys- tematically reviewed barriers and facilitators for imple- mentation of workplace physical activity policies and found that not having a clear company policy on work- place PA is a vital barrier for implementation . Other researchers have suggested that the suboptimal results of implementation of general health enhancing interventions could be due to limited use of a theoretical foundation to underpin such interventions [21, 22]. Several implementa- tion theories, models, and frameworks exist, which may provide better understanding and explanation of how and why implementation succeeds or fails . Nilsen suggests the use of determinant frameworks to describe factors that impact implementation outcomes, i.e., factors that either impede or enable uptake . One of these determinant frameworks is the widely used Theoretical Domains Framework (TDF). TDF is a comprehensive synthesis of theories of behaviour and behaviour change [23, 24]. It is a multilevel framework, which allows identification of de- terminants at different levels, from the individual user, to the organization and beyond . Like many other deter- minant frameworks, it does not specify causal mecha- nisms, but provides potentially useful information for designing and executing implementation strategies .
There was considerable discussion about what was described as a lack of an enabling environment in mental healthservices, which were seen as too clinical and sterile, and set in closed rooms liable to evoke negative experiences among refugees. Participants suggested greater use of outreach services, and engaging young people from refugee background in community settings where mental health professionals could be seen in a less formal way: “we sit and wait!” (FGD14); “go where the young people are” (FGD8). Schools were considered to be good environments for early identification of mental health issues and to offer a “safe place to talk.” (FGD6). Engaging young people in informal ways, such as through recreational activities out of the office (“More contact activity instead of therapy”, FGD18) was suggested as beneficial to build relationships and improve service accessibility.
This review has several limitations. This review did not include studies focusing on men who were gene carriers, prisoners, disabled, drug users, in military service, homeless, immigrants, refugees as well as aboriginal and gay men. These groups of men face additional barriers when seeking healthcare and deserve separate reviews, some of which have been published. For example, systematic reviews have been conducted on barriers to HIV testing in men who have sex with men (MSM) (Lorenc et al., 2011) and hepatitis C testing in people who inject drugs (Jones et al., 2014).
Surabhi Chaturvedi aimed to bridge the research gap by conducting face to face semi- structured interviews with six clients from homelessness charity in London, United Kingdom (Surabhi, 2016) The interview specifically addressed perceived facilitators and barriers to counseling service or psychological therapies. Following thematic analysis of transcribing verbatim interviews, five themes emerged on barriers: “resistance to opening up, stigma, past experiences of help-seeking, denial about needing help, and lack of familiarity with therapy” (Surabhi, 2016). Personal resistant to seeking out and accepting support through psychological therapies stemmed from “feeling overwhelmed” and the idea of “close interpersonal contact” with counselors (Surabhi, 2016). Stigmas discussed by the participants reflected an internalized stigmatization separate from societal views defined by negative perceptions about needing or being offered counseling (Surabhi, 2016). Beyond personalized stigmas, reluctance to seek help was influenced by past experiences of receiving substandard support or loss of trust consistent with the trauma and familial problems identified in this population (Surabhi, 2016). Denying the need for help and the generalized fear surrounding counseling due to lack of knowledge and exposure beyond media portrayal influences participants’ propensity to accessing services (Surabhi, 2016).
Although the spectrum of clinical conditions from which the modeling studies were selected was intended to be broad, in most case studies, a deterministic state-transition model was replicated, and therefore the ﬁndings might not be generalizable to other, more complex model types. There was also a limited range of modeling software used, and therefore the potential bene ﬁts or dif ﬁculties of using other software, such as R, were not explored. The results of the replications are highly dependent on the com- petencies of the replicator and therefore may not necessarily be a true re ﬂection on the quality or replicability of the model within the original publication. Attempts were made to mitigate this, however, by using different modelers for each of the case studies, each of whom had varying levels of experience. Importantly, none of the case studies were chosen to single out any author, institu- tion, or journal.
Methods: The Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) 2015 Statement was adopted as the framework for reporting this manuscript. We will apply broad-spectrum search strategies and will search MEDLINE and more than 40 other databases. We will conduct searches in the gray literature, screen reference lists, and hand-search 12 journals. All study designs, stakeholders, interventions, settings, and languages will be eligible. We will search studies that report on barriers or facilitators to the implementation of orthodontic mini implants (OMIs) in clinical practice. Implementation constructs and their prevalence among pertinent stakeholders will be our primary outcomes. All searching and data extraction procedures will be conducted by three experienced reviewers. We will also contact authors and investigators to obtain additional information on data items and unidentified studies. Risk of bias will be scored with tools designed for the specific study designs. We will assess heterogeneity, meta-biases, and the robustness of the overall evidence of outcomes. We will present findings in a systematic narrative synthesis and plan meta-analyses when pertinent criteria are met.