BACKGROUND: Pregnancy presents an opportune time for oral health promotion and intervention; however, implementation of the prenatal oral health guidelines remains a challenge among prenatal and oral health providers. The purpose of this study was twofold: To employ a theory-based approach to identify high-priority Consolidated Framework for Implementation Research (CFIR) constructs with the greatest potential to impact prenatal oral health guideline implementation, and to operationalize and pre-test survey items based on the prioritized CFIR constructs. Identifying barriers and facilitators to guideline implementation will inform the development of targeted interventions that address gaps in adherence which can positively impact oral-systemic health.
METHODS: The online survey development process employed three rounds of a modified-Delphi technique with prenatal (i.e., MD/DO, CNM) and oral health (i.e., DMD) Practice Advisory Board Members, cognitive interviews with prenatal and oral health providers, and deliberations among the research team and a Scientific Advisory Board (OBGYN, pediatric dentist, and researchers). High-impact CFIR constructs were identified and translated into survey items that were subsequently piloted and finalized.
RESULTS: During three modified-Delphi rounds, a total of 39 CFIR constructs were evaluated with final input and deliberations with the Practice Advisory Board, Scientific Advisory Board, and the research team achieving consensus on 19 constructs. The instrument was pre-tested with four prenatal and two oral health providers. Overall, participants reported that the survey items were feasible to respond to, took an appropriate length of time to complete, and were well-organized. Participants identified specific areas of improvement to clarify CFIR items. The final survey instrument included 21 CFIR items across four domains, with five constructs included from the intervention characteristics domain, two from the process domain, two from the outer setting domain, and 12 from the inner setting domain.
CONCLUSIONS: Lessons learned from the survey development process include the importance of soliciting diverse scientific and practice-based input, distinguishing between importance/impact and direction of impact (barrier/facilitator), and the need for additional qualitative methods during interdisciplinary collaborations. Overall, this study illustrated an iterative approach to identifying high-priority CFIR constructs that may influence the implementation of the prenatal oral health guidelines into practice settings.

Food insecurity (FI), the limited access to healthy food to live an active and healthy life, is a social determinant of health linked to poor dietary health and difficulty with disease management in the United States (U.S.). Healthcare experts support the adoption of validated screening tools within primary care practice to identify and connect FI patients to healthy and affordable food resources. Yet, a lack of standard practices limits uptake. The purpose of this study was to understand program processes and outcomes of primary care focused FI screening initiatives that may guide wide-scale program implementation.
This was an embedded multiple case study of two primary care-focused initiatives implemented in two diverse health systems in Chicago and Suburban Cook County that routinely screened patients for FI and referred them to onsite food assistance programs. The Consolidated Framework for Implementation Research and an iterative process were used to collect/analyze qualitative data through semi-structured interviews with N = 19 healthcare staff. Intended program activities, outcomes, actors, implementation barriers/facilitators and overarching implementation themes were identified as a part of a cross-case analysis.
Programs outcomes included: the number of patients screened, identified as FI and that participated in the onsite food assistance program. Study participants reported limited internal resources as implementation barriers for program activities. The implementation climate that leveraged the strength of community collaborations and aligned internal, implementation climate were critical facilitators that contributed to the flexibility of program activities that were tailored to fill gaps in resources and meet patient and clinician needs.
Highly adaptable programs and the healthcare context enhanced implementation feasibility across settings. These characteristics can support program uptake in other settings, but should be used with caution to preserve program fidelity. A foundational model for the development and testing of standard clinical practice was the product of this study.

Clinical practice guidelines (CPGs) distil an evidence base into recommendations. CPG adherence is associated with better patient outcomes. However, preparation and dissemination of CPGs are a costly task involving multiple skilled personnel. Furthermore, dissemination alone does not ensure CPG adherence. Reasons for nonadherence are often complex, but understanding practice variations and reasons for nonadherence is key to improving CPG adherence and harmonising clinically appropriate and cost-effective care.
To overview approaches to improving guideline adherence, to provide urology-specific examples of knowledge-practice gaps, and to highlight potential solutions informed by implementation science.
Three common approaches to implementation science (the Knowledge-To-Action framework, the Consolidated Framework for Implementation Research, and the Behaviour Change Wheel), are summarised.
Three implementation problems in urology are illustrated: underuse of single instillation of intravesical chemotherapy in non-muscle-invasive bladder cancer, overuse of androgen deprivation therapy in localised prostate cancer, and guideline-discordant imaging in prostate cancer. Research using implementation science approaches to address these implementation problems is discussed.
Urologists, patients, health care providers, funders, and other key stakeholders must commit to reliably capturing and reporting data on patient outcomes, practice variations, guideline adherence, and the impact of adherence on outcomes. Leverage of implementation science frameworks is a sound next step towards improving guideline adherence and the associated benefits of evidence-based care.
Clinical practice guideline documents are created by expert panels. These documents provide overviews of the evidence for the tests and treatments used in patient care. They also provide recommendations and it is expected that in most circumstances clinicians will follow these recommendations. Sometimes, health care professionals cannot or do not follow these recommendations and it is not always clear why. In this review article we look at some examples of research approaches to addressing this problem of nonadherence and we provide some examples specific to urology.

BACKGROUND: Systemic treatment for breast cancer in sub-Saharan Africa (SSA) is cost effective. However, there are limited real-world data on the translation of breast cancer treatment guidelines into clinical practice in SSA. The study aimed to identify provider factors associated with adherence to breast cancer guideline-concordant care at Princess Marina Hospital (PMH) in Botswana.
METHODS: The Consolidated Framework for Implementation Research was used to conduct one-on-one semistructured interviews with breast cancer providers at PMH. Purposive sampling was used, and sample size was determined by thematic saturation. Transcribed interviews were double-coded and analyzed in NVivo using an integrated analysis approach.
RESULTS: Forty-one providers across eight departments were interviewed. There were variations in breast cancer guidelines used. Facilitators included a strong tension for change and a government-funded comprehensive cancer care plan. Common provider and health system barriers were lack of available resources, staff shortages and poor skills retention, lack of relative priority compared with HIV/AIDS, suboptimal interdepartmental communication, and lack of a clearly defined national cancer control policy. Community-level barriers included accessibility and associated transportation costs. Participants recommended the formal implementation of future guidelines that involved key stakeholders in all phases of planning and implementation, strategic government buy-in, expansion of multidisciplinary tumor boards, leveraging nongovernmental and academic partnerships, and setting up monitoring, evaluation, and feedback processes.
CONCLUSIONS: The study identified complex, multilevel factors affecting breast cancer treatment delivery in Botswana. These results and recommendations will inform strategies to overcome specific barriers in order to promote standardized breast cancer care delivery and improve survival outcomes.
CONCLUSIONS: To address the increasing cancer burden in low- and middle-income countries, resource-stratified guidelines have been developed by multiple international organizations to promote high-quality guideline-concordant care. However, these guidelines still require adaptation in order to be successfully translated into clinical practice in the countries where they are intended to be used. This study highlights a systematic approach of evaluating important contextual factors associated with the successful adaptation and implementation of resource-stratified guidelines in sub-Saharan Africa. In Botswana, there is a critical need for local stakeholder input to inform country-level and facility-level resources, cancer care accessibility, and community-level barriers and facilitators.

BACKGROUND: Mental health problems are one of the most pressing public health concerns of our time. Sweden has seen a sharp increase in mental disorders among children and youth during the last decade. The evidence base for treatment of psychiatric conditions has developed strongly. Clinical practice guidelines aim to compile such evidence and support healthcare professionals in evidence-based clinical decision-making. In Sweden, the national guidelines for the treatment of depression and anxiety disorders in children and adolescents were launched in 2010. The aim of this study was two folded, (i) to explore to what extent these guidelines were known and adhered to by health professionals in Child and Adolescent Mental Health Services and (ii) to investigate factors influencing implementation of the guidelines informed by the Consolidated Framework for Implementation Research.
METHODS: A qualitative approach was used, and data were collected through interviews with 18 health professionals in Child Mental Health Services in Sweden and a combination of conventional and directed content analyses was used. The Consolidated Framework for Implementation Research guided and structured data collection and analysis.
RESULTS: The guidelines were largely unknown by health professionals in Child Mental Health Services in all the clinics investigated. Adherence to guideline recommendations was reported as very low. Barriers to implementation were found in relation to the characteristics of the intervention, outer setting, inner setting and characteristics of the individuals involved.
CONCLUSIONS: The government initiative to develop and disseminate the guidelines seems to have made very little impact on health professionals\' clinical practice. The guidelines were poorly aligned with the health professionals\' knowledge and beliefs about effective mental health services for children and youth with depression and anxiety disorders. Suggestions for future efforts to improve the development and implementation of guidelines in Child Mental Health Services settings are given.

In high-income countries a large proportion of all deaths occur in hospitals. A common way to translate knowledge into clinical practice is developing guidelines for different levels of health care organisations. During 2012, national clinical guidelines for palliative care were published in Sweden. Later, guidance for palliative care was issued by the National Board of Health and Welfare. The aim of this study was two-fold: to investigate perceptions regarding these guidelines and identify obstacles and opportunities for implementation of them in acute care hospitals. Interviews were conducted with local politicians, chief medical officers and health professionals at acute care hospitals. The Consolidated Framework for Implementation Research was used in a directed content analysis approach. The results showed little knowledge of the two documents at all levels of the health care organisation. Palliative care was primarily described as end of life care and only few of the participants talked about the opportunity to integrate palliative care early in a disease trajectory. The environment and culture at hospitals, characterised by quick decisions and actions, were perceived as obstacles to implementation. Health professionals\' expressed need for palliative care training is an opportunity for implementation of clinical guidelines. There is a need for further implementation of palliative care in hospitals. One option for further research is to evaluate implementation strategies tailored to acute care.