Background and objective Implementing electronic patient-reported outcomes (ePROs) in oncology practice has shown substantial clinical benefits. However, it can be challenging in routine practice, warranting strategies to adapt to different clinical contexts. In light of this, this study aimed to describe the implementation process of the ePRO system and elucidate the provider-level implementation barriers and facilitators to a novel ePRO system at cancer hospitals in Japan. Methods We implemented an ePRO system linked to electronic medical records at three cancer hospitals. Fifteen patients with solid cancers at the outpatient oncology unit were asked to regularly complete the Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE™) questionnaire and European Organization for Research and Treatment Core Quality of Life questionnaire (EORTC QLQ C30) by using the smartphone app between October 2021 and June 2022. Thirteen healthcare professionals were interviewed to identify implementation barriers and facilitators to the ePRO system by using the Consolidated Framework for Implementation Research framework. Results The healthcare professionals identified a lack of clinical resources and a culture and system that emphasizes treatment over care as the main barriers; however, the accumulation of successful cases, the leadership of managers, and the growing needs of patients can serve as facilitators to the implementation. Conclusions Our experience implementing an ePRO system in a few Japanese oncology practices revealed comprehensive barriers and facilitators. Further efforts are warranted to develop more successful implementation strategies.

OBJECTIVE: Pediatric burn injuries are a global clinical issue causing significant morbidity. Early adjunctive negative pressure wound therapy improves re-epithelialization rates in children with burns, yet adoption in acute burn care is inconsistent. This investigation aimed to determine barriers to the implementation of adjunctive negative pressure wound therapy for the acute management of pediatric burns and co-design targeted implementation strategies.
METHODS: A sequential mixed methods design was used explore barriers to adjunctive negative pressure wound therapy implementation in acute pediatric burn care. An online questionnaire was disseminated to healthcare professionals within four major Australian pediatric hospitals, each with a dedicated burns service. Barriers were coded according to the Consolidated Framework for Implementation Research (CFIR). Semi-structured interviews with senior clinicians tailored implementation strategies to local contexts. A stakeholder consensus meeting consolidated implementation strategies and local processes.
RESULTS: Sixty-three healthcare professionals participated in the questionnaire, and semi-structured interviews involved nine senior burn clinicians. We identified eight implementation barriers across all five CFIR domains then co-designed targeted strategies to address identified barriers. Barriers included lack of available resources, limited access to knowledge and information, individual stage of change, patient needs and resources, limited knowledge and beliefs about the intervention, lack of external policies, intervention complexity, and poor implementation planning.
CONCLUSIONS: Multiple contextual factors affect negative pressure wound therapy uptake in acute pediatric burn settings. Results will inform a multi-state stepped-wedge cluster randomized controlled trial. Additional resources, education, training, updated policies, and guidelines are required for successful implementation. It is anticipated that adjunctive negative pressure wound therapy, in conjunction with tailored implementation strategies, will enhance adoption and sustainability.
BACKGROUND: Australian and New Zealand Clinical Trials Registry: ACTRN12622000166774. Registered 1 February 2022.

OBJECTIVE: There is a high prevalence of frailty amongst older patients in hospital settings. Frailty guidelines exist but implementation to date has been challenging. Understanding health professional attitudes, knowledge, and beliefs about frailty is critical in understanding barriers and enablers to guideline implementation, and the aim of this study was to understand these in rehabilitation multidisciplinary teams in hospital settings.
METHODS: Twenty-three semistructured interviews were conducted with health professionals working in multidisciplinary teams on geriatric and rehabilitation wards in Adelaide and Sydney, Australia. Interviews were audio recorded, transcribed, and coded by 2 researchers. A codebook was created and interviews were recoded and applied to the Framework Method of thematic analysis.
RESULTS: Three domains were developed: diagnosing frailty, communicating about frailty, and managing frailty. Within these domains, 8 themes were identified: (1) diagnosing frailty has questionable benefits, (2) clinicians don\'t use frailty screening tools, (3) frailty can be diagnosed on appearance and history, (4) frailty has a stigma, (5) clinicians don\'t use the word \"frail\" with patients, (6) frailty isn\'t always reversible, (7) there is a lack of continuity of care after acute admission, and (8) the community setting lacks resources.
CONCLUSIONS: Implementation of frailty guidelines will remain challenging while staff avoid using the term \"frail,\" don\'t perceive benefit of using screening tools, and focus on the individual aspects of frailty rather than the syndrome holistically. Clinical champions and education about frailty identification, reversibility, management, and communication techniques may improve the implementation of frailty guidelines in hospitals.

BACKGROUND: Implementing PBL in teaching and learning can be challenging due to a variety of complex barriers. Studies on barriers to the implementation of problem-based learning in Ethiopia are scarce. This study aimed to explore the barriers to the implementation of problem-based learning at the Debre Berhan University Medical School.
METHODS: A qualitative study was conducted among faculty and medical students at the medical school. Purposive sampling was used to select participants. Semi-structured interviews were conducted with tutors and academic leaders, including the problem-based learning coordinator, the biomedical sciences coordinator, and the school dean. Data was also collected from students through focus group discussions. All interviews and discussions were recorded. The four steps of data analysis of Spradley, including domain analysis, taxonomic analysis, componential analysis, and theme analysis, were employed.
RESULTS: The study identified student-related, tutor-related, case scenario-related, and assessment-related barriers as the most significant obstacles to implementing problem-based learning. These barriers included work overload for both students and tutors, lack of training and experience among tutors, student reluctance, absence of standardized case scenarios, subjectivity of assessment methods, and on-the-spot assessment of students.
CONCLUSIONS: Lack of both tutor and student commitment, lack of standardized cases, absence of a recognition of staff input, gap in communication skills, work overload, lack of continuous training, and at-spot evaluation of students were identified as the main barriers to the implementation of PBL.

BACKGROUND: Quality in healthcare is a subject in need of continuous attention. Quality improvement (QI) programmes with the purpose of increasing service quality are therefore of priority for healthcare leaders and governments. This study explores the implementation process of two different QI programmes, one externally driven implementation and one internally driven, in Norwegian nursing homes and home care services. The aim for the study was to identify enablers and barriers for externally and internally driven implementation processes in nursing homes and homecare services, and furthermore to explore if identified enablers and barriers are different or similar across the different implementation processes.
METHODS: This study is based on an exploratory qualitative methodology. The empirical data was collected through the \'Improving Quality and Safety in Primary Care - Implementing a Leadership Intervention in Nursing Homes and Homecare\' (SAFE-LEAD) project. The SAFE-LEAD project is a multiple case study of two different QI programmes in primary care in Norway. A large externally driven implementation process was supplemented with a tracer project involving an internally driven implementation process to identify differences and similarities. The empirical data was inductively analysed in accordance with grounded theory.
RESULTS: Enablers for both external and internal implementation processes were found to be technology and tools, dedication, and ownership. Other more implementation process specific enablers entailed continuous learning, simulation training, knowledge sharing, perceived relevance, dedication, ownership, technology and tools, a systematic approach and coordination. Only workload was identified as coincident barriers across both externally and internally implementation processes. Implementation process specific barriers included turnover, coping with given responsibilities, staff variety, challenges in coordination, technology and tools, standardizations not aligned with work, extensive documentation, lack of knowledge sharing.
CONCLUSIONS: This study provides understanding that some enablers and barriers are present in both externally and internally driven implementation processes, while other are more implementation process specific. Dedication, engagement, technology and tools are coinciding enablers which can be drawn upon in different implementation processes, while workload acted as the main barrier in both externally and internally driven implementation processes. This means that some enablers and barriers can be expected in implementation of QI programmes in nursing homes and home care services, while others require contextual understanding of their setting and work.

BACKGROUND: Persistent somatic symptoms and functional disorders (PSS/FD) are often complex conditions requiring care from multiple disciplines. One way of bringing the different disciplines together is through collaborative care. Little is known about the implementation barriers faced and relevant strategies to tackle the barriers in this field. Therefore, using expert knowledge, we aim to develop realistic strategies for dealing with implementation barriers of collaborative care in PSS/FD.
METHODS: The Research World Café method is a single-session, expert-based method with multiple focus-groups forming and reforming to answer a set of inter-related questions, under the guidance of moderators. Using this method, participants involved in PSS/FD care across different areas of healthcare in the Netherlands developed several realistic strategies for dealing with ten implementation barriers for collaborative care in PSS/FD that were previously identified in a Delphi study. Strategies were grouped into strategy clusters using a card-sorting task.
RESULTS: Thirty-three participants took part, representing ten different disciplines, most commonly physiotherapists, psychologists, and physicians. In total, 54 strategies, identified in response to the ten barriers, were grouped into eight strategy clusters. The strategy clusters were professional education, communication, care coordination, care pathways, joint consults, funding, patient involvement, and prevention.
CONCLUSIONS: We identified a number of useful strategies for dealing with implementation barriers for collaborative care in PSS/FD. Many strategies provided ways to deal with multiple barriers at once. The effects of applying these strategies in collaborative care in PSS/FD will need testing through implementation studies, as well as in other areas needing multidisciplinary care.

BACKGROUND: Addressing health inequities that Māori (Indigenous peoples) communities face in New Zealand is a key aim of researchers and practitioners. However, there is limited understanding of the implementation processes and outcomes of health programmes for addressing these inequities. The aim of this study was twofold: (a) to identify correlates of implementation outcomes and (b) to identify facilitators and barriers to implementation effectiveness.
METHODS: The study involved a concurrent mixed method approach. Through an online survey, 79 participants with experience in implementing a health programme with a Māori community identified outcomes and processes of the programme. Additionally, nine Māori community providers shared their perceptions and experience of facilitators and barriers to implementation effectiveness through an in-depth interview. The quantitative and qualitative findings were integrated to address the aims of the study.
RESULTS: For the first aim, we identified two key outcomes: overall health impacts and sustainability. Three of the variables had significant and positive bivariate correlations with health impacts: cultural alignment, community engagement, and individual skills. The only significant correlate of sustainability was evidence-based. For the second aim, participants described four facilitators (leadership, whanaungatanga [relationships], sharing information, digestible information) and four barriers (system constraints, lack of funding, cultural constraints, lack of engagement) to effective implementation.
CONCLUSIONS: Overall, leadership, aligning culture, and building on whanaungatanga, while getting financial resources and systems support, are the core elements to supporting implementation efforts in Māori communities.

BACKGROUND: Digital mental health interventions (DMHIs) are getting increasingly important for mental health care. In the case of eating disorders (EDs), DMHIs are still in early stages. Few studies so far investigated the views of mental health professionals for EDs on the integration of DMHIs in routine care.
OBJECTIVE: To gain insights into the experiences, perspectives, and expectations of mental health professionals for EDs regarding DMHIs and to identify requirements for the future integration of DMHIs into routine care.
METHODS: Semi-structured qualitative telephone interviews with 24 German mental health professionals treating patients with EDs were conducted. A content analysis following a deductive-inductive approach asked for experiences, advantages and chances, disadvantages and boundaries, desired functions and properties, target groups, and general conditions and requirements for DMHIs for patients with EDs.
RESULTS: Only few professionals reported experiences with DMHIs besides video-based psychotherapy during the pandemic. From the therapists\' point of view, DMHIs have the potential to deliver low-threshold access for patients with EDs. Useful functionalities were seen in digital meal records, skills training, and psychoeducation. However, a stable therapeutic alliance was reported as an important prerequisite for the successful integration into care. Therapists expressed concerns in case of severe anorexia nervosa or suicidality. The participants felt to be informed inadequately on recent developments and on the evidence base of DMHIs.
CONCLUSIONS: Mental health professionals for EDs show positive attitudes towards DMHIs, however many barriers to the integration in routine care were observed. The highest potential was seen for the use of DMHIs in addition to outpatient care and in aftercare. Specific requirements for DMHIs are related to different areas of the healthcare spectrum and for the different symptom profiles in anorexia nervosa, bulimia nervosa and binge eating disorder. Targeted DMHIs are needed and appropriate especially for concepts of blended care.
Digital mental health interventions are therapeutic services for people with a mental disorder that can be delivered on electronic devices. They are getting increasingly important, as many patients have to wait long for a therapy. In eating disorders these interventions are still in early stages. Twenty-four telephone interviews were held with German professionals treating adolescent and adult patients with eating disorders. The aim was to understand their experiences, perspectives, and expectations regarding digital mental health interventions and to find out what is needed to integrate them into care in the future. In general, the interview partners showed positive attitudes towards these interventions. However, only few reported experiences and many obstacles were observed. The highest potential was seen for the use in addition to care outside the hospital setting and after treatment has ended. However, in case of a severe eating disorder, such as anorexia, or self-harm and suicidality, they were against the use of digital interventions. A stable personal relationship to their patients was seen as particularly important before recommending a digital intervention. Finally, the interview partners felt not informed in a sufficient way on the scientific basis and regulations regarding digital mental health interventions.

Although pig systems start from a favourable baseline of environmental impact compared to other livestock systems, there is still scope to reduce their emissions and further mitigate associated impacts, especially in relation to nitrogen and phosphorous emissions. Key environmental impact hotspots of pig production systems are activities associated with feed production and manure management, as well as direct emissions (such as methane) from the animals and energy use. A major contributor to the environmental impacts associated with pig feed is the inclusion of soya in pig diets, especially since European pig systems rely heavily on soya imported from areas of the globe where crop production is associated with significant impacts of land use change, deforestation, carbon emissions, and loss of biodiversity. The \"finishing\" pig production stage contributes most to these environmental impacts, due to the amount of feed consumed, the efficiency with which feed is utilised, and the amount of manure produced during this stage. By definition therefore, any substantial improvements pig system environmental impact would arise from changes in feed production and manure management. In this paper, we consider potential solutions towards system environmental sustainability at these pig system components, as well as the bottlenecks that inhibit their effective implementation at the desired pace and magnitude. Examples include the quest for alternative protein sources to soya, the limits (perceived or real) to the genetic improvement of pigs, and the implementation of alternative manure management strategies, such as production of biogas through anaerobic digestion. The review identifies and discusses areas that future efforts can focus on, to further advance understanding around the potential sustainability benefits of modifications at various pig system components, and key sustainability trade-offs across the environment-economy-society pillars associated with synergistic and antagonistic effects when joint implementation of multiple solutions is considered. In this way, the review opens a discussion to facilitate the development of holistic decision support tools for pig farm management that account for interactions between the \"feed * animal * manure\" system components and trade-offs between sustainability priorities (e.g., environmental vs economic performance of pig system; welfare improvements vs environmental impacts).

BACKGROUND: There is an unmet need for One Health (OH) surveillance and reporting systems for antimicrobial resistance (AMR) in resource poor settings. District health information system, version 2 (DHIS2), is a globally recognized digital surveillance platform which has not been widely utilized for AMR data yet. Our study aimed to understand the local stakeholders\' viewpoints on DHIS2 as OH-AMR surveillance platform in Jimma, Ethiopia which will aid its further context specific establishment.
METHODS: We performed an exploratory qualitative study using semi-structured key informant interviews (KIIs) in Jimma Zone at Southwest Ethiopia. We interviewed 42 OH professionals between November 2020 and February 2021. Following verbatim transcription of the audio recordings of KIIs, we conducted thematic analysis.
RESULTS: We identified five major themes which are important for understanding the trajectory of OH-AMR surveillance in DHIS2 platform. The themes were: (1) Stakeholders\' current knowledge on digital surveillance platforms including DHIS2. (2) Stakeholders\' perception on digital surveillance platform including DHIS2. (3) Features suggested by stakeholders to be included in the surveillance platform. (4) Comments from stakeholders on system implementation challenges. (5) Stakeholders\' perceived role in the process of implementation. Despite several barriers and challenges, most of the participants perceived and suggested DHIS2 as a suitable OH-AMR surveillance platform and were willing to contribute at their current professional roles.
CONCLUSIONS: Our study demonstrates the potential of the DHIS2 as a user friendly and acceptable interoperable platform for OH-AMR surveillance if the technology designers accommodate the stakeholders\' concerns. Piloting at local level and using performance appraisal tool in all OH disciplines should be the next step before proceeding to workable format.