Factors influencing implementation of an insulin patient decision aid at public health clinics in Malaysia: A qualitative study

Background Many patient decision aids (PDAs) are developed in academic settings by academic researchers. Academic settings are different from public health clinics where the focus is on clinical work. Thus, research on implementation in public health settings will provide insights to effective implementation of PDA in real-world settings. This study explores perceived factors influencing implementation of an insulin PDA in five public health clinics. Methods This study adopted a comparative case study design with a qualitative focus to identify similarities and differences of the potential barriers and facilitators to implementing the insulin PDA across different sites. Focus groups and individual interviews were conducted with 28 healthcare providers and 15 patients from five public health clinics under the Ministry of Health in Malaysia. The interviews were transcribed verbatim and analysed using the thematic approach. Results Five themes emerged which were: 1) time constraint; 2) PDA costs; 3) tailoring PDA use to patient profile; 4) patient decisional role; and 5) leadership and staff motivation. Based on the interviews and drawing on observations and interview reflection notes, time constraint emerged as the common prominent factor that cut across all the clinics, however, tailoring PDA use to patient profile; patient decisional role; leadership and staff motivation varied due to the distinct challenges faced by specific clinics. Among clinics from semi-urban areas with more patients from limited education and lower socio-economic status, patients’ ability to comprehend the insulin PDA and their tendency to rely on their doctors and family to make health decisions were felt to be a prominent barrier to the insulin PDA implementation. Staff motivation appeared to be stronger in most of the clinics where specific time was allocated to diabetes team to attend to diabetes patients and this was felt could be a potential facilitator, however, a lack of leadership might affect the insulin PDA implementation even though a diabetes team is present. Conclusions This study found time constraint as a major potential barrier for PDA implementation and effective implementation of the insulin PDA across different public health clinics would depend on leadership and staff motivation and, the need to tailor PDA use to patient profile. To ensure successful implementation, implementers should avoid a ‘one size fits all’ approach when implementing health innovations.

8. Will the implementation of the PDA result in any change in your organization or your healthcare system? Any benefit or harm in implementing the PDA? (example: positive or negative changes -improve communication between HCP-Pt, reduce or prolong consultation time, provide information, facilitate doctor's consultation, administrative factors, additional resources, financial resources) (intention, beliefs about consequences, optimism)

Preamble:
Ice-breaking • Explain information given will be kept private and confidential • Explain no right or wrong answer • Need to get consent for the interview and recording • Do not have to answer if the participant doesn't wish to do so • Interested in getting a wide range of information and would appreciate if they can share their views as much as possible • Explain that: We would like to implement the insulin PDA in the public and university-based primary care clinics in Malaysia. This interview is about what are the barriers and facilitators to implementing the insulin PDA in your healthcare organization or in Malaysian public and university-based primary healthcare practices in general, so that it is effective and sustainable to be used.

• Show and tell on the 3 insulin PDA models
Appendix 1 Phase 1 interview guide for healthcare policy maker, healthcare providers and patients 9. Are you confident/positive/optimistic that your institution is capable to successfully implement the insulin PDA despite any difficulty? Yes/No, why? (beliefs about capabilities, optimism) 10. *As a policy maker, what reinforcements you think can be done to ensure the successful implementation of the insulin PDA? (example: incentives, regulations, guidelines, reminders, protocols, audit, education and training, field visits, patient charters) (reinforcement) 11. If you will implement the insulin PDA in your organization, what are the goals you want to achieve? (example: to develop professional expertise, to improve patient care) (goals) 12. Do you think by implementing the insulin PDA, this will affect your organization/clinic's goals and targets? (example: Hba1c target, insulin uptake). How will it affect the implementation of the PDA? ( people embrace) will affect the implementation of the PDA? (environmental context and resources) Probe: How will they embrace the use of the insulin PDA in the clinic?
Individuals involved: healthcare policymaker, healthcare provider and patients 16. As a policy maker, how confident are you with the implementation of the insulin PDA?
(example: the evidence, the institution which developed the insulin PDA) Why? (social professional role and identity) 17. Do you think HCPs/patients will want to use the insulin PDA? Why? (intentions) 18. *How can we increase HCPs'/patients' intention to use the PDA? (intentions) 19. *Who do you think will be using the insulin PDA with the patients or who will help to implement/coordinate the implementation of the insulin PDA? Why? (example: doctors, nurses, pharmacist) (social professional role and identity) 20. Do you think the HCPs/patients have the knowledge and skills to use the insulin PDA?
(example: understanding of the insulin PDA, its purpose, and how to use, communication skills, computer skills, interpersonal skills, counselling skills, literacy skills, health conditions) ( 28. What feelings do you think HCPs will have if they were asked to use the insulin PDA (booklet, tablet, webpage)? (emotions; social professional role and identity) 29. Do you think the insulin PDA will affect HCP role? (example: losing control of the consultation, determining what is best for the patient, compromising clinical expertise and medical judgment). How will this affect the implementation of the PDA? (social professional role and identity) 30. What do you think patients will feel when you introduced the insulin PDA (booklet, tablet, webpage) to them? (example: afraid, fear, hopeful, sad, confuse). Probe: Do you think they will feel to be pushed to use insulin? How will this affect the implementation of the insulin PDA? (