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Improving the quality of self-management support in ambulatory cancer care: a mixed-method study of organisational and clinician readiness, barriers and enablers for tailoring of implementation strategies to multisites
  1. Doris Howell1,
  2. Melanie Powis2,
  3. Ryan Kirkby2,
  4. Heidi Amernic3,
  5. Lesley Moody2,
  6. Denise Bryant-Lukosius4,
  7. Mary Ann O'Brien5,
  8. Sara Rask6,
  9. Monika Krzyzanowska7
  1. 1Supportive Care, Princess Margaret Cancer Centre Research Institute, Toronto, Ontario, Canada
  2. 2Medical Oncology and Hematology, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
  3. 3Cancer Care Ontario Branch, Ontario Health, Toronto, Ontario, Canada
  4. 4Oncology, Hamilton Health Sciences Centre, Hamilton, Ontario, Canada
  5. 5Family Medicine, University of Toronto, Toronto, Ontario, Canada
  6. 6Medical Oncology, Royal Victoria Regional Health Centre, Barrie, Ontario, Canada
  7. 7Medical Oncology & Hematology, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
  1. Correspondence to Dr Doris Howell, Supportive Care, Princess Margaret Hospital Cancer Centre, Toronto, Canada; Doris.Howell{at}


Introduction Improving the quality of self-management support (SMS) for treatment-related toxicities is a priority in cancer care. Successful implementation of SMS programmes depends on tailoring implementation strategies to organisational readiness factors and barriers/enablers, however, a systematic process for this is lacking. In this formative phase of our implementation-effectiveness trial, Self-Management and Activation to Reduce Treatment-Related Toxicities, we evaluated readiness based on constructs in the Consolidated Framework for Implementation Research (CFIR) and Normalisation Process Theory (NPT) and developed a process for mapping implementation strategies to local contexts.

Methods In this convergent mixed-method study, surveys and interviews were used to assess readiness and barriers/enablers for SMS among stakeholders in 3 disease site groups at 3 regional cancer centres (RCCs) in Ontario, Canada. Median survey responses were classified as a barrier, enabler or neutral based on a priori cut-off values. Barriers/enablers at each centre were mapped to CFIR and then inputted into the CFIR-Expert Recommendations for Implementing Change Strategy Matching Tool V.1.0 (CFIR-ERIC) to identify centre-specific implementation strategies. Qualitative data were separately analysed and themes mapped to CFIR constructs to provide a deeper understanding of barriers/enablers.

Results SMS in most of the RCCs was not systematically delivered, yet most stakeholders (n=78; respondent rate=50%) valued SMS. For centre 1, 7 barriers/12 enablers were identified, 14 barriers/9 enablers for centre 2 and 11 barriers/5 enablers for centre 3. Of the total 46 strategies identified, 30 (65%) were common across centres as core implementation strategies and 5 tailored implementation recommendations were identified for centres 1 and 3, and 4 for centre 2.

Conclusions The CFIR and CFIR-ERIC were valuable tools for tailoring SMS implementation to readiness and barriers/enablers, whereas NPT helped to clarify the clinical work of implementation. Our approach to tailoring of implementation strategies may have relevance for other studies.

  • implementation science
  • health services research
  • ambulatory care
  • chronic disease management

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  • Contributors Planning: DH, MP, RK, LM, MAO'B, MK. Conduct: DH, MP, RK, HA, LM, DB-L, MAO'B, SR, MK. Reporting: DH, MP, RK, HA, LM, DB-L, MAO'B, SR, MK. Overall content as guarantor(s): DH.

  • Funding Funding for this project was provided by the Canadian Institutes of Health Research’s (CIHR) Operating Grant (HRC 154129): Partnerships for Health System Improvement for Cancer Control, and in-kind contributions by Cancer Care Ontario.

  • Disclaimer The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsements by CIHR or Cancer Care Ontario is intended or should be inferred.

  • Competing interests HA and LM were employees of Cancer Care Ontario (CCO, now part of Ontario Health), who provided in-kind support for this study.

  • Patient consent for publication Not required.

  • Ethics approval The study has been approved through Clinical Trials Ontario (CTO), a centralised ethics review organisation for multicentre studies that is used by the three participating cancer centres. Approval number: 1371.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information. Aggregate data generated or analysed during this study are included in this published article (and its supplementary information files). Raw data generated or analysed during this study are available from the corresponding author on reasonable request.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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