Table 2 Key barriers to SBIR implementation

Intervention Characteristic–

Adaptability

Design quality & packaging

CTI:

Participants perceived SBIR paper form could not be adapted to patients or local needs:

Patients were overwhelmed by the amount of brochure information

IST:

Paper format increased workload

CTI:

SBIR paper format interrupted workflow and limited understanding of risk factor assessment

• Questions did not always fit with the main reason for patients’ appointments/visits; referral resources for healthy eating and physical activity not found in patients’ community

• SBIR form did not prioritize which factors should be focused on, so nurses gave information for all medium to high risk factors.

• Easy to make errors for data transfer; hinder information flow; incomplete due to user error; patient confidentiality and privacy

• Risk level calculation algorithm for factors in SBIR form was not obvious or easily understood - needed continue referencing to paper source to understand; limited number of health factors covered

“Some of the questions I thought were good conversation starters, [but] for lots of people they wondered, ‘why is this important, how many fruits and vegetables I eat when I’m here for my addictions appointment?’” (Interview 4)

“[CTI] didn’t like it, especially to scan it back [to IST], and then evaluate the results that needed to be completed in a specific way.…I think it created some extra problems… If you accidentally put a mark somewhere,…then it would show up incorrectly in our system.” (Interview 5)

If [patients] end up taking up the whole 15 min because there’s a lot of questions about the vaccine, then there was no time left to go through those questions… so your intervention was just really time consuming” (Interview 6)

Outer Setting– Patient’s needs & resources

CTI:

Patients’ needs and resources not met

CTI did not prioritize SBIR factors

Community lacked resources for patients

Health system barriers to meeting patient needs

Patients’ knowledge and beliefs

Relationship between provider and patients

• Patients found brochures and information from SBIR overwhelming; timely resources are needed– lengthy referral wait time

• Insufficient clinical programs or resources to support patients when they are ready to change

• Difficult referral pathway after SBIR questionnaire was completed - long wait time reduces patients’ motivation to change; the referral pathway focuses on disease treatment not on prevention; lack of resources to support patients’ readiness to change

• Patients’ health choices are based on health inequities: inability to understand scientific studies and assess risk; lack of early health prevention education; lack of health behavior understanding.

• Patients desire for immediate results from initial health choice - “an all or nothing approach” that prevents behavior change and choices; choices are limited due to poverty and convenience; lack of understanding of food choices and health problems; need easy win solutions for changes to behavior

• Lack of trust in the clinicians– past negative experiences with clinicians can create hesitancy to disclose alcohol and tobacco usage

“Maybe you’re motivated for a minute but if we make you wait six weeks, [you’re] not really interested in going for a walk or… I think we must catch people when they’re ready.” (Interview 4)

“I feel community stakeholders would have been better… places to refer [patients] for the dietitian. If they want to increase their exercise, it would have been nice to have some type of input on community resources and where they could go to increase activities.” (Interview 6)

“We spend way too much time on tertiary care and not so much on preventative and primary… I think, we’re trying to put out fires.” (Interview 4)

“I think [people] just always want that immediate gratification. If we go for a walk one day, we want to think that we’ll get a washboard stomach, and it doesn’t quite work that way. (Interview 4).

Characteristics of the Individuals–Knowledge and beliefs

CTI:

CTI were hesitant to implement SBIR

Patients’ knowledge / beliefs about health and hesitancy to change

Pilot site management hesitancy

• Risk factor screening questions to patients deemed too personal and not within provider role; small community means clinician and patient are neighbors; perception that SBIR would not make a health difference (provider see patient in late stage of health decline; provider see patients choices influenced by other factors like poverty and cannot make changes); patients lack interest in the questions

• Desire for immediate results from initial health choice; inability to understand scientific studies and assess risk; lack of early health prevention education; lack of health behavior understanding - All or nothing approach that prevents behavior change and choices; choose convenience over healthy options; lack understanding of food choices and health problems

• Patients’ late stage of health decline and SBIR is too late

“You absolutely need to teach people to be comfortable with the questions. You need to teach them to know how to handle the answers,… oh you’re only having one glass of wine at night, which is good, right?…I think in healthcare where we go wrong, is that kind of high and mighty attitude.” Interview 4