Devane Courtney, Renner Regina M, Munro Sarah, Guilbert Édith, Dunn Sheila, Wagner Marie-Soleil, Norman Wendy V
1Contraception and Abortion Research Team, Women's Health Research Institute, BC Women's Hospital and Health Center, Vancouver, BC Canada.
2School of Nursing, University of British Columbia, Vancouver, BC Canada.
Pilot Feasibility Stud. 2019 Nov 8;5:126. doi: 10.1186/s40814-019-0520-8. eCollection 2019.
Direct primary care provision of first-trimester medical abortion could potentially address inequitable abortion access in Canada. However, when Health Canada approved the combination medication Mifegymiso® (mifepristone 200 mg/misoprostol 800 mcg) for medical abortion in July 2015, we hypothesized that the restrictions to distribution, prescribing, and dispensing would impede the uptake of this evidence-based innovation in primary care. We developed and pilot-tested a survey related to policy and practice facilitators and barriers to assess successful initiation and ongoing clinical provision of medical abortion service by physicians undertaking mifepristone training. Additionally, we explored expert, stakeholder, and physician perceptions of the impact of facilitators and barriers on abortion services throughout Canada.
In phase 1, we developed a survey using 2 theoretical frameworks: Greenhalgh's conceptual model for the Diffusion of Innovations in health service organizations (which we operationalized) and Godin's framework to assess the impact of professional development on the uptake of new practices operationalized in Légaré's validated questionnaire. We finalized questions in phase 2 using the modified Delphi methodology. The survey was then tested by an expert panel of 25 nationally representative physician participants and 4 clinical content experts. Qualitative analysis of transcripts enriched and validated the content by identifying these potential barriers: physicians dispensing the medication, mandatory training to become a prescriber, burdens for patients, lack of remuneration for mifepristone provision, and services available in my community. To assess the usability and reliability of the online survey, in phase 3, we pilot-tested the survey for feasibility.
We developed and tested a 61-item Mifepristone Implementation Survey suitable to study the facilitators and barriers to implementation of mifepristone first-trimester medical abortion practice by physicians in Canada.
Our team operationalized Greenhalgh's theoretical framework for Diffusion of Innovations in health systems to explore factors influencing the implementation of first-trimester medical abortion provision. This process may be useful for those evaluating other health system innovations. Identification of facilitators and barriers to implementation of mifepristone practice in Canada and knowledge translation has the potential to inform regulatory and health system changes to support and scale up facilitators and mitigate barriers to equitable medical abortion provision.
在加拿大，由直接初级保健提供孕早期药物流产服务可能有助于解决堕胎服务获取不平等的问题。然而，当加拿大卫生部于2015年7月批准将复方药物米非司酮米索前列醇片（米非司酮200毫克/米索前列醇800微克）用于药物流产时，我们推测，在药物分发、处方开具和配药方面的限制会阻碍这种基于证据的创新在初级保健中的应用。我们开发并进行了一项关于政策及实践促进因素和障碍的调查，以评估接受米非司酮培训的医生成功启动并持续提供药物流产服务的情况。此外，我们还探讨了专家、利益相关者和医生对促进因素和障碍对加拿大各地堕胎服务影响的看法。
在第一阶段，我们利用两个理论框架开发了一项调查：格林哈尔希的卫生服务组织创新扩散概念模型（我们将其进行了实际应用）以及戈丁的框架（该框架通过勒加雷经验证的问卷来评估专业发展对新实践应用的影响）。在第二阶段，我们采用改进的德尔菲法确定了最终的问题。随后，该调查由一个由25名具有全国代表性的医生参与者和4名临床内容专家组成的专家小组进行测试。通过对访谈记录的定性分析，识别出了这些潜在障碍，从而丰富并验证了调查内容：医生配药、成为处方开具者的强制培训、患者负担、提供米非司酮缺乏报酬以及所在社区可获得的服务。为了评估在线调查的可用性和可靠性，在第三阶段，我们对该调查进行了可行性预测试。
我们开发并测试了一项包含61个条目的米非司酮实施情况调查，该调查适用于研究加拿大医生实施米非司酮孕早期药物流产实践的促进因素和障碍。
我们的团队运用了格林哈尔希的卫生系统创新扩散理论框架，以探索影响孕早期药物流产服务实施的因素。这一过程可能对评估其他卫生系统创新的人员有所帮助。识别加拿大米非司酮实践实施的促进因素和障碍以及知识转化，有可能为监管和卫生系统变革提供参考，以支持并扩大促进因素的作用，减轻公平提供药物流产服务的障碍。
