Reza Yousefi-Nooraie

Healthcare workers (HCWs) are at risk of substance use disorders (SUD) due to factors such as burnout, stress, and occupational trauma, which may contribute to drug diversion (theft or unauthorized redirection of controlled substances), placing HCWs at risk of overdose, death, professional discipline and legal consequences. Within healthcare settings, workplace social relationships may facilitate access to controlled substances. However, these dynamics are complex, and such relationships may reflect genuine personal, professional, and peer connections rather than solely attempts to obtain controlled substances. This exploratory single case-study design used semi-structured interviews and investigative reports to examine diversion mechanisms. Transcripts were pseudonymized and analyzed thematically to identify diversion mechanisms. Six diversion themes emerged: (1) professional relationships, legitimacy, and forged prescribing practices, (2) professional trust and authority in unauthorized prescriptions, (3) familial relationships and professional acquaintance as concealment, (4) peer relationships and collegial discretion, (5) emergency department (ED) workflow coordination through acquaintanships, and (6) community-based networks with people who use substances (PWUS) and prescription filling. This case illustrates how social connections may facilitate diversion and provides preliminary insights into relational mechanisms that warrant further investigation.

Background: Diabetic retinopathy is the leading cause of blindness in US adults. Fewer than half of patients with diabetes in rural areas complete the recommended screening that could prevent blindness. Store-and-forward teleophthalmology and mobile pop-up eye clinics have each been shown to improve screening access, but studies examining the implementation of both modalities within the same rural primary care system are lacking. Objective: This study aimed to identify multilevel facilitators and barriers to implementing teleophthalmology and pop-up eye clinics for diabetic eye care in 2 rural primary care clinics in upstate New York. Methods: We conducted a mixed methods implementation study with prospective semistructured interviews and retrospective, descriptive electronic health record data at 2 university-affiliated primary care clinics classified as “isolated rural,” guided by the Consolidated Framework for Implementation Research (CFIR). Electronic health record data from 885 adults with diabetes were used to characterize patient demographics and eye care use. Patients were categorized into 3 groups: eye exam with an eye doctor (n=586), on-site primary care–based eye exam (n=91; teleophthalmology n=39 and pop-up clinic n=52), or no recent eye exam (n=208). Semistructured interviews were conducted with 20 patients (n=5 per subgroup) and 14 staff members (primary care clinicians, optometrists, and administrative personnel), purposively sampled to capture diverse perspectives across eye care pathways and roles. Interviews were coded using CFIR domains and analyzed thematically until no new themes emerged. Results: Patients in the on-site primary care eye exam group were the most socially disadvantaged, with the lowest proportions reporting no transportation needs (42/91, 46.2%), no housing instability (28/91, 30.8%), and no food insecurity (36/91, 39.6%). Over 18 months, 58.4% (52/89) of scheduled pop-up clinic appointments were completed, and 92.3% (36/39) of teleophthalmology images were gradable. Pop-up clinics detected higher rates of diabetic retinopathy (11/52, 21.2% vs 3/39, 7.7%), cataract (29/52, 55.8% vs 3/39, 7.7%), and reduced visual acuity (23/52, 44.2% vs 11/39, 28.2%) than teleophthalmology. Qualitative analysis revealed that patients viewed both modalities as a convenient “one-stop shop” and valued trust in primary care staff. Staff identified complementary barriers: training and workflow complexity for teleophthalmology, and underutilization and scheduling challenges for pop-up clinics. Implementation champions across roles proposed an integrated workflow in which same-day teleophthalmology becomes a default component of annual diabetes visits, with targeted referral to pop-up clinics for patients with abnormal findings. Conclusions: Primary care–based eye programs in rural settings preferentially reached socially vulnerable patients with diabetes and detected substantial unmet eye pathology. However, operating teleophthalmology and pop-up clinics as separate programs led to inefficiencies in both programs. A stakeholder-driven integrated model embedding teleophthalmology into routine diabetes care, with targeted pop-up clinic referrals, may improve the reach, efficiency, and sustainability of diabetic eye screening in rural populations.

Background and Objectives: Understanding the factors that enable or hinder successful implementation is essential for improving patient outcomes. Hospital in Home (HiH) programs provide hospital-level care in patients’ homes to reduce hospitalization, enhance satisfaction, and improve resource use. Within the Veterans Health Administration (VHA), 14 sites have implemented HiH programs, yet limited research has examined implementation within a large integrated system. This study identifies factors that can support or hinder HiH implementation. Research Design and Methods: We conducted interviews with 48 key informants across 14 VHA HiH sites. Guided by the (Consolidated Framework for Implementation Research (CFIR), 2022) 2.0, we applied directed content analysis using a priori constructs, then developed site-level matrices to summarize findings and compare patterns across sites. Results: We identified 18 CFIR constructs—nine that primarily facilitated implementation and nine mixed factors that acted as both facilitators and barriers. Key facilitators included two Individual-level factors (HiH lead capability and motivation, team motivation), one Innovation factor (relative advantage of HiH), and four Implementation Process factors (planning, teaming, reflecting and evaluating, and adapting). Mixed factors were mostly within the inner setting, reflecting the medical center context, along with two individual-level mixed factors (leader and recipient motivation). Discussion and Implications: HiH programs hold strong potential to transform care for older adults, but success depends on addressing barriers and leveraging facilitators, particularly within the inner setting. Understanding key implementation determinants can enhance adoption, improve outcomes, and strengthen healthcare delivery.

BACKGROUND Diabetic retinopathy is the leading cause of blindness in working-age US adults. Fewer than half of patients with diabetes in underserved rural areas complete recommended screening that could prevent blindness. Store-and-forward teleophthalmology and mobile pop-up eye clinics have each been shown to improve screening access, but studies examining the implementation of both modalities coexisting within the same rural primary care system are lacking. OBJECTIVE To identify multilevel facilitators and barriers to implementing teleophthalmology and pop-up eye clinics for diabetic eye care in two rural primary care clinics in upstate New York. METHODS We conducted a qualitative implementation study with prospective semistructured interviews and retrospective descriptive electronic health record (EHR) data at two university-affiliated primary care clinics classified as “isolated rural”, guided by the Consolidated Framework for Implementation Research (CFIR). EHR data from 885 adults with diabetes were used to characterize patient demographics and eye care utilization. Qualitative interviews were the primary data source for identifying implementation facilitators and barriers. Patients were categorized into three groups: eye exam with an eye doctor (n=586), on-site primary care-based eye exam (n=91; teleophthalmology n=39, pop-up clinic n=52), or no recent eye exam (n=208). Semistructured interviews were conducted with 20 patients (5 per subgroup) and 14 staff members (primary care clinicians, optometrists, administrative personnel), purposively sampled to capture diverse perspectives across eye care pathways and roles. Interviews were coded using CFIR domains and analyzed thematically until no new themes emerged. RESULTS Patients in the on-site primary care eye exam group were the most socially disadvantaged, with the lowest proportions reporting no transportation needs (46.2%), no housing instability (30.8%), and no food insecurity (39.6%). Over 18 months, 58.4% of scheduled pop-up clinic appointments were completed, and 92.3% of teleophthalmology images were gradable. Pop-up clinics detected higher rates of diabetic retinopathy (21.2% versus 7.7%), cataract (55.8% versus 7.7%), and reduced visual acuity (44.2% versus 28.2%) than teleophthalmology. Qualitative analysis revealed that patients viewed both modalities as a convenient "one-stop shop" and valued trust in primary care staff. Staff identified complementary barriers: training and workflow complexity for teleophthalmology and underutilization and scheduling challenges for pop-up clinics. Implementation champions across clinical and administrative roles proposed an integrated workflow in which same-day teleophthalmology becomes a default component of annual diabetes visits, with targeted referral to pop-up clinics for patients with abnormal findings. CONCLUSIONS Primary care-based eye programs in isolated rural settings preferentially reached socially vulnerable patients with diabetes and detected substantial unmet eye pathology. However, operating teleophthalmology and pop-up clinics as separate programs led to inefficiencies in both. A stakeholder-driven integrated model embedding teleophthalmology into routine diabetes care with targeted pop-up clinic referral may improve reach, efficiency, and sustainability of diabetic eye screening in rural populations.

Improvements in patient safety and quality of care can be achieved by improvements in clinicians’ teamwork, coordination, and communication. Growing

Interventions designed for individual or collective behaviour change are implemented within social systems. Individuals engage with these interventions through the lens of their existing knowledge and attitudes, which are shaped by social interactions, norms, and values. As implementation proceeds, individuals also interact with one another, influencing behaviour and either supporting or hindering change by sharing – or withholding – information, advice, and resources. Popular or influential individuals can advance or impede implementation by shaping their peers’ beliefs and actions. The spread of desired behaviours may get trapped within social circles that rarely communicate. These interconnected dynamics create a complex system of interaction and influence that needs to be addressed in the process of intervention development. This chapter explores how understanding social networks and designing interventions that intentionally optimise them is an important aspect of effective development and implementation of complex interventions.

Implementation is an inherently collaborative and transdisciplinary activity; however, engaging key partners across research, practice, and policy sectors is challenging. Successful implementation requires supportive infrastructure for both research and practice. This paper presents practice-based reflections on the value of exploratory social network analysis during the early phases of developing implementation infrastructure in Alberta, Canada. Specifically, we argue that exploratory social network analysis, when paired with follow-up qualitative interviews, can help identify local implementation science assets, inform network-building, and promote implementation support services to target users. Exploratory social network analysis helped our team identify key implementation researchers and implementation support practitioners in Alberta’s health-research ecosystem. The analysis also showed that implementation research in the province of Alberta follows a consultation model, with one-way assistance requests, while implementation practice is more collaborative in nature. The follow-up interviews provided an opportunity to engage with teams across the networks and allowed participants to contextualize the social network analysis findings. This uncovered: (1) widespread need for implementation science capacity-building, and (2) key implementation partnership considerations. These results illustrate how organizations can employ social network analysis in practical ways to inform implementation infrastructure development.

Background: Compared with implementation, the conceptual frameworks, strategies, and outcomes of efforts to disseminate behavioral interventions are less developed. We conducted a scoping review of the systematic reviews of social media strategies to disseminate behavior change interventions. We focused on the common themes in the methodology and evaluation frameworks of social media–based dissemination strategies. Objective: This scoping review aims to identify common themes in the design, delivery, and impact assessment of social media–based dissemination strategies for behavior change interventions. Methods: We searched the Epistemonikos database (until 2024) to retrieve systematic reviews on social media dissemination. A total of 2 independent reviewers screened the abstracts and full texts. We extracted and classified the data on the characteristics of the included reviews and outcome assessments. We followed the reflexive thematic analysis steps to identify the main themes of the ingredients of the social media dissemination strategies. Results: We screened 613 records based on the title and abstract, followed by the assessment of 100 full texts of potentially eligible reviews. The 43 included reviews assessed a median of 20 empirical studies (IQ range 21). The study designs, intervention strategies, and evaluation measures of social media dissemination interventions were diverse. We classified the main themes of the ingredients of social media dissemination strategies into 4 main categories: 1-way spread (aiming for spread and diffusion, with little or no effort to develop 2-way communications or engage target users in conversation and feedback; n=37), invoking conversations (facilitating and enhancing the 1-way spread using conversational and community features of social media to promote dialogue among users or between the users and experts; n=21), peer motivation (facilitate sharing individual behavior on social media to receive confirmation, feedback, and support, to further personalize the dissemination; n=11), and miscellaneous (eg, dissemination through online multiplayer games; n=3). The main outcomes of dissemination efforts were reach and engagement (n=12), user perception of their knowledge, intention to change the behavior, feasibility and acceptability of the intervention (n=24), and impact on health and health-related behaviors (n=43). The majority of theoretical frameworks that were identified by the reviews were individual and social behavior change models (including the theory of planned behavior and Social Cognitive Theories). A smaller number of reviews also identified social and contextual models (eg, Social Network Theory), dissemination and implementation frameworks (eg, Diffusion of Innovation), and social marketing and action models (eg, community mobilization and Reader-to-Leader framework). Conclusions: Researchers use various features of social media (eg, peer-to-peer sharing, online engagement in conversations, one-on-one, or with a broad audience), formation of clusters and communities, and peer feedback to complement and enhance the 1-way dissemination. Further research is needed to inform the theoretical underpinnings and the interventional ingredients of social media dissemination strategies.

Community Health Workers (CHWs) are members of healthcare teams that are integrated in, and often share language, beliefs, and lived experiences with their communities. They use their formal and informal social networks to promote healthy behavior, to connect community members to resources, and to build more resilient community networks. We propose a framework to conceptualize CHW interventions aiming to operationalize and optimize CHW social relations and networks. CHW-mediated network interventions can focus on the dissemination and diffusion of health messages, using the channels of trust and formal and informal relations, as well as, engaging communities to enhance the cascade of spreading/diffusion. Network interventions can also focus on network-building and community dialog, relying on the role of CHWs in bringing the community members together in facilitating conversation, promoting social justice and inclusion, and mobilizing the community in collective action. In addition, the network interventions can aim for boundary-spanning and bridging activities, to facilitate the community’s access to health services and external resources, as well as bringing the community voice to health systems to influence priorities and policies. Similar to any other complex interventions, CHW network interventions should be fine-tuned and adapted to local and community needs, capacities, and network structures, and actively involve community members in the conceptualization, delivery, and evaluation.