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Table 3 Barriers identified to the implementation and strategies employed to address them

From: Developing an implementation strategy for a digital health intervention: an example in routine healthcare

Barrier Strategy to address barrier Strategies operationalised for HeLP-Diabetes
Collective action (contextual integration)
 Staff unwilling or unable to provide the resources to implement the facilitation aspect of the registration process (see Table 1). Tailored intervention For practice who identified a lack of resources to implement HeLP-Diabetes a streamlined process which removed the facilitation aspect was offered. of the process.
 Even after removal of facilitation aspect some practices still couldn’t find resources to register patients Tailored intervention Alternative patient registration methods including patient self-registration and peer supported were offered to practices.
Collective action (Skill Set Workability)
 Nurses, who had originally been targeted to deliver the intervention, felt that the using a digital intervention underutilized their own knowledge about diabetes. Health Care Assistants with additional knowledge. Tailored intervention Health Care Assistants were targeted to deliver the as they were often younger, IT literate, keen to help patients, but knew there were limitations to their diabetes knowledge that the intervention could help provide them.
Cognitive participation
 Some staff reported not remembering or having other competing priorities which prevented HeLP-Diabetes being offered to patients. Reminders To keep the new way of working in view and connect it to the people who needed to be doing the work, HeLP-Diabetes was integrated within practice templates which prompted staff during appointments with patients with T2DM to mention HeLP-Diabetes and provide a leaflet.
Collective action (relational integration)
 Some staff were unaware of HeLP-Diabetes within practices where adoption had been agreed. This was often due to teams not communicating about HeLP-Diabetes or in several cases because those who made adoption decisions (usually GPs) were not the ones tasked with implementing it. Educational meetings and materials To increase the visibility of HeLP-Diabetes additional staff focussed advertising was introduced including exhibition stalls, talks and demonstrations at staff education events. HeLP-Diabetes was also frequently advertised in the CCG’s bulletin to GPs. HeLP-Diabetes was also included by the CCG as one of their Locally Enhanced Services and added to the Map of Medicine system used by GP practices in the CCG.
Reflexive monitoring impacting on interactional workability
 Staff suggested that they would offer HeLP-Diabetes to patients more if they were receiving more requests or enquiries from patients about it. Patient-mediated interventions Additional patient focussed advertising strategies were introduced to promote HeLP-Diabetes to increase the requests/enquiries from patients about HeLP-Diabetes. These included TV screen adverts in waiting rooms, talks given at patient self-management groups, attendance at Diabetes UK events, coverage in Practice newsletters and a mass mail out to all patients in some practices.