Longstanding variation in the views of family physicians (FPs) on the role of opioids seems to translate into widely varying prescribing rates. Improvement interventions are unlikely to achieve change if they do not understand and explicitly target the factors that determine physician prescribing behaviour. The aim of this work was to understand (1) the perspectives of FPs as it relates to opioid prescribing, and (2) the perceived barriers and enablers to guideline-adherent opioid prescribing and management of chronic non-cancer pain. A qualitative study involving one-on-one, semi-structured interviews with a sample of FPs in Ontario, Canada. Interviews were analyzed using a directed content analysis informed by the Theoretical Domains Framework. A framework approach was used to explore interaction across behavioural determinants (factors influencing behaviour) as well as demographic sources of variation. The behaviour of interest for the current study was the prescribing of opioid medications (including initiation, renewal, and dose reduction) for patients with chronic, non-cancer pain. Associated issues in the overall management of such patients were also explored. Interviews were conducted with 22 FPs. Behavioural determinants interacted with one another to influence FPs prescribing behavior. The TDF domain Beliefs about Consequences played a central role in explaining physician prescribing behaviours as they related to the management of chronic non-cancer pain. Individual beliefs about prescribing consequences and patient behaviour interacted with prescriber beliefs about capabilities and perceptions of the FP’s professional role to influence prescriber behaviour. Emotion and the environmental context influenced the impact of these determinants on opioid prescribing and the management of chronic non-cancer pain. FPs face a wide range of complex (and often interacting) challenges when prescribing opioid therapy to their patients. Solution-based strategies should target these determinants directly using evidence-based strategies that move beyond guideline dissemination and general education. Shared decision-making strategies and patient-facing decision aids are likely to decrease the tension experienced in challenging conversations.

Objective To explore values and preferences towards medical cannabis among people living with chronic pain. Design Mixed-methods systematic review. Data sources We searched MEDLINE, EMBASE and PsycINFO from inception to 17 March 2020. Study selection Pairs of reviewers independently screened search results and included quantitative, qualitative and mixed-methods studies reporting values and preferences towards medical cannabis among people living with chronic pain. Review methods We analysed data using meta-narrative synthesis (quantitative findings were qualitised) and tabulated review findings according to identified themes. We used the Grading of Recommendations Assessment, Development and Evaluation approach to assess certainty of evidence. Results Of 1838 initial records, 15 studies proved eligible for review. High to moderate certainty evidence showed that patient’s use of medical cannabis for chronic pain was influenced by both positive (eg, support from friends and family) and negative social factors (eg, stigma surrounding cannabis use). Most patients using medical cannabis favoured products with balanced ratios of tetrahydrocannabinol (THC) and cannabidiol (CBD), or high levels of CBD, but not high THC preparations. Many valued the effectiveness of medical cannabis for symptom management even when experiencing adverse events related to concentration, memory or fatigue. Reducing use of prescription medication was a motivating factor for use of medical cannabis, and concerns regarding addiction, losing control or acting strangely were disincentives. Out-of-pocket costs were a barrier, whereas legalisation of medical cannabis improved access and incentivised use. Low to very low certainty evidence suggested highly variable values towards medical cannabis among people living with chronic pain. Individuals with pain related to life-limiting disease were more willing to use medical cannabis, and preferred oral over inhaled administration. Conclusions Our findings highlight factors that clinicians should consider when discussing medical cannabis. The variability of patients’ values and preferences emphasise the need for shared decision making when considering medical cannabis for chronic pain.

PURPOSE We examined the perspectives of family physicians (FPs) on opioid prescribing and management of chronic pain to better understand the barriers to safer prescribing in primary care and differences in perspectives that may be potential drivers of practice variation. METHODS We used an exploratory qualitative study design. Semistructured interviews were conducted in June and July 2017 with 22 FPs in Ontario and coded inductively. Thematic analysis was used to identify themes, and a framework analysis explored the influence of physician demographics on prescribing experience. RESULTS Three key themes emerged: the discrepancy between FPs’ training and current practice, the tension between the FP’s role and patient and system expectations, and the influence of length of time in practice and strength of therapeutic relationships on perspectives on opioid prescribing. There was an overarching sentiment among participants that FPs are unsupported in their efforts to manage chronic pain. More years in practice (≥15 years) seems to influence practice patterns by increasing trust in therapeutic relationships and decreasing reliance on emergent guidelines (vs clinical experience). CONCLUSION Number of years in practice influences FPs’ response to emergent evidence, requiring initiatives to include strategies tailored to individual beliefs. Initiatives must move beyond dissemination and education to equip FPs with the skills they need to navigate emotionally charged conversations. External pressures and misaligned system and patient expectations place FPs at the center of a challenging situation, which may result in a higher risk of burnout compared with that of their specialist colleagues.

Background: Physical inactivity is associated with increased health risks. Primary care providers (PCPs) are well positioned to support increased physical activity (PA) levels through screening and provision of PA prescriptions. However, PCP counseling on PA is not common. Objective: This study aimed to assess the feasibility of implementing an electronic health (eHealth) tool to support PA counseling by PCPs and estimate intervention effectiveness on patients’ PA levels. Methods: A pragmatic pilot study was conducted using a stepped wedge cluster randomized trial design. The study was conducted at a single primary care clinic, with 4 pre-existing PCP teams. Adult patients who had a periodic health review (PHR) scheduled during the study period were invited to participate. The eHealth tool involved an electronic survey sent to participants before their PHR via an email or a tablet; data were used to automatically produce tailored resources and a PA prescription in the electronic medical record of participants in the intervention arm. Participants assigned to the control arm received usual care from their PCP. Feasibility was assessed by the proportion of completed surveys and patient-reported acceptability and fidelity measures. The primary effectiveness outcome was patient-reported PA at 4 months post-PHR, measured as metabolic equivalent of task (MET) minutes per week. Secondary outcomes assessed determinants of PA, including self-efficacy and intention to change based on the Health Action Process Approach behavior change theory. Results: A total of 1028 patients receiving care from 34 PCPs were invited to participate and 530 (51.55%) consented (intervention [n=296] and control [n=234]). Of the participants who completed a process evaluation, almost half (88/178, 49.4%) stated they received a PA prescription, with only 42 receiving the full intervention including tailored resources from their PCP. A cluster-level linear regression analysis yielded a non–statistically significant positive difference in MET-minutes reported per week at follow-up between intervention and control conditions (mean difference 1027; 95% CI −155 to 2209; P=.09). No statistically significant differences were observed for secondary outcomes. Conclusions: Our results suggest that it is feasible to build an eHealth tool that screens and provides tailored resources for PA in a primary care setting but suboptimal intervention fidelity suggests greater work must be done to address PCP barriers to resource distribution. Participant responses to the primary effectiveness outcome (MET-minutes) were highly variable, reflecting a need for more robust measures of PA in future trials to address limitations in patient-reported data. Trial Registration: ClinicalTrials.gov NCT03181295; https://clinicaltrials.gov/ct2/show/NCT03181295

Background: Workers supporting adults with intellectual disabilities (ID) experience significant stress in their essential role during COVID‐19 due to the high risk of their clients contracting COVID‐19 and having adverse outcomes. The purpose of the current study was to describe the attitudes of workers towards COVID‐19 vaccination prior to vaccination rollout, with a view to informing strategies to promote vaccine uptake within this high‐risk sector.Methods: An online survey was sent via email to workers supporting adults with ID in Ontario, Canada, between January 21 and February 3, 2021 by agency leadership and union representatives.Results: Three thousand and three hundred and seventy‐one workers, representing approximately 11.2% of Ontario workers supporting adults with ID completed an online survey. Most reported that they were very likely (62%) or likely (20%) to get a COVID‐19 vaccine (vaccination intent) although 18% reported they were less likely to do so (vaccination nonintent). Workers with vaccination nonintent were younger and were more likely to endorse the beliefs that (1) it will not benefit them or those around them, (2) it was not part of their job, (3) rapid development confers uncertainties and risks, and (4) they were scared of potential vaccine side effects.Conclusions: There is need to address common misconceptions among workers supporting adults with ID to help activate them as vaccine advocates in the communities they serve. Partnered efforts between workers, unions and agency leadership with public health experts to address concerns are required.

Task shifting interventions have been implemented to improve health and address health inequities. Little is known about how inequity and vulnerability are defined and measured in research on task shifting. We conducted a systematic review to identify how inequity and vulnerability are identified, defined and measured in task shifting research from high-income countries. We implemented a novel search process to identify programs of research concerning task shifting interventions in high-income countries. We searched MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and CENTRAL to identify articles published from 2004 to 2016. Each program of research incorporated a "parent" randomized trial and "child" publications or sub-studies arising from the same research group. Two investigators extracted (1) study details, (2) definitions and measures of health equity or population vulnerability, and (3) assessed the quality of the reporting and measurement of health equity and vulnerability using a five-point scale developed for this study. We summarized the findings using a narrative approach. Fifteen programs of research met inclusion criteria, involving 15 parent randomized trials and 62 child publications. Included programs of research were all undertaken in the United States, among Hispanic- (5/15), African- (2/15), and Korean-Americans (1/15), and low socioeconomic status (2/15), rural (2/15) and older adult populations (2/15). Task shifting interventions included community health workers, peers, and a variety of other non-professional and lay workers to address a range of non-communicable diseases. Some research provided robust analyses of the affected populations' health inequities and demonstrated how a task shifting intervention redressed those concerns. Other studies provided no such definitions and measured only biomedical endpoints. Included studies vary substantially in the definition and measurement of health inequity and vulnerability. A more precise theoretical and evaluative framework for task shifting is recommended to effectively achieve the goal of equitable health.