Fourteen individuals were initially invited to participate; one was unavailable to be interviewed, and one did not respond to correspondence. Of the 12 individuals that participated, eight reported substantial review of the iGeriCare intervention prior to being interviewed, while four reported little-to-no review. Participants had the following disciplines/specialty roles: family medicine (3), geriatrics (3), nursing (2), neurology (1), geriatric psychiatry (1), general internal medicine (1), and social science (1); nine participants were physicians. We tried to engage regional opinion leaders; nine participants were affiliated with the host institution, McMaster University, while three participants were from other institutions/organizations. We present key findings within each of the five CFIR domains and the relevant constructs within each.
Intervention characteristics refers to specific characteristics of iGeriCare.(20)
iGeriCare was generally perceived as a high-quality, trusted intervention for caregiver education, with many participants highlighting the relative advantage of a web-based format.
The ‘design, quality and packaging’ of iGeriCare was perceived by many participants as being expertly bundled, presented, and assembled, noting that it was a resource that was ‘trusted’ and ‘valuable’.
I really like this, partly because it’s knowledge that has been vetted, so it’s not the same as googling dementia and you really can’t control what comes up and what doesn’t. So, I like the fact that it’s summarized it’s at a level where it is easily digestible, and it’s not something that is difficult for family members. (Participant 001)
It’s a very nice-looking website… from what I’ve seen it’s very comprehensive. I mean like, you’re hitting caregiver wellness, you’re hitting apathy, you’re hitting driving – you know, you’re hitting promotion of brain health. I mean, it seems like, I don’t see any gaps just from a superficial look at it. It looks like it’s gone through multiple passes and stuff. It looks very polished. It seems to me that a lot of work has gone into it. (Participant 006)
‘Relative advantage’ refers to the participants’ perception of the advantage of implementing iGeriCare versus an alternative solution. Most participants perceived the online format and increased ease of access to facilitate dementia education for a wider caregiver audience as a ‘relative advantage’ when compared with traditional current practice or formats.
I think with the videos and that sort of thing [iGeriCare] is a much better alternative. It’s something that allows them to sit and watch and say, ‘oh that’s a digestible portion of information that I can take.’ (Participant 001)
I think it is important. We can’t possibly educate everybody about all of this in the context of clinic, nor does it always feel like the right place for it. People just sometimes need to learn on their own at home, and then come back with questions once they’ve had a chance to be exposed to it. (Participant 002)
The hundreds of people that I’ve heard say in an education series, ‘I wish my brothers were here’, or ‘I wish my father would have joined me.’ And they’re not coming through our door, and they’re not going to their local chapter, or if they live in another part of the province – that they can access [iGeriCare]. (Participant 011)
A few participants did, however, voice concerns about the format, noting that much of their current caregiver education was delivered with more traditional approaches such as face-to-face delivery or printed pamphlets. Additionally, there remains a perception that older adults do not use the internet or search online for information.
Many of the older persons that we deal with are either not really that computer-savvy, maybe they spend a little bit of time on the internet and might play some games on their computer, but many of them don’t use it to search for information. I think that’s a younger generation kind of thing. (Participant 007)
Theme 2: iGeriCare is perceived as being readily usable, with minimal disruption to existing workflows, and can be customized or revised as needed.
The iGeriCare intervention was seen to have minimal barriers to immediate implementation; aligning with the CFIR construct of ‘trialability’.
It will be helpful …I can see us having it up during our memory clinic. (Participant 002)
I am thrilled, this is really phenomenal, I’m going to immediately start using this. (Participant 006)
We’re already using it. We have the [iGeriCare educational prescription pad], and I give it to families as I’m talking about supports (Participant 008)
The overall construct of ‘intervention characteristics’ was perceived positively by the majority of participants.
The outer setting is the economic, political, and social context within which an organization resides.(20) It influences implementation and is often mediated through changes in the inner setting.
Theme 1: iGeriCare was seen to meet patient needs, due to its alternative format, and in part because the flexibility of web-based learning ‘on demand’ helps to overcome the time constraints that are barriers for both clinicians and caregivers.
The ‘patient needs and resources’ construct identifies the extent to which organizations understand the barriers and facilitators to meeting patient needs, as well as their ability to prioritize those needs.(20) Patient needs were identified as an important outer setting construct that could drive demand for services and facilitate participants’ support for implementing the intervention.
[Education] is a lot of ‘here are some pamphlets’, and it’s a lot of relying on the caregiver or on the person who may have an MCI [Mild Cognitive Impairment] diagnosis to go on and sort of read for themselves. So, it can be a little overwhelming … it’s a lot of text and sometimes you can get overwhelmed … by the end of that hour and a half both of them are tired right, and so something like this [iGeriCare] is great to say ‘here, you don’t need to try to remember everything I said, I really think you should read this and this, and when I see you again in 6 months, we can answer any questions’. (Participant 001)
I definitely think that there’s obviously a need. Some people don’t like to go to a [location] to be with other caregivers, that’s not how they learn. (Participant 008)
As noted above, patient/caregiver needs were seen to be met through the increased ease of access for a wider audience than traditional education practices currently in place. Healthcare provider participants highlighted the importance of having alternative resources available for delivery to their patients and families.
The inner setting refers to the provider’s specific practice setting, and includes features of structural, political, and cultural contexts through which the implementation process will proceed.(20) Our specific cohort of participants were selected because they were leaders and decision-makers in their healthcare settings and could provide insight into existing workflows.
Theme 1: The majority of participants saw the iGeriCare intervention as a good fit with their existing workflows. Conversely, a few participants expressed concerns about implementation within their practice settings and existing workflows.
Many participants outlined that iGeriCare is presently being used or could easily be implemented due to its ‘compatibility’ and ‘relative priority’. ‘Relative priority’ refers to the individual perception of the importance of implementation within an organization.(20)
I think that it would definitely streamline my practice. Because I know that it’s one resource that I can trust, and I don’t need to be looking for. (Participant 001)
If I have a patient with dementia and I meet with the family I would say, ‘there’s a nice program [iGeriCare] that you could look at, go look at it and then when you come back to see me, later on, we can go over things that you don’t understand’. (Participant 012)
‘Implementation climate’ identifies the stage of change an organization is in, how receptive individuals are to an intervention, and the extent to which it will be supported in the organization.(20) Within this construct, some participants identified barriers to implementation of web-based education due to their current practices or concerns regarding caregiver demographics.
I give my overall framework for the patient, I then give them this Alzheimer’s Society pack, with lots of information…and I give them a referral sheet. (Participant 003)
I think we do a lot of that already via other ways, and I think that for the right person, I could see perhaps if it were a younger caregiver who was looking for more detailed information, perhaps that might be something we might include – but I don’t think I would. (Participant 007)
Characteristics of Individuals
Characteristics of individuals includes aspects that impact individuals involved with the intervention and/or implementation process.(20)
Theme 1: Many participants were familiar with the intervention and felt confident in their ability to implement iGeriCare.
‘Knowledge and beliefs about the intervention’ refers to the participants’ attitudes toward and value placed on the intervention as well as familiarity with facts, truths, and principles related to it.(20) Our findings showed that those individuals who had taken the time to review iGeriCare were more positively predisposed toward it and placed a higher value on the intervention than those who were less familiar with it.
I thought it was high quality, overall very useful. (Participant 004; substantial review of the intervention)
It would certainly fit with the National Dementia Strategy (Participant 010; substantial review of the intervention)
I think it’s great that people can go on, listen again to a session that they might have already done, share it with family and friends so there’s consistency in, you know, messaging. We want to get everyone within a family network or small community on the same page if you will. (Participant 011; substantial review of the intervention)
Theme 2: The relationship of the participants to the iGeriCare developers’ institution impacted on their degree of commitment to the intervention.
Participants did not specifically reference ‘individual identification with the organization’, a broad construct related to how individuals perceive the organization and their degree of commitment to it.(20) Rather, this was expressed as a sense of pride in their organization’s current educational practices. Individuals who more clearly identified with the organizations of the developers of the intervention were more positively predisposed to the intervention and its implementation. Individuals who did not clearly identify with the organizations of the developers were less predisposed to the intervention and its implementation.
Successful ‘implementation process’ typically requires an active change process aimed to achieve individual and organization level use of the intervention as designed.(20)
Theme 1: Most participants felt that they could implement iGeriCare through the use of collateral promotional materials or by sharing the website URL.
Most participants were confident in their abilities to implement iGeriCare according to plan, which aligns with the CFIR construct of ‘executing’. Participants commented on the need to give something to families to go home with and praised the pre-existing iGeriCare promotional materials that are available.
I think the only way that I can easily pass this information on to patients and their families is if I had something in my hand that I could give them to go away with. Whether it’s a card or a link to a website something that can say ‘I can vouch for this, this is a good resource I need you to look at this’. (Participant 002)
This is great [iGeriCare educational prescription pad], this is so easy you know it’s something that can be ready to pull out for every patient. (Participant 004)
Although most participants felt that they could easily implement iGeriCare, one barrier identified was the need for a constant reminder about the resource to keep it front and centre with the organizations and individuals.
In primary care there are barriers to any new resource or any new community program and the biggest one is just the ‘noise’- the sheer number and volume of programs and tools and resources that are coming at us. (Participant 002)
Theme 2: Participants suggested several strategies to continue engaging stakeholders, including finding ‘champions’, engaging others in the circle of care, presenting at medical conferences, and incorporating the resource into various health professions’ curricula.
Participants commented on the importance of attracting and involving appropriate individuals in the implementation and use of the intervention through a combined strategy of social marketing, education, role modeling, training, and other similar activities, which aligns with the CFIR construct of ‘engaging’.
I do think it requires someone that is a champion that can bring it in and talk to the benefits of it. And I think when people kind of see how this can match their learning gaps or their knowledge gaps then that’s when you are going to get it to pick up for that. (Participant 001)
That might be something good to send back to the family doctor to say, ‘look I’ve recommended these things for your families and I think that they many actually come to talk about. Just so you know these are the resources,’ and to have that, so the family doctors are aware of, ‘maybe I should take a quick look at what’s gone on,’ and things like that. (Participant 001)
It might help with Alzheimer Society’s or First Links navigators, where a lot of this one to one peer education may be saved by helping people go through this, but I think it could certainly augment the care that’s being provided and it might help provide again support that actually might save some of the [the time of ]allied health staff] (Participant 003)
What about the family docs, are you going to be explaining it to them? That’s where the patients really are … (Participant 012)
In addition to the above identified barriers and facilitators related to implementation of iGeriCare within existing clinical workflows, we also discovered insights into implementation of web-based education more broadly. Participant-identified barriers and facilitators related to implementation of web-based educational interventions for caregivers related to CFIR constructs are summarized in Table 1.
Participant-identified barriers and facilitators related to implementation of web-based educational interventions for caregivers (to be inserted on page 19; line 416 above ‘Discussion’)
The design quality of the intervention in part because of its simplistic layout, large icons, minimal effort.
Skepticism about the relative advantage of web-based nature of intervention.
The intervention is easily implemented into everyday workflows, allows for healthcare providers to trial with users before committing.
The intervention source being seen as externally developed.
The format of the intervention being web-based is variably perceived as both a facilitator and a barrier. Tension between healthcare providers as some have positive opinions of the web-based format, and others would not recommend due to concerns that the format might not be useful for some caregivers.
The content and format are perceived to be aligned with caregiver needs.
The lack of language, cultural adaptations, and alternative formats (i.e. print).
Some networking with other external organizations (i.e. Alzheimer Society, hospitals, memory clinics, Family Health Teams).
A lack of external policy and incentives to encourage adoption.
The intervention easily fits into and is compatible with existing workflows.
Healthcare providers concerns over the amount of time it would take to review materials prior to recommending to patients and families. Lack of integration with Electronic Medical Record (EMR).
Some settings have a higher relative priority than others for implementation.
Lack of tension for change.
Access to knowledge and information.
Lack of organizational incentives and rewards.
Characteristics of Individuals
Level of knowledge about the intervention.
Identification with the developer organization.
Identification with an external organization.
Technophobe and/or assumes older adults do not use the Internet.
Ease and enthusiasm to ‘execute’.
Needs ongoing ‘campaigns’ to maintain awareness of resource.
Needs constant reminders.
Existing promotional materials
Costs of promotional materials.
Existing champions and opinion leaders.
Costs of attending conferences and/or identifying and promoting resource to new champions.