145 Barriers to and enablers of the use of the Otology Questionnaire Amsterdam in clinical practice 7 Implementation strategy The key barriers and enablers were mapped to their corresponding intervention functions and policy categories of the BCW (Additional online file S3) and can be found in Table 8 and 9. The BCT were used as examples for determining the content of the interventions. Implementation strategy should focus on education and training about the objective, outcomes and relevance of the OQUA, environmental restructuring regarding the optimal use of the OQUA, and incentivisation with feedback on the valuable outcomes of the OQUA for the patient, professional and healthcare. Discussion The application of the implementation strategy approach may contribute to enhancing the uptake of the OQUA in clinical practice. This study provides a foundation for developing interventions aimed at overcoming barriers and/or strengthening enablers, in order to realize the potential benefits of the OQUA on patient-centred care within otology practice. The findings in our study are consistent with the most reported barriers in the literature3,6,12,13, which supports our hypothesis. Several studies reported the insufficient knowledge of individual clinicians about PROMs as an influential barrier6,12,13 as it can affect their ability to interpret scores and their confidence in skills to use PROMS in clinical decisions.21-23 In addition, it is recognized that if PROMS are not considered useful in the clinical decision-making process, this may further limit their implementation.13 In the case of the OQUA, ENT professionals received very little information before, during or after implementation about the content, objectives and outcomes. In addition, no information was available as a reference guide to facilitate the use and interpretation of the OQUA. Previous studies have captured the technological barriers of PROMs, which mainly referred to the limited integration, accessibility and visibility of PROMs in the electronic patient record3,9,24. These barriers are in line with the reported problems in our study and can be explained by the lack of availability of user-friendly and reliable software and hardware for PROM integration12. The technological limitations appear to have a significant impact on the effectiveness of the uptake of PROMs into clinical practice.25 Studies have suggested that the scepticism about the usefulness may be caused by the professionals’ lack of awareness and understanding of the value of PROMs for
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