Applied Science, Faculty of
Medicine, Faculty of
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Family Practice, Department of
Nursing, School of
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Pilot and Feasibility Studies. 2019 Nov 08;5(1):126
The Author(s).
Devane, Courtney
Renner, Regina M
Munro, Sarah
Guilbert, Édith
Dunn, Sheila
Wagner, Marie-Soleil
Norman, Wendy V
Background: Direct primary care provision of first-trimester medical abortion could potentially address inequitable abortion access in Canada. However, when Health Canada approved the combination medication Mifegymiso® (mifepristone 200 mg/misoprostol 800 mcg) for medical abortion in July 2015, we hypothesized that the restrictions to distribution, prescribing, and dispensing would impede the uptake of this evidence-based innovation in primary care. We developed and pilot-tested a survey related to policy and practice facilitators and barriers to assess successful initiation and ongoing clinical provision of medical abortion service by physicians undertaking mifepristone training. Additionally, we explored expert, stakeholder, and physician perceptions of the impact of facilitators and barriers on abortion services throughout Canada. Methods: In phase 1, we developed a survey using 2 theoretical frameworks: Greenhalgh’s conceptual model for the Diffusion of Innovations in health service organizations (which we operationalized) and Godin’s framework to assess the impact of professional development on the uptake of new practices operationalized in Légaré’s validated questionnaire. We finalized questions in phase 2 using the modified Delphi methodology. The survey was then tested by an expert panel of 25 nationally representative physician participants and 4 clinical content experts. Qualitative analysis of transcripts enriched and validated the content by identifying these potential barriers: physicians dispensing the medication, mandatory training to become a prescriber, burdens for patients, lack of remuneration for mifepristone provision, and services available in my community. To assess the usability and reliability of the online survey, in phase 3, we pilot-tested the survey for feasibility. Results: We developed and tested a 61-item Mifepristone Implementation Survey suitable to study the facilitators and barriers to implementation of mifepristone first-trimester medical abortion practice by physicians in Canada. Conclusions: Our team operationalized Greenhalgh’s theoretical framework for Diffusion of Innovations in health systems to explore factors influencing the implementation of first-trimester medical abortion provision. This process may be useful for those evaluating other health system innovations. Identification of facilitators and barriers to implementation of mifepristone practice in Canada and knowledge translation has the potential to inform regulatory and health system changes to support and scale up facilitators and mitigate barriers to equitable medical abortion provision.
RESEARCH Open AccessImplementation of mifepristone medicalabortion in Canada: pilot and feasibilitytesting of a survey to assess facilitators andbarriersCourtney Devane1,2, Regina M. Renner1,3, Sarah Munro1,3, Édith Guilbert1,4, Sheila Dunn1,5,Marie-Soleil Wagner1,6 and Wendy V. Norman1,3,7,8*AbstractBackground: Direct primary care provision of first-trimester medical abortion could potentially address inequitableabortion access in Canada. However, when Health Canada approved the combination medication Mifegymiso®(mifepristone 200 mg/misoprostol 800 mcg) for medical abortion in July 2015, we hypothesized that the restrictionsto distribution, prescribing, and dispensing would impede the uptake of this evidence-based innovation in primarycare. We developed and pilot-tested a survey related to policy and practice facilitators and barriers to assesssuccessful initiation and ongoing clinical provision of medical abortion service by physicians undertakingmifepristone training. Additionally, we explored expert, stakeholder, and physician perceptions of the impact offacilitators and barriers on abortion services throughout Canada.Methods: In phase 1, we developed a survey using 2 theoretical frameworks: Greenhalgh’s conceptual model forthe Diffusion of Innovations in health service organizations (which we operationalized) and Godin’s framework toassess the impact of professional development on the uptake of new practices operationalized in Légaré’s validatedquestionnaire. We finalized questions in phase 2 using the modified Delphi methodology. The survey was thentested by an expert panel of 25 nationally representative physician participants and 4 clinical content experts.Qualitative analysis of transcripts enriched and validated the content by identifying these potential barriers:physicians dispensing the medication, mandatory training to become a prescriber, burdens for patients, lack ofremuneration for mifepristone provision, and services available in my community. To assess the usability andreliability of the online survey, in phase 3, we pilot-tested the survey for feasibility.Results: We developed and tested a 61-item Mifepristone Implementation Survey suitable to study the facilitatorsand barriers to implementation of mifepristone first-trimester medical abortion practice by physicians in Canada.(Continued on next page)© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.* Correspondence: wendy.norman@ubc.ca1Contraception and Abortion Research Team, Women’s Health ResearchInstitute, BC Women’s Hospital and Health Center, Vancouver, BC, Canada3Faculty of Medicine, University of British Columbia, Vancouver, BC, CanadaFull list of author information is available at the end of the articleDevane et al. Pilot and Feasibility Studies (2019) 5:126 https://doi.org/10.1186/s40814-019-0520-8(Continued from previous page)Conclusions: Our team operationalized Greenhalgh’s theoretical framework for Diffusion of Innovations in healthsystems to explore factors influencing the implementation of first-trimester medical abortion provision. This processmay be useful for those evaluating other health system innovations. Identification of facilitators and barriers toimplementation of mifepristone practice in Canada and knowledge translation has the potential to informregulatory and health system changes to support and scale up facilitators and mitigate barriers to equitablemedical abortion provision.Keywords: Mifepristone, Canada, Abortion, Survey, Family planning, Family physician, Delphi approach, Diffusion ofInnovation, Implementation scienceBackgroundAbortion health services are safe, common, and legal inCanada [1]. The rate of induced abortion is approxi-mately 14–15/1000 females aged 15–44, annually [2, 3].In Canada, abortion is a publicly funded service. Abor-tion services are accessed in Canada either by self-referral to an abortion/reproductive health care facilityor through a referral from their family physician to anabortion provider [4, 5]. In 2016, surgical terminationsrepresented 94.7% of all first-trimester abortions acrossthe country [2]. In Canada, geography is a significantbarrier to accessing abortion facilities; for example, inthe province of British Columbia, 90% of all abortionsare provided in large urban cities, despite the fact that43% of reproductive-aged women live outside thesemetropolitan areas [6]. Having abortion services limitedto urban centers significantly impacts access to care foralmost half of the population of reproductive-agedwomen in Canada [4].One solution to increase equity in access to abortion isthrough the provision of first-trimester medical abortionin primary care settings. In 2005, the World HealthOrganization (WHO) added mifepristone (RU 486) totheir list of essential medications, naming mifepristonethe gold standard for first-trimester medical abortioncare [7]. In high-income countries, the implementationof mifepristone has been associated with an increase inthe proportion of abortions performed as medical abor-tions [8–11]. However, rates of mifepristone implemen-tation have differed greatly internationally [9, 10, 12–14].Emerging evidence from Australia and the USA sug-gests that variations in access to mifepristone may bedue to the differences in health systems, provider train-ing and supports, financial barriers, and legal restrictions[15–17]. For example, in the USA, mifepristone may bedispensed only by the prescriber and not by a pharma-cist. Ten years after the introduction of mifepristone inthe USA, first-trimester medical abortions only repre-sented 36% of all abortions compared to over 80% offirst-trimester abortions in many European countries[10, 18]. Furthermore, in Australia, where pharmacistsmay dispense mifepristone, women must pay $560 AUDupfront and attend a mandatory follow-up visit 1 weeklater [17], and abortion remains legally restricted or pro-hibited in some jurisdictions [19–21].In July 2015, Health Canada approved Mifegymiso® (acombination product containing mifepristone 200 mgand misoprostol 800 mcg) for medical abortion, makingCanada the 63rd country to approve the medicationsince 1988 [22, 23]. In 2016, the Society of Obstetriciansand Gynecologists (SOGC) published new Canadianclinical practice guidelines for medical abortion [24],prior to commercial availability of the product. However,the initial approval of mifepristone in Canada stipulatedrestrictive constraints that did not conform with theclinical guidelines or usual clinical practice includingdistribution of the medication only directly to physiciansand pharmacists who had completed a certified trainingprogram and registered with the licensed distributor,prescribing and dispensing limited to these certified phy-sicians, ultrasound required for gestational dating priorto administration, physician observation of patient inges-tion of mifepristone, and use up to only 49 days gesta-tional age [22]. These stipulations were not consistentwith the extensive evidence on safety and effectivenessfor this medication. Family planning experts deemed therestrictions unnecessary [24, 25].We hypothesized that these federal regulations wouldrestrict patient access by impeding the uptake of mife-pristone abortion practice, particularly for those profes-sionals working in primary care, such as familyphysicians who are not primarily abortion providers,pharmacists, nurse practitioners, and midwives who havea critical role to play in expanding access to abortionservices beyond large urban settings. We were unable toidentify a survey instrument that comprehensively ex-plored factors influencing the implementation of medicalabortion practice. Prior to January 2017 when mifepris-tone became available in the Canadian market, we devel-oped and pilot-tested a survey to investigate healthpolicy, health system, and health care delivery factorsthat influenced the uptake and implementation processfor mifepristone first-trimester medical abortion prac-tice. Our objectives were to develop a survey instrumentDevane et al. Pilot and Feasibility Studies (2019) 5:126 Page 2 of 14informed by a theoretical framework (phase 1), validatethe survey content using qualitative group interview data(phase 2), and pilot test the usability and readability ofthe survey in an online format for feasibility (phase 3).Our goal was to understand how policy and practicecharacteristics relate to access to abortion servicesthroughout Canada.MethodsWe conducted this Mifepristone Survey DevelopmentStudy as one component of our larger mixed-methodsstudy, Mifepristone Implementation Research in Canada[26]. This comprehensive study examines the health pol-icy, system, and service facilitators and barriers affectingthe initiation and ongoing provision of medical abortionservices in Canada [26]. Our data collection for themixed methods study includes the following: (A) surveyswith pharmacists and prescribers at baseline, 6 monthsand 1 year following the introduction of mifepristonemedical abortion to their practice; (B) interviews withpharmacists and prescribers; (C) interviews with policyand health system stakeholders; (D) creation of an onlinecommunity of practice platform to detect and supportpolicy, system, and practice challenges; and (E) theevaluation of continuous integrated knowledge transla-tion with health policy, system, and service decision-makers and health professional organizations (i.e., co-production of evidence by researchers and decision-makers). In this paper, we report the developmentprocess for the prescriber’s survey (data collectionmethod “A”).Our survey development process involved three phasesthat occurred between July 2015 and January 2017: (1)development of preliminary survey items [group I], (2)content validation via a modified Delphi process with apanel of physician experts [group II], and (3) pilot test-ing of the draft survey for reliability and usability in anonline format [group III]. In phase 2, the panel of phys-ician experts also provided their perceptions of the im-pact of facilitators and barriers on abortion servicesthroughout Canada which further informed the contentwe aimed to cover in our survey instrument. This studywas conducted by the members of the Contraceptionand Abortion Research Team—Groupe de recherche surl’avortement et la contraception (CART-GRAC), a na-tional, interdisciplinary, cross-sectoral collaboration en-gaging in research to support the provision of healthservices and implementation of policies that ensureequitable access to high-quality family planning know-ledge, methods, and services for women and familiesthroughout Canada [27]. Ethics approval for this studywas obtained from the University of British ColumbiaChildren’s and Women’s Hospital Research Ethics Boardfor research involving human subjects (H15-03207).Phase 1: Development of preliminary survey itemsThe development of the survey question constructs wasguided by two conceptual frameworks: (1) Roger’s Theoryof the Diffusion of Innovation as conceptualized byGreenhalgh et al. [28], which describes the determinantsfor implementation of innovations in health service de-livery and has been used previously in Canada to under-stand the implementation of task-shifting contraceptivecare from physicians to nurses [29]; (2) Godin framework[30], which integrates the Theory of Planned Behavior[31] and Triandis’ Theory [32] to predict an individual’sintention and uptake of clinical behavior. Greenhalgh’sframework posits that the interaction between theinnovation, the intended adopter(s), and a particularcontext influences diffusion, dissemination, and imple-mentation. The Greenhalgh framework consists of nineconstructs: characteristics of the innovation and adopter,methods of diffusion and dissemination (e.g., communi-cation and influence), system antecedents and readiness,outer context (e.g., external influences), resource systemsand change agents (e.g., administrators, public healthagents, public advocates), and the role of these con-structs in facilitating the implementation process [28].Légaré’s validated instrument [33] is based on the Godinframework [30] and assesses the impact of professionaldevelopment on the uptake of new practice by measur-ing the following constructs: belief about capabilities, so-cial influences, and beliefs about consequences, moralnorms, and intentions. This framework has good appli-cation to practice in the abortion context, where roleidentity, moral norm, and social factors could have astrong influence on behavior. Figure 1 identifies theseconstructs and the dimensions by which each constructcan be evaluated for the innovation’s adoption withinthe health system. Because mifepristone is a new ap-proach to medical abortion services in a Canadiancontext, Godin and Greenhalgh’s frameworks fit concep-tually with the goals of our survey.Based on the conceptual frameworks above and previ-ous work [34, 35], in October 2015, 4 of our clinician-researchers who are experts in abortion care (group I:RR, WVN, SD, EG) created a survey instrument with 47baseline questions and 21 follow-up questions. The ques-tions were developed to assess facilitators and barriers tothe adoption of mifepristone into practice as well as theimpact of mandatory training on the practice of mifepris-tone medical abortion. This occurred prior to the January2017 market availability of mifepristone. The clinician-researchers identified key questions in a recursive fashionuntil consensus was reached. Constructs were restrictedbased on the relevance to abortion practice in Canada.The divisions of questions among Greenhalgh’s domainswere as follows: Outer Context (n = 11), System Anteced-ents for Innovation (n = 6), Characteristics of theDevane et al. Pilot and Feasibility Studies (2019) 5:126 Page 3 of 14Innovation (n = 10), System Readiness for Innovation (n =7, including 3 “matrix-style” questions with 32 responseboxes combined), Adopter/Assimilation (n = 6), and Com-munication and Influence (n = 11) plus 15 demographicquestions and 2 open-ended questions. An example ofhow questions were mapped to each domain of Green-halgh’s conceptual framework is depicted in Table 1. TwoGreenhalgh domains, Characteristics of the Innovationand Outer Context, include stigma and harassment. Ques-tions exploring physician attitudes toward and experienceswith abortion, including stigma and harassment, weremeasured using the validated instrument developed byHarris et al. [36, 37]. The clinician-researchers chose notto include questions pertaining to Greenhalgh’s domain“Implementation” at baseline and opted to explore thisconstruct in 6-month and 12-month follow-up surveys.Phase 2: Content validationParticipantsPhysician experts in sexual and reproductive health[group II] were invited to participate in group interviewsto examine face and content validity of the first versionof the survey instrument developed by group I, using amodified Delphi method [38]. Group interviews tookplace over a 5-week period in January and February2016. Criteria for inclusion were holding a current pro-fessional license to practice as a physician in at least oneCanadian jurisdiction and willingness to participate.Emailed invitations were circulated via professional sex-ual and reproductive health care networks, among physi-cians who were current abortion providers and alsoamong primary care and specialist physicians known tobe involved in women’s reproductive health care whomight consider providing abortion in their practice. Afollow-up email was sent out 7 to 10 days after the firstcontact. Panelists in group II were encouraged to inviteeligible colleagues to participate through a snowballsampling approach. We received 28 replies, and eachparticipant received a copy of the consent form in ad-vance and had at least 1 week to decide if they wished toparticipate. There were 3 panelists who were unable toattend in-person or through teleconferencing. Each ofthe 25 final panelists received a $200 honorarium fortheir 2.5 h of time.Data collectionThe Delphi method is a process that structures commu-nication among large groups of individuals to collectivelyobtain an expert opinion for a valid and useful result[39]. The Delphi approach is used widely in researchwhere the research problem “does not lend itself to pre-cise analytical techniques but can benefit from subjectivejudgments on a collective basis” [40]. This approach en-abled us to involve a representative panel of expertabortion practitioners, non-provider physicians, andphysician-researchers from across the country, stratifiedby province, to discuss and validate the preliminary sur-vey questions. The Mifegymiso® product label and asso-ciated regulations were publicly available, but not widelydisseminated as the product was not yet on the market.Thus, prior to focus group data collection, panelists hadminimal knowledge of how mifepristone was likely to beimplemented in Canada.Fig. 1 A conceptual model of diffusion of innovations in health service delivery and organizations, adapted from Greenhalgh et al. [28]Devane et al. Pilot and Feasibility Studies (2019) 5:126 Page 4 of 14A distinct characteristic of the Delphi method is thesequential, staged approach, whereby panelists are in-volved in subsequent “rounds” [41]. We modified thisapproach by involving group II in just one round be-cause the goal of our group interviews was to collectimportant input and not to reach consensus. Further-more, between each group interview, we revised the sur-vey instrument to reflect the input provided by theprevious group. A final version of the survey instrumentwas created after all five group interviews. Each groupTable 1 Example of mapping questions to domains of Greenhalgh (“Outer Context” domain shown below)Greenhalgh’saspectsQuestion ResponseoptionsAspect FactorRegulatoryfederalHealthsystemprovincialHealthservicescommunityfacilityPracticecommunityattitudesFacilitator BarrierIncentives andmandatesHave you previously orderedand stocked at your office orfacility any medications for saleto your patients? (samples notapplicable)YesNoX Nationalregulatorysupport forabortion (CMAcode of ethics)MD office tobuy andstockmedicationInter-organizationalnorm settingand networksWho will be responsible forordering mifepristone at yourfacility?I will beThe medicaldirector oranotherphysicianA pharmacistat our facilityor in ourcommunityA non-physician,non-pharmaciststaff memberNo one willtakeresponsibilityunder currentregulationsUncertain atthis time[pleaseelaborate]Other [pleaseelaborate]X Provincialregulatorysupport forabortion(licensing)Physicianoffice to buyand stockmedicationWill you travel to providemedical abortion? (i.e., outsidethe community where youprimarily practice)YesNoXIf “yes” to 19, how far is thecommunity where you willprovide medical abortion fromyour home?[number] km XIf “yes” to 19, how will youtravel?RoadFerryAirXPlease indicate the number ofwomen per month youcurrently see for abortion whotravel for 3 h or more to reachyour service.[number] X Distancebetweenwoman andabortionserviceAre there abortion servicescurrently available in yourcommunity?SurgicalabortionMedicalabortionBothNeitherX Establishedcommunity orfacilitymandateThecommunitymay haveno priorabortionservicesDevane et al. Pilot and Feasibility Studies (2019) 5:126 Page 5 of 14consisted of three to six expert panelists led by at leasttwo experienced moderators who were research teammembers (WVN, RR, SD). Group interviews were con-ducted face-to-face or through video conference andbegan with a brief overview of the proposed regulationfor mifepristone in Canada as well as an introduction tothe research project. First, discussions guided by a semi-structured interview guide (see Table 2) were audio-recorded and then transcribed. Using a modified Delphiapproach, drafts of the survey were distributed for expertopinion and review during each group interview. Expertpanelists [group II] reviewed each question on the firstversion of the survey instrument for clarity and rele-vance. Survey questions and response options were pre-sented individually on a PowerPoint slide. Panelists wereinvited to give feedback on the question wording andthe rationale for their suggestions, suggest non-essentialquestions to be removed, provide feedback on whetheror not the proposed questions would capture address-able barriers and facilitators for dissemination, and sug-gest appropriate sub-dimensions and items to ensurethat the questions captured relevant elements of ourconceptual frameworks and provided appropriate re-sponse options. We allowed time for open-ended discus-sion for panelists to share their perceptions, attitudes,and beliefs regarding barriers and facilitators to mifepris-tone implementation, including identification of add-itional factors that should be explored in the survey.Panelists were given the option to submit written com-ments to maintain anonymity. Questions that were morechallenging to articulate were presented first in eachgroup. Between group interviews, questions were refinedto ensure we were adequately capturing informationrelevant to different practices and communities in a lo-gical progression. The audio recording from each groupinterview was transcribed digitally by a transcriptionistadhering to confidentiality.AnalysisOur team facilitators (WVN, RR, SD) reviewed thegroup interview transcripts several times independentlyto identify emerging themes. Together, they conducted acontent analysis using the data collected from the groupinterviews in a recursive fashion to identify common andconflicting viewpoints in a stepwise analysis. Similaritiesand differences across the sub-groups (i.e., rural versusurban practice setting, specialty practice versus primarycare, current abortion providers versus potential newproviders) were also explored. The aim of our analysiswas to ensure that questions of the survey instrumentwere relevant, understandable, provided clear answers,and included the range of relevant factors related tophysician initiation and ongoing provision of mifepris-tone medical abortion practice.Step 1: Usability Step 1 of the analysis involved an it-erative process of identifying and itemizing potentialchanges to the format of the survey questions. This in-cluded a thorough review of comments from the groupinterviews about which survey questions were clear, con-cise, and comprehensive, and which questions requiredadditional editing. As Fowler [38] suggests, “Poor ques-tion design is pervasive, and improving question designis one of the easiest, most cost-effective steps that canbe taken to improve the quality of survey data” (p. vii).For example, each focus group provided feedback on theimportance of consistency between Likert scale ratingresponse directions throughout the survey, i.e., fromstrongly disagree to strongly agree, from less to more,from harmful to beneficial, or from extremely difficult toextremely easy. Other discussions involved clarifyingambiguous terms or concepts and the potential conse-quences of response alternatives for participant answers.For example, to understand the degree of burden a phys-ician will experience if they are required to sell mifepris-tone directly to patients at their facility, we initiallyasked about the cost of stocking the medication. How-ever, two key concepts in this question were identified:“burden” and “cost.” We therefore went on to distin-guish both “cost” burden and the “administrative” bur-den of ordering and maintaining stock. Panelistsemployed at private clinics suggested they would beTable 2 Focus group instructions for question analysisPrompts for individual items in the questionnaire1. How did you find the wording of the question?2. What are your thoughts on the purpose of the question? Elaborateif necessary: “purpose” as in “what is the question trying to ask?”3. What are your thoughts on the correlation between the questionand the options listed for that question?4. Were there any options that you would like to have responded tobut were not listed in the question? If so, what were these options?5. Were there any options that you feel were unnecessary? If so, whatwere these options?After all items from the questionnaire have been completed, thepanelists will engage in a general feedback section comprised of thefollowing questions.Prompts for general feedback for the questionnaire1. What were the strengths of the questionnaire? What were theweaknesses of the questionnaire?2. Was the questionnaire presented in a logical manner? If not,what would be a more logical progression for the questionnaire?3. Were there any missing topics of questions that you feel may bebeneficial for our study? Please elaborate.4. If you were requested to complete this survey in the community,are there any barriers that would prevent you from completing thesurvey?5. Other comments?Devane et al. Pilot and Feasibility Studies (2019) 5:126 Page 6 of 14considering the high purchase cost as part of the over-head of keeping stock (estimated at $300 per dose). Con-versely, panelists employed in settings that already sellcontraceptives reported that they would experience noburden themselves, but that it was likely their patientswould, due to the high cost.Step 2: Content and context The second step of theanalysis involved a general inductive approach to under-stand the necessary content modifications to the ques-tions and response options. For example, each focusgroup engaged in the discussion about the definition ofthe term “community.” A participant employed in a ruralsetting explained that “community” does not accuratelyrepresent the vast geographic population catchmentsthat rural and remote physicians typically serve: “I’mlooking at women that are a two-to-three-and-a-half-hour flight away from me, that are in my ‘service region’”(focus group 2, family doctor, rural). Conversely, a par-ticipant employed in an urban setting stated, “If I haveto drive for more than 10 minutes, I’m outside of mycommunity” (focus group 4, OB-GYN, urban). As poorlydefined terms can negatively impact the reliability ofparticipants’ responses, we edited and replaced ambigu-ous terms or jargon based on panelist feedback. This in-cluded defining terms in the wording of the question orasking supplementary questions (e.g., How far from yourhome is the community where you will provide medicalabortion?).Several additional questions were suggested by thepanelists that did not contribute to the goals for thestudy or fit within the survey’s conceptual framework.For example, panelists suggested to include questions re-lated to patient satisfaction or to conduct an economicanalysis comparing surgical abortion to mifepristonemedical abortion. These questions were not included toensure the final survey met the aims of the researchquestion [26]. Following all group II input and the asso-ciated analysis, a second version of the survey instru-ment was iteratively reviewed by group I until consensuswas reached and the indicated domains in the theoreticalframeworks were represented by appropriate questions.Step 3: Thematic analysis of facilitators and barriersIn order to ensure that our survey instrument capturedrelevant perceived barriers and facilitators to implemen-tation of mifepristone, we also conducted a thematicanalysis of group interview transcripts, informed by crit-ical realist principles—that is, we explored how panelistsmade meaning of their abortion provision intentions andexperiences and the ways that social context informedthem, while considering the material reality in whichmifepristone would be implemented in Canada [42]. Thepurpose of conducting a thematic analysis of the groupinterview data was to enhance the development of thesurvey instrument. One qualitatively trained researcher(CD) read the transcripts to become immersed in thedata and identify patterns across panelists and groups.She independently developed a codebook of initial cat-egories related to panelists’ perceptions of barriers andfacilitators to implementation of mifepristone, followingthese phases: (1) initial coding for candidate categoriesand patterns in the transcripts, (2) focused coding formain categories and patterns, and (3) reviewing and re-fining categories. This nurse-researcher was not involvedin the data collection phases, which helped to facilitate adata-driven inductive approach as she did not share thesame assumptions and analytic preconceptions as to theother members of the research team, who were expertsin family planning research. She coded the transcriptsindependently and discussed her analysis at weekly inter-vals with a postdoctoral fellow (SM) with expertise inqualitative methods who had been involved in designingthe protocol and data collection. Together, they engagedin a reflexive dialog about the emerging categories, thesignificance of the categories, the convergence and in-consistencies between the groups [43], and the conse-quent implications for facilitating or impeding access tomifepristone medical abortion. Together, they wrote theresults of the analysis into a rich, descriptive narrative.All analysis was conducted in Microsoft Word.Finalizing the survey procedureThe second version of the survey instrument was dir-ectly translated in French using a translation service.The Francophone investigators on our team (EG, MSW)reviewed the translated survey for content and face val-idity to ensure the correct translation of medical termin-ology and relevance for Francophone physicians.Following the translation, the survey instrument wasentered, in both English and French, into a ResearchElectronic Data Capture (REDCap) platform, a secureweb-based meta-data-driven application, housed at ourresearch institution [44]. Branching logic was used to de-termine the respondents’ pathway in the survey. Thismitigated the potential for survey fatigue by ensuringquestions were relevant based on variables in responses.Phase 3: Pilot testingTo assess usability and reliability of the online survey,we invited the 9 physician co-investigators on the widerstudy, who were not involved in phase 2 content valid-ation, to pilot test the second version of the survey in-strument [group III]. To support rigor, conducting apilot test with participants who are representative of thestudy sample interests is recommended [38, 45]. Eachphysician co-investigator was emailed a link to the RED-Cap survey in December 2016 to January 2017 and wasDevane et al. Pilot and Feasibility Studies (2019) 5:126 Page 7 of 14given instructions to complete the survey and respondby email with recommendations. Our team revised theonline survey in real time as recommendations fromgroup III were received. This iterative cycle of testing,revising, and retesting the survey identified fewer issuesin each subsequent co-investigator response until no fur-ther issues remained. The English survey link was tested139 times and the French survey link was tested 43times among group III, and finally by all members ofgroup I, during this phase.ResultsDevelopment of preliminary survey items (phase 1)The first version of the survey instrument consisted of68 questions involving demographic and practice charac-teristics (22 questions), previous experience providingabortion services (8 questions), theoretical domains fromGreenhalgh’s framework (24 questions), and the 12-itemquestionnaire adapted from Légaré’s validated instru-ment [27]. The Légaré instrument questions applied to arange of content areas; therefore, very few wordingchanges were required (see Table 3). Appropriate ques-tions stemmed from 3 previously developed and fieldedinstruments developed by CART for the diffusion ofcontraception practice innovations [34, 35, 46] withminor modifications (e.g., “mifepristone” replacing“contraceptive” where appropriate).Results of expert content validation (phases 2 and 3)Expert panelists [group II] in phase 2 (n = 25) who par-ticipated in a total of 5 group interviews representedphysicians who provided abortion and those who hadnot, from primary care and specialty practice settings,rural and urban communities, in 3 provinces and 2 terri-tories (British Columbia, Ontario, Nova Scotia, NorthWest Territories, and Yukon) including those trained asfamily physicians and obstetrician gynecologists (seeTable 4). After phase 2, 5 clinical content experts (whichincluded representation from the fourth province, Que-bec) finalized the Mifepristone Implementation Surveyto distribute for pilot testing. Group III participants in-volved in the final phase of development provided repre-sentation from additional 3 provinces (Alberta,Manitoba, and Quebec). By phase 3, the survey lengthincreased from 47 baseline questions to 65 baselinequestions which addressed Greenhalgh’s domains: “Sys-tem Readiness for Change” (n = 19), “Outer Context”(n = 21), and “System Antecedents for Innovation” (n =25). This increase was as a result of feedback receivedduring phase 2, in which expert panelists [group II]Table 3 Continuing professional development questionnaire (adapted from Légaré et al. [33])1 I intend to provide medical abortion. Strongly disagree Strongly agree1 2 3 4 52 To the best of my knowledge, the percentage of my colleagues who provide medical abortion is: 0–20%, 21–40%, 41–60%, 61–80%, 81–100%3 I am confident that I could provide medical abortion if I wanted to. Strongly disagree Strongly agree1 2 3 4 54 Providing medical abortion is the ethical thing to do. Strongly disagree Strongly agree1 2 3 4 55 For me, providing medical abortion would be: Extremely difficult Extremely easy1 2 3 4 56 Now think about a co-worker whom you respect as a professional. In your opinion, does he/sheprovide medical abortion?Never Always1 2 3 4 57 I plan to provide medical abortion. Strongly disagree Strongly agree1 2 3 4 58 Overall, I think that for me providing medical abortion would be: Useless Useful1 2 3 4 59 Most people who are important to me in my profession provide medical abortion. Strongly disagree Strongly agree1 2 3 4 510 It is acceptable to provide medical abortion. Strongly disagree Strongly agree1 2 3 4 511 I have the ability to provide medical abortion. Strongly disagree Strongly agree1 2 3 4 512 Overall, I think that for me providing medical abortion would be: Harmful Beneficial1 2 3 4 5Devane et al. Pilot and Feasibility Studies (2019) 5:126 Page 8 of 14identified several questions where division into 2 individ-ual questions improved clarity. For example, a partici-pant suggested, “I guess maybe the question is, youmight have one [an ultrasound] in your facility but ifyou’re not trained to use it, do you have somebody whocan do it?” (focus group 4, OB-GYN, urban). This is anexample of how questions related to practical implica-tions and to constructs from Greenhalgh’s framework[24]. For this participant, it was more meaningful to askabout access to a skilled ultrasonographer as a potentialbarrier rather than if they had an ultrasound machine intheir facility.Consideration of rural and urban differences was keyin validating response options. For example, open-endedresponses suggested that practitioners in rural settingsdefined community very broadly in comparison withpractitioners in urban centers: “I think 15 kilometers is apretty urban number” (focus group 1, OB-GYN, rural).Similarly, practitioners employed in hospital-affiliatedabortion facilities were less concerned about ordering,stocking, or selling medications than their colleagues inprivate offices or clinics: “Our hope is that it will be onour hospital formulary and that it be at no cost to thepatient” (focus group 5, family physician, urban).Perceptions of potential barriers and facilitators tomifepristone implementationAnalysis of group interviews led to our identification ofcategories that represent physicians’ and abortion ex-perts’ perceptions of potential barriers and facilitators tothe implementation of mifepristone in Canada. None ofthe categories discussed was characterized as facilitators;the key categories that emerged from the analysis of thegroup interview transcripts included the following bar-riers: physicians dispensing the medication, mandatorytraining to become a prescriber, burdens for patients, lackof remuneration for mifepristone provision, and servicesavailable in my community. This qualitative data furtherTable 4 Characteristics of focus group panelists (group II)Focus group 1(n = 5)Focus group 2(n = 6)Focus group 3(n = 5)Focus group 4(n = 6)Focus group 5(n = 3)Total, n(%)DisciplineFamily practice 3 4 3 2 2 14 (56%)Obstetrics-gynecology (OB-GYN) 2 2 2 4 1 11 (44%)Experience* (years)No abortion experience 1 1 1 3 (8%)Less than 5 1 1 1 1 4 (15%)5–9 1 1 2 (13%)10–19 2 2 1 4 (15%)20+ 3 2 1 6 (24%)Primary practice typeHospital 2 2 1 3 2 10 (40%)Clinic 2 1 1 3 1 8 (32%)Primary care 2 3 5 (20%)GenderMale 2 2 6 10 (40%)Female 5 4 3 3 15 (60%)ProvinceBritish Columbia 5 4 5 14 (56%)Ontario 6 2 8 (32%)Nova Scotia 1 1 (4%)Territories 2 2 (8%)SettingUrban 5 3 6 2 16 (64%)Rural 6 2 1 9 (36%)Total 25 (100%)*Experience refers to the number of years the participant has been providing abortion services (medical, surgical, or both) after post-graduate training; numbersmay not add up to 100% due to incomplete dataDevane et al. Pilot and Feasibility Studies (2019) 5:126 Page 9 of 14supported and enriched the expert content validation byclarifying and validating the questions and responseoptions.Burdens for patients Group panelists (group II) empha-sized that having medical abortion services in primarycare in remote communities would be important to en-sure that patients can remain close to home. Rural phy-sicians from one focus group identified potentialrevisions to the survey to reflect the reality of providingfamily planning services in remote communities thatserve vast catchment areas and have limited resourcesfor surgical backup in the event of a failed first-trimestermedical termination. As one physician from the farnorth clarified, a question could explore, “If I’m in a big-ger [rural] community like I am, I am the abortion pro-vider, ‘What communities do [you] service and how far[away] are the women that are potentially seeking thathelp?’” She went on to explain that her large communityserves “women that are a 2 to 3 ½ hour flight away”(focus group 2, family doctor, rural). Panelists also per-ceived that the federal requirement for patients to signmandatory consent forms and be observed while ingest-ing the medication was “so insulting to women” (focusgroup 1) and excessive in comparison with other treat-ments: “I suspect you sign fewer forms if you’re goingfor cardiovascular surgery” (focus group 1).Physicians dispensing the medication Panelists ob-served that the federal restriction for “physician-only(not pharmacist) dispensing” of mifepristone would be akey barrier in primary care settings, compared topurpose-built abortion facilities or hospitals. The re-quirement that a physician dispenses medication in placeof the medication being available to purchase at a phar-macy is highly unusual in a Canadian context. Thiswould require physicians interested in prescribing mife-pristone, to set up the infrastructure to stock and sellthe medication: “So it’s sort of a two-pronged thing. Oneis additional cost associated with the actual selling of theprescription to the patient like a dispensing fee, what-ever. The other is capital cost to be able to sell it. So thecabinet maker, and the fees for the credit card machine”(focus group 4, OB-GYN, urban). Most physicians’ of-fices do not have such infrastructure, which led paneliststo engage in discussion about what, hypothetically, thisnew practice change might look like: “And this is a lot ofmoney. Like what would people do? Take VISA? I meanit does raise logistical questions, right?” (focus group 4,family physician, urban). Physician-only dispensing alsomay prevent patients from filling their prescriptions at aconvenient time and location: “That in itself is a burden,if you have to wait for the pharmacy to courier it back[to the physician]. You’ve only got a certain time. Areyou going to put her out in the waiting room and seesomeone else or?” (focus group 3, OB-GYN, rural, expe-rienced provider).Mandatory training to become a prescriber InCanada, physicians are expected to maintain skills andcompetency through self-study and continuing profes-sional development. Panelists’ comments indicated thatthe unique requirement of completing a mandatorytraining program, only for this medication, and to regis-ter with the manufacturer may discourage physiciansand pharmacists to adopt medical abortion practice andpatients would have limited access to qualified providers.As one participant described: “But if you go in there andthe [trained] person isn’t working that day, or has to besick, or on holidays, or anything else and nobody elsecan fill that stupid prescription?” (focus group 3, familyphysician, urban). It also may mean that trained physi-cians would face the burden of being a solo abortionprovider: “I can’t see a bunch of people doing all thetraining. Like, I anticipate it’s going to put more of aburden on smaller numbers of people.” (focus group 2,family physician, rural).Lack of remuneration for providing medical abortionThe lack of existing remuneration structures (e.g., billingcodes) for medical abortion was identified as anothercritical barrier. As one experienced abortion providerclarified, providers would have to cobble together differ-ent fees to adequately cover the costs of providing thisservice: “As you say, if somebody does not, they will billwhatever they can do in the way of a counselling fee, aphysical examination, et cetera, and so the question is,‘Is that going to be adequate?’ So, if we’re going to do it,you might want to just say straightforwardly, ‘In yourjurisdiction, are you paid well enough to cover yourcosts?’” (focus group 1, family physician, urban). She andother experienced providers noted that low fees for med-ical abortion could be a deterrent for new providers andtheir practices: “But my point is, automatically there’s acost. It’s whether it’s enough of a barrier for you to pro-vide it or not.” (focus group 3, family physician, urban).Services available in my community Finally, panelists’feedback illuminated the barriers associated with havinglimited resources to support the provision of medicalabortion. Timely access to ultrasound was a particularchallenge for small rural communities, as one participantdescribed: “Yeah, so I mean in smaller towns ultrasoundis not – it’s really – we have a bedside ultrasound inEmergency, but there’s no other ultrasound in townavailable outside of the hospital. Then in [larger town]there’s community ultrasound place, but they’re not gen-erally run – You know, they’re like business hours right”Devane et al. Pilot and Feasibility Studies (2019) 5:126 Page 10 of 14(focus group 5, family physician, rural). Further, in bothurban and rural sites, some panelists described havinglimited support from surgeons in the rare event of afailed termination or complication that requires surgery.While colleagues may provide support if “the person isunstable or it’s an emergency, or they have to, ‘those’people who don’t want to be involved in terminationswill choose not to be involved” (focus group 3, OB-GYN, rural). Limited collegial support can be a deterrentfor new abortion providers, who may not wish to straintheir interprofessional relationships by introducing abor-tion to their scope of practice.Results of pilot testing (phase 3)In phase 3, 1 round of surveys was administered viaREDCap and distributed for readability and usabilitytesting through an online link that included modifica-tions based on the feedback from the larger CART-GRAC network (group III). The second version of oursurvey instrument consisted of 9 demographic questions,52 questions mapped to Greenhalgh’s conceptual model(see Table 1 for an example), the 12-item questionnaireadapted from Légaré’s validated instrument, and 17open-ended questions that provided respondents withthe option to elaborate their responses. During phase 3,minor technical changes took place including spellingerrors, changing the order of demographic questions,improving the clarity of partner logo images, and movinghyperlinks to resources to the end of the survey. Onceeach of the technical changes was addressed, we estab-lished our final survey instrument.Between phases 2 and 3 of the Mifepristone Imple-mentation Survey Development Study, Health Canadaremoved the requirement for physician observation ofthe patient swallowing mifepristone (October 2016, priorto market availability in January 2017). This change wasdue in part to the early dissemination of our focus groupfinding that observation would create an unnecessaryburden for patients [47–49]. However, package labelingin the marketed product did not reflect this change untilSeptember 2017. Our research team made the decisionto include the questions we had developed and tested infocus groups around physician observed dosing to cap-ture the impact of a regulatory change not necessarilyreflected physically on the packaging materials and onphysician knowledge and practice.DiscussionWe undertook a rigorous process to develop and pilottest a survey instrument to investigate the health policy,health system, and health care delivery factors impactingfirst-trimester mifepristone abortion practice in Canada.In phase 1, family planning experts grounded the firstversion of the survey instrument in establishedtheoretical frameworks. In phase 2, 5 group interviewsleveraged the expertise of reproductive health providersfrom across the country and determined that HealthCanada’s proposed regulations would act as barriers toimplementation, particularly in primary care. We col-lected initial impressions on potential barriers from asample population of physicians and developed a 65-item baseline survey using 3 of Greenhalgh’s domains:“System Readiness for Change” (n = 19), “Outer Context”(n = 21), and “System Antecedents for Innovation” (n =25) to pilot test. In phase 3, a larger network providedfeedback to refine the survey. The Mifepristone Imple-mentation Survey is the result of a 3-phase process todevelop a comprehensive, nationally relevant instrument.We intend to administer our survey with a national sam-ple of mifepristone providers and to use our findings toinform future medical abortion policy, health system,and service decisions in Canada. Our larger program ofresearch will go on to collect 6-, 12- and 24-monthfollow-up data from this prescriber survey, and from aplanned pharmacist survey, to measure the change inpractice experiences and behavior. We will tailor follow-up survey content to focus on the constructs of Diffu-sion of Innovations that relate to the barriers and facili-tators we identify from the baseline survey and todetermine the uptake of mifepristone abortion practiceby respondents.Our study process resulted in a more comprehensivesurvey than any we were able to identify in the inter-national literature to understand the barriers to contra-ceptive and abortion service provision in high-incomecountries [5, 50–52]. For example, to assess similar fac-tors in a related field in 2011, Hulme et al. conducted 72interviews with healthcare providers and health systemstakeholders to understand the barriers to contraceptiveuse in Canada [53]. Interviews were informed by 2 vali-dated frameworks for access and quality in family plan-ning; however, the sample primarily includedparticipants from Canada’s 3 largest provinces, Quebec,Ontario, and British Columbia, and may not havereflected policy issues in other provinces, territories, andbetween rural and urban [54]. Furthermore, in 2013,Guilbert et al. surveyed 78 abortion facilities and theirabortion providers across Canada to understand the na-tional availability and practice of first-trimester medicalabortion [5]. Their survey instrument, which wasadapted from USA research for the Canadian context,investigated the facility and staff demographics as well asclinical practice such as pre-procedure evaluation, medi-cation regimens, and follow-up for abortion service pa-tients [51, 52]. The survey was suitable to describe theusual practice, but facilitators and barriers to first-trimester medical abortion practice were not investi-gated. This limitation was accounted for in our surveyDevane et al. Pilot and Feasibility Studies (2019) 5:126 Page 11 of 14instrument by specifically developing questions to targetbarriers to medical abortion practice identified by physi-cians from diverse practice settings.A significant strength in the development of this sur-vey was the use of established conceptual frameworksthat assess multiple dimensions of implementation andthat explore physician and organizational behavior inimplementing an innovation. While Greenhalgh’s [28]comprehensive model of diffusion, dissemination, andimplementation is based on a systematic review of em-pirical and theoretical models, it has been criticized forits lack of “operational definitions or measurement” formany of the constructs (Cook et al. 2012, p. 12). Oursurvey development process is an “operationalization” ofthe Greenhalgh framework and applies the framework toa health system implementation scenario.Our study was also strengthened by group interviewswith a national expert panel representing both familymedicine and obstetrics-gynecology training, urban andrural communities, and specialty and primary care prac-tices. This allowed us to capitalize on the strengths ofgroup decision-making despite geographic separation.The panelists’ diverse contributions enhanced the clarityand relevance of the questions thereby ensuring highface validity of our survey content. This exploratory ap-proach surfaced issues that could not have been identi-fied by our research team alone. Further, this approachallowed us to explore physicians’ perceptions of potentialbarriers and facilitators due to Health Canada’s restrict-ive regulations for prescribing and dispensing mifepris-tone. Physician dispensing and mandatory training wereregulatory barriers that were perceived to have the po-tential to increase the burden on patients seeking med-ical abortion by inhibiting physicians from implementingmifepristone abortion care in their practices. Lack ofbilling codes to support remuneration and limited avail-ability of ultrasound and surgical backup were practicalbarriers that were related to regional health systemdecision-making, rather than federal medication policy.Furthermore, Dressler et al. [54] identified barriers thatpractitioners experience based on their geographic loca-tion across Canada. They found that logistical barriers toprovision, professional isolation, and lack of replacementproviders including barriers to receive training areuniquely identified by providers in rural and remotecommunities. These concepts were validated by the ex-pert panel as important areas to explore in the survey.The barriers identified in this current study are investi-gated in the survey instrument so that we may furtherunderstand what factors influence the implementation ofmifepristone across the country.Limitations to the Delphi approach include the poten-tial for panelists to be influenced by the questions for-mulated by the research team and panelists’ failure tounderstand the primary purpose of the study. For ex-ample, we did not aim for our survey to capture all po-tential questions related to barriers and facilitators ofabortion provision in Canada, but only those most rele-vant to mifepristone. It was challenging to balance thelength of the survey with our desire to collect adequate,relevant information. This meant that we had toprioritize several of the dimensions of the frameworkover others, based on the relevance to our research ob-jectives. For example, we prioritized collecting data onbarriers perceived to be addressable through health pol-icy, system, or service delivery changes not individual at-titudes or knowledge change.Phase 3 pilot testing only focused on the readability andtechnical aspects of the online survey instrument. We didnot include specific measurements such as Cronbachalpha coefficients to assess internal consistency, test-retestreliability testing, or factor analysis to describe variabilityamong items. However, some of the basic instruments weused to build our survey instrument did report strong psy-chometric testing [33].The introduction of mifepristone and the develop-ment of new clinical practice guidelines [24] presentan exceptional opportunity to improve women’s ac-cess to abortion in Canada, particularly in rural andremote areas [1, 55–57] and to improve women’ssafety and privacy by reducing the stigma and harass-ment that can occur for women seeking a surgicalabortion [58]. To advance mifepristone practice inCanada, health policy, system, and health care deliv-ery implementation factors will need to be identifiedto facilitate the promotion of equitable access toabortion care. This survey will be used to assess thosebarriers and facilitators of mifepristone implementa-tion in Canada. Given that the rates of mifepristoneimplementation have differed greatly internationally, itwill be crucial that barriers to practice are adequatelycaptured and presented to decision-makers acrossCanada in a timely way.ConclusionThe Mifepristone Implementation Survey DevelopmentStudy employed a rigorous process to develop a compre-hensive, nationally representative survey instrument.The specific questions were developed using frameworksthat comprehensively covered barriers and facilitators toprovider implementation of medical abortion practice.As such, they constitute a good basis for surveys in otherjurisdictions that want to study barriers and facilitatorsto medical abortion. Data from the fielding of this surveywill be used to inform decision-makers across Canadaand to facilitate more equitable access to abortionservices.Devane et al. Pilot and Feasibility Studies (2019) 5:126 Page 12 of 14AcknowledgementsWe would like to acknowledge the entire CART-GRAC network for their con-tributions to women’s sexual and reproductive health research, particularlytheir ongoing collaboration in the CART-Mifepristone Implementation Study.Authors’ contributionsWVN, SD, and EG conceptualized this research project. WVN, SD, EG, RR, andSM designed the study protocol and substantially contributed to the dataanalysis in phase 2. EG and MSW provided important Francophoneinterpretation of the data in phases 2 and 3. CD analyzed the data in phase3 and was a major contributor in writing the manuscript. Expert qualitativeresearcher SM provided guidance during the analysis and interpretation ofthe data in phase 3. SM and RR substantively revised the manuscript. Allauthors have read and approved the final manuscript.FundingThis study was supported by the Canadian Institutes of Health Research,Partnerships for Health Systems Improvement Grant (PHE148161), inpartnership with the Michael Smith Foundation for Health Research (Award#16743). WVN is supported as a scholar of the Michael Smith Foundation forHealth Research (2012-5139 HSR) and as an applied public health researchchair by the Canadian Institutes of Health Research (CPP-329455-107837). SMis supported as a trainee of the Michael Smith Foundation for HealthResearch (2016-16603). In-kind support was contributed by the Society ofObstetricians and Gynecologists of Canada (SOGC), the College of FamilyPhysicians of Canada, the Canadian Pharmacists Association, and theWomen’s Health Research Institute of British Columbia Women’s Hospitaland Health Center of the Provincial Health Services Authority of BritishColumbia.Availability of data and materialsThe data generated and analyzed during the current study are available fromthe corresponding author upon reasonable request. The final version of theMifepristone Implementation Survey is available at http://med-fom-cart-grac.sites.olt.ubc.ca/files/2019/03/Mife-MD_Survey.pdfEthics approval and consent to participateEthics approval for this study was obtained from the University of BritishColumbia Children’s and Women’s Hospital Research Ethics Board forresearch involving human subjects (H16-01006).Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Author details1Contraception and Abortion Research Team, Women’s Health ResearchInstitute, BC Women’s Hospital and Health Center, Vancouver, BC, Canada.2School of Nursing, University of British Columbia, Vancouver, BC, Canada.3Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.4Institut national de santé publique du Québec, Quebec City, QC, Canada.5Department of Family and Community Medicine, University of Toronto,Toronto, ON, Canada. 6Department of Obstetrics and Gynaecology, Universityof Montreal, CHU Sainte-Justine, Montreal, QC, Canada. 7Faculty of PublicHealth & Policy, London School of Hygiene and Tropical Medicine, London,UK. 8Department of Family Practice, Women’s Health Research Institute,University of British Columbia, E202-4500 Oak Street, Vancouver, BC V6H 3N1,Canada.Received: 12 April 2019 Accepted: 17 October 2019References1. Norman WV. Induced abortion in Canada 1974–2005: trends over the firstgeneration with legal access. Contraception. 2012;85(2):185–91.2. Canadian Institutes of Health Information. Induced Abortions Reported inCanada in 2016 | CIHI [Internet]. 2018 Jun [cited 2018 Nov 6]. Availablefrom: https://www.cihi.ca/en/induced-abortions-reported-in-canada-in-20163. Shaw D, Norman WV. When there are no abortion laws: a case study ofCanada. Best Pract Res Clin Obstetrics Gynaecol. 2019; [cited 2019 Aug 22];Available from: http://www.sciencedirect.com/science/article/pii/S1521693419300550.4. Norman WV, Guilbert ER, Okpaleke C, Hayden AS, Steven Lichtenberg E,Paul M, et al. Abortion health services in Canada: results of a 2012 nationalsurvey. Can Fam Phys. 2016;62(4):e209–17.5. Guilbert ER, Hayden AS, Jones HE, White KO, Lichtenberg ES, Paul M,Norman WV. First-trimester medical abortion practices in Canada. Can FamPhysician. 2016;62:e201–8.6. Norman WV, Soon JA, Maughn N, Dressler J. Barriers to rural inducedabortion services in Canada: findings of the British Columbia AbortionProviders Survey (BCAPS). PLoS ONE. 2013;8(6):e67023.7. WHO Drug Information Vol. 19, No. 3, 2005 [Internet]. World HealthOrganization. [cited 2018 Nov 6]. Available from: http://apps.who.int/medicinedocs/en/d/Js7918e/8. Sedgh G, Bearak J, Singh S, Bankole A, Popinchalk A, Ganatra B, et al.Abortion incidence between 1990 and 2014: global, regional, andsubregional levels and trends. Lancet. 2016;388(10041):258–67.9. Løkeland M, Iversen OE, Engeland A, Økland I, Bjørge L. Medical abortionwith mifepristone and home administration of misoprostol up to 63 days’gestation. Acta Obstet Gynecol Scand. 2014;93(7):647–53.10. Templeton A, Grimes DA. A request for abortion. N Engl J Med. 2011;365(23):2198–204.11. Jones RK, Jerman J. Abortion incidence and service availability in the UnitedStates, 2011. Perspect Sex Reprod Health. 2014;46(1):3–14.12. Oppegaard KS, Qvigstad E, Fiala C, Heikinheimo O, Benson L, Gemzell-Danielsson K. Clinical follow-up compared with self-assessment of outcomeafter medical abortion: a multicentre, non-inferiority, randomised, controlledtrial. Lancet. 2015;385(9969):698–704.13. Winikoff B, Westhoff C. Fifteen years: looking back and looking forward.Contraception. 2015;92(3):177–8.14. Jones RK, Henshaw SK. Mifepristone for early medical abortion: experiencesin France, Great Britain and Sweden. Perspect Sex Reprod Health. 2002;34(3):154–61.15. Newton D, Bayly C, McNamee K, Bismark M, Hardiman A, Webster A, et al.‘… a one stop shop in their own community’: medical abortion and therole of general practice. Aust N Z J Obstet Gynaecol. 2016;56(6):648–54.16. Grossman D, Goldstone P. Mifepristone by prescription: a dream in theUnited States but reality in Australia. Contraception. 2015;92(3):186–9.17. Shankar M, Black KI, Goldstone P, Hussainy S, Mazza D, Petersen K, et al.Access, equity and costs of induced abortion services in Australia: a cross-sectional study. Aust N Z J Public Health. 2017;41(3):309–14.18. Jones HE, White KO, Norman WV, Guilbert E, Lichtenberg ES, Paul M. Firsttrimester medication abortion practice in the United States and Canada.PLoS One. 2017;12(10):e0186487.19. de Moel-Mandel C, Shelley JM. The legal and non-legal barriers to abortionaccess in Australia: a review of the evidence. Eur J Contracept ReprodHealth Care. 2017;22(2):114–22.20. de Costa C, Douglas H, Hamblin J, Ramsay P, Shircore M. Abortion lawacross Australia – a review of nine jurisdictions. Aust N Z J Obstet Gynaecol.2015;55(2):105–11.21. Australian abortion law and practice - Children by Choice [Internet]. [cited2019 Aug 22]. Available from: https://www.childrenbychoice.org.au/factsandfigures/australianabortionlawandpractice.22. Regulatory decision summary: MIFEGYMISO. [Internet]. Health Canada. 2015.Available from: http://www.hc-sc.gc.ca/dhp-mps/prodpharma/rds-sdr/drug-med/rds_sdr_mifegymiso_160063-eng.php. Accessed 3 Oct 2015.23. List of Mifepristone Approvals - Gynuity Health Projects [Internet]. [cited2019 Feb 12]. Available from: https://gynuity.org/resources/list-of-mifepristone-approvals24. Costescu D, Guilbert E, Bernardin J, Black A, Dunn S, Fitzsimmons B, et al.Medical abortion. J Obstet Gynaecol Can. 2016;38(4):366–89.25. Norman WV, Soon JA. Requiring physicians to dispense mifepristone: anunnecessary limit on safety and access to medical abortion. Can Med AssocJ. 2016;188(17/18):E429–30.26. Norman WV, Munro S, Brooks M, Devane C, Guilbert E, Renner R, Kendall T,Soon JA, Waddington A, Wagner M-S, Dunn S. Could implementation ofmifepristone address Canada’s urban-rural abortion access disparity: amixed-methods implementation study protocol. BMJ Open 2019;9:e028443.https://doi.org/10.1136/bmjopen-2018-028443.Devane et al. Pilot and Feasibility Studies (2019) 5:126 Page 13 of 1427. About Us | CART-GRAC [Internet]. [cited 2019 Feb 12]. Available from: http://cart-grac.ubc.ca/about-us/28. Greenhalgh T, Robert G, MacFarlane F, Bate P, Kyriakidou O. Diffusion ofinnovations in service organizations: systematic review andrecommendations. Milbank Quarterly. 2004;82(4):581–629.29. Guilbert ER, Robitaille J, Guilbert AC, Morin D. Determinants of theimplementation of a new practice in hormonal contraception by Quebecnurses. Can J Hum Sex. 2014;23(1):34–48.30. Godin G, Bélanger-Gravel A, Eccles M, Grimshaw J. Healthcare professionals’intentions and behaviours: a systematic review of studies based on socialcognitive theories. Implement Sci. 2008;3(1) Available from: http://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-3-36.[cited 2018 Nov 6].31. Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process.1991;50(2):179–211.32. Triandis HC. Interpersonal behaviour. Monterey, California, Brooks/ColePublisher. 1977;329.33. Légaré F, Borduas F, Freitas A, Jacques A, Godin G, Luconi F, et al.Development of a simple 12-item theory-based instrument to assess theimpact of continuing professional development on clinical behavioralintentions. PLoS ONE. 2014;9(3):e91013.34. Wong M, Soon JA, Zed P, Norman WV. Development of a survey to assessacceptability of an innovative contraception practice among ruralpharmacists. Pharmacy. 2014;2(1):124-136.35. Guilbert E, Rousseau M, Guilbert A, Robitaille J, Gagnon H, Morin D. Processevaluation of a task-shifting strategy in hormonal contraception: doestraining translate into practice?- ClinicalKey. J Obstet Gynaecol Can. 2013;35(12):1090–100.36. Harris LH, Martin L, Debbink M, Hassinger J. Physicians, abortion provisionand the legitimacy paradox. Contraception. 2013;87(1):11–6.37. Martin LA, Debbink M, Hassinger J, Youatt E, Eagen-Torkko M, Harris LH.Measuring stigma among abortion providers: assessing the abortionprovider stigma survey instrument. Women Health. 2014;54(7):641–61.38. Fowler F. Survey Research Methods (4th ed.) [Internet]. 2455 Teller Road,Thousand Oaks California 91320 United States: SAGE Publications, Inc.; 2009[cited 2018 Nov 6]. Available from: http://methods.sagepub.com/book/survey-research-methods39. Linstone HA, Turoff M. The Delphi Method. Techniques and Applications.2002;618. Accessible online at: https://web.njit.edu/~turoff/pubs/delphibook/delphibook.pdf. Accessed 31 Oct 2019.40. Murry JW, Hammons JO. Delphi: a versatile methodology for conductingqualitative research. Rev Higher Educ. 1995;18(4):423–36.41. Iqbal S, Pipon-Young L. The Delphi method [Internet]. The psychologist.2009 [cited 2019 Aug 27]. Available from: https://thepsychologist.bps.org.uk/volume-22/edition-7/delphi-method42. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol.2006;3(2):77–101.43. Morse JM. Confusing categories and themes. Qual Health Res. 2008;18(6):727–8.44. BCCHR REDCap [Internet]. [cited 2019 Feb 12]. Available from: https://rc.bcchr.ca/45. Turner DW. Qualitative interview design: A practical guide for noviceinvestigators. The Qualitative Report. 2010;15:754–60.46. Norman WV, Soon JA, Panagliotoglou D, Albert A, Zed P. The Acceptabilityof Contraception Task-sharing Among Canadian Pharmacists: The ACT-Pharm Study. Contraception 2015;92(1):55-6147. Kirkey S. Home abortion pill about to hit market in Canada, but has alreadygarnered criticism. Interview (print) with Dr. Norman. National Post[Internet]. 2016 Apr 19; Available from: http://news.nationalpost.com/news/canada/0420-na-abortion. Accessed 31 Oct 2019.48. Quinn S. Restrictions on coming ‘abortion pill’ are ‘demeaning’ to women,prof says. Live radio interview with Dr. Norman. On the coast. Vancouver, B.C: CBC Radio; 2016.49. Editorial: What is Health Canada thinking on the abortion pill? Interviewwith Dr. Norman. Ottawa Citizen [Internet]. 2016 Apr 20; Available from:http://ottawacitizen.com/opinion/editorials/editorial-what-is-health-canada-thinking-on-the-abortion-pill. Accessed 31 Oct 2019.50. Aiyer AN, Ruiz G, Steinman A, Ho G. Influence of physician attitudes onwillingness to perform abortion. Obstet Gynecol. 1999;93(4):576–80.51. Wiegerinck MMJ, Jones HE, O’Connell K, Lichtenberg ES, Paul M, WesthoffCL. Medical abortion practices: a survey of National Abortion Federationmembers in the United States. Contraception. 2008;78(6):486–91.52. Lichtenberg ES, Paul M, Jones H. First trimester surgical abortion practices: asurvey of National Abortion Federation members. Contraception. 2001;64(6):345–52.53. Hulme J, Dunn S, Guilbert E, Soon J, Norman W. Barriers and facilitators tofamily planning access in Canada. Healthcare Policy. 2015;10(3):48–63.54. Dressler J, Maughn N, Soon JA, Norman WV. The perspective of ruralphysicians providing abortion in Canada: qualitative findings of the BCAbortion Providers Survey (BCAPS). PLoS ONE. 2013;8(6):e67070.55. Sethna C, Doull M. Far from home? A pilot study tracking women’s journeysto a Canadian abortion clinic. J Obstet Gynaecol Can. 2007;29(8):640–7.56. Kaposy C. Improving abortion access in Canada. Health care analysis : HCA;New York. 2010;18(1):17–34.57. Sethna C, Doull M. Spatial disparities and travel to freestanding abortionclinics in Canada. Women’s Stud Int Forum. 2013;38:52–62.58. Bertrand JT, Hardee K, Magnani RJ, Angle MA. Access, quality of care andmedical barriers in family planning programs. Int Fam Plan Perspect. 1995;21(2):64.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Devane et al. Pilot and Feasibility Studies (2019) 5:126 Page 14 of 14
Article
eng
Reviewed
Vancouver : University of British Columbia Library
BioMed Central
Attribution 4.0 International (CC BY 4.0)
Faculty
Mifepristone
Canada
Abortion
Survey
Family planning
Family physician
Delphi approach
Diffusion of Innovation
Implementation science
Implementation of mifepristone medical abortion in Canada: pilot and feasibility testing of a survey to assess facilitators and barriers
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