Aim
The aim of the PolyPrime process evaluation is to test the implementation of the PolyPrime intervention in primary care.
The objectives of the study are to:
- Assess if the intervention is delivered and received as intended (intervention fidelity)
- Assess the acceptability of the intervention to GPs, practice staff and patients
- Identify the intervention’s likely mechanisms of action.
Methods
Study design
A mixed methods process evaluation study will be undertaken, involving interviews with GPs and practice staff, patient feedback questionnaires, data collection forms completed by practice staff and audio-recordings of patient medication review appointments. Ethical approval has been obtained from by the North of Scotland (REC reference: 19/NS/0100) and the Irish College of General Practitioners Research Ethics Committees (RECs).
Setting
The main PolyPrime study is currently being conducted in 11 GP practices in Northern Ireland (NI) and the border counties of the Republic of Ireland [ROI] (Donegal, Leitrim, Sligo, Cavan, Monaghan and Louth). The process evaluation will be conducted in the GP practices randomised to the intervention arm.
GP and practice staff recruitment
A detailed overview of the sampling and recruitment procedures for GPs and patients has been described elsewhere [14]. Briefly, GP practice recruitment (now complete) took place in two stages. Firstly, a random sample of GP practices were contacted via a letter seeking expressions of interest. The second stage involved research nurses from the Northern Ireland Clinical Research Network (NICRN – Primary Care) and Trinity College Dublin (TCD) telephoning the practice manager or lead GP in each practice to determine their interest in receiving information about the study. GPs were asked to provide written informed consent, which included agreeing to take part in an interview towards the end of the study and to audio-record the discussion during a medication review with a patient’s consent should the practice be randomised to the intervention arm.
One member of practice staff (i.e. practice manager or receptionist) from each intervention arm practice (i.e. those involved in implementing the intervention within the practice) was recruited to facilitate implementation of the intervention (i.e. patient recruitment and scheduling medication review appointments), complete data collection forms and to participate in a post-intervention feedback interview. Practice staff received an information sheet providing details about the interviews and were asked to provide written informed consent.
Patient recruitment
Following GP practice recruitment, practice staff were asked to screen patient records to identify potentially eligible patients with the goal of recruiting up to 10 patients per practice. Patients have been asked to provide written informed consent, which includes agreeing to complete a feedback questionnaire towards the end of the study and to the GP audio-recording the discussion during their medication review appointments should they be from a GP practice randomised to the intervention arm. Patients will still be able to participate in the main pilot cRCT even if they do not agree to have their medication review appointments audio-recorded. At the time of submission, patient recruitment is almost complete.
Data Collection
Intervention fidelity
Data will be collected on intervention fidelity [9] as summarised in Table 2; this will be evaluated in relation to the delivery, receipt and/or enactment of the four intervention components (i.e. online video, patient recall, weekly meetings and prompts/cues). Firstly, delivery and/or receipt of each of the four intervention components by GPs will be explored. The practice staff role in facilitating the implementation of the prompts/cues component of the intervention will also be examined. Secondly, enactment of the intervention (by GPs) will be explored (i.e. whether medication reviews were completed by GPs as intended). Finally, the delivery of any additional BCTs aimed at improving the prescribing of appropriate polypharmacy during the medication reviews with patients by GPs will be assessed (see Table 2).
Table 2: Intervention fidelity data collected as part of process evaluation
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Intervention component
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Aim (what is being assessed)
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Data collected
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Data sourcea
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Online video
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Delivery/receipt of the intervention
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The number of times the GPs access the online video
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Online video administration page
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Weekly meetings
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Delivery/receipt of the intervention
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The number of weekly practice staff meetings held (at which explicit plans will be made to recall patients for medication reviews)
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Data collection forms completed by practice staff
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Prompts/cues
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Delivery/receipt of the intervention
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The number of prompts GPs receive from practice staff to conduct medication reviews
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Data collection forms completed by practice staff
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Patient recall
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Delivery/receipt of the intervention
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The number of appointments scheduled and attended
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Data collection forms completed by practice staff
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Enactment of the intervention
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Fidelity of medication reviews conducted by GPs
Additional BCTs delivered to the patient by the GP during the process of the medication review
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Audio-recorded medication reviews
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BCT, behaviour Change Technique; GP, General Practitioner
aBased on data collected from the 6 intervention arm GP practices
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Intervention acceptability
Data will be collected on the acceptability of study procedures and the acceptability of the intervention to GPs, practice staff and patients (see Data collection methods section). Semi-structured interview and questionnaire items relating to the acceptability of the overall intervention have been framed using the constructs of the TFA: affective attitude; burden; intervention coherence; opportunity costs; perceived effectiveness and self-efficacy (Table 1) [22]. However, questions relating to the TFA constructs ‘self-efficacy’, ‘opportunity costs’ or ‘intervention coherence’ have not been included in the patient questionnaire as the intervention is aiming to change what GPs do as part of delivering routine care, rather than what patients do. Similarly, questions relating to the constructs ‘self-efficacy’, ‘perceived effectiveness’ or ‘intervention coherence’ have not been included in the practice staff interview topic guide. Finally, due to the nature of the intervention and following consultation with the various stakeholders on the Project Management Team, a question relating to the TFA construct ‘ethicality’ (i.e. the extent to which the intervention was a good fit with an individual’s value system) has not been included. GPs, practice staff and patients will also be asked a broad “yes or no” question regarding the acceptability of the overall intervention.
Mechanisms of action
Data will be collected to identify the intervention’s likely mechanisms of action (i.e. the process whereby an intervention component exerts its effect). Firstly, we will explore if the online video component brought about changes in the GPs’ beliefs about capabilities (e.g. their self-efficacy) [27] to provide appropriate polypharmacy for the effective clinical management of older people in primary care. Secondly, we will explore if the patient recall process was effective in bringing about positive attitudes towards the medication reviews (‘Salience of consequences’ for GPs). Finally, we will explore if weekly meetings (BCT: ‘Action planning’) and practice staff delivering prompts to GPs (BCT: ‘Prompts/cues’) were perceived to be effective and/or useful in reminding GP practices to organise appointments and reminding GPs to deliver a medication review to the patient (see Table 3). In our qualitative assessment of the likely mechanisms of action for the PolyPrime intervention we will use established methods that link BCTs to theoretically defined mechanisms of action [28]. For example, we can assess the extent to which the BCT ‘prompts/cues’ was perceived to influence memory, attention, and decision processes or relevant behavioural cueing processes that help initiate and maintain medication reviews, as part of routine care. This analysis of potential mechanisms of action will help refine the process evaluation and theoretical underpinning of any subsequent full trial of future iterations of the PolyPrime intervention [9]. This will be integrated into the interpretation phase of the framework analyses described below.
Table 3: Mechanisms of action and data collected as part of process evaluation
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Mechanisms of action
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Impact
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Data collected
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Data sourcea
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Online video
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Changes in the GPs’ beliefs about capabilities (e.g. their self-efficacy) to prescribe appropriate polypharmacy during a consultation with an older patient
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GP views on the usefulness of the online video
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GP feedback interviews
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Weekly meetings
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Weekly meetings are perceived to be effective in GPs making plans to schedule patient appointments
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The number of weekly practice staff meetings held
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Data collection forms completed by practice staff
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GP views on the effectiveness/usefulness of weekly meetings
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GP feedback interviews
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Practice staff views on the effectiveness/usefulness of weekly meetings
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Practice staff feedback interviews
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Prompts/cues
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Prompts from practice staff were perceived to be effective in reminding GPs to deliver a medication review to patients
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The number of prompts GPs receive from practice staff to conduct medication reviews
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Data collection forms completed by practice staff
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GP views on the effectiveness/usefulness of receiving prompts
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GP feedback interviews
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Practice staff views on the effectiveness/usefulness of delivering prompts
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Practice staff feedback interviews
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Patient recall
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GPs reporting positive attitudes towards the medication review
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GP views on the impact of the intervention
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GP feedback interviews
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GP, General Practitioner
aBased on data collected from the 6 intervention arm GP practices
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Data collection methods
The following text refers to the data sources identified in Tables 2 and 3.
Quantitative data
The following data will be collected on study-specific data collection forms:
- The number of times the GPs (allocated to the intervention arm) access the online video: In order to collect information on the number of times each GP accessed the online server to watch the video, an administrator login page has been developed which can be accessed by the research team. This page will record the following details for each GP (based on their individual usernames): number of times logged in, date of last login and number of times pressed play (on the video).
- The number of weekly practice staff meetings held (at which explicit plans will be made to recall patients for medication reviews): Practice staff will be asked to record the number of weekly practice staff meetings held in the intervention arm practices, and during which, plans are made to recall patients for medication review in the form of a scheduled appointment.
- The number of prompts GPs receive from practice staff to conduct medication reviews: Practice staff will be asked to record the number of prompts GPs receive from practice staff to conduct medication reviews. Practice staff will record details on which member of practice staff delivered the prompt, the number of prompts made to the GP and how prompts were given (i.e. verbally or using a computerised system). Practice staff will be asked to provide this information for both the initial and 6-month follow-up medication review appointments.
- Patient feedback questionnaire: Patients from the six intervention arm practices will be asked to complete a feedback questionnaire as soon as possible after delivery of the intervention (i.e. after completion of their final follow-up questionnaires). The questionnaires will be posted to patients by the Research Fellow/Assistant and they will be asked to return them using a pre-paid envelope provided. Patients will be telephoned as a reminder to complete the feedback questionnaire if this has not been returned, and where necessary, patients will be given the opportunity to complete this via the telephone. Patients will be asked about their views on the following:
- Acceptability of study procedures including recruitment, completing questionnaires and support provided by the research team
- Medication review appointments – including mode of delivery
- Acceptability of the intervention (questions based on TFA) (Table 1) [22].
Qualitative data
GP feedback interview: At the end of the intervention delivery phase (i.e. after both the initial and 6-month medication reviews are completed), qualitative interviews will be conducted with up to 10 GPs in the six intervention arm practices. GPs will be interviewed as soon as possible after receipt of the training to deliver the PolyPrime intervention and subsequent delivery of the intervention to patients, using a semi-structured interview guide. The interviews will be completed either face-to-face at a location that is mutually convenient for both the GPs and the researcher (e.g. GP practices), via the telephone or video-call. GPs will be given an honorarium of £46/€54 to compensate them for the time associated with participation in an interview. GPs will be asked about their views on the following:
- Acceptability of study procedures including patient screening and recruitment and support provided by the research team
- Experience of the PolyPrime intervention including how it enhanced knowledge, skills and confidence in abilities
- Online video (and supporting materials)
- Weekly practice meetings
- Prompts/cues
- Patient recall process – including mode of delivery
- Acceptability of the intervention (questions based on TFA) (Table 1) [22].
Practice staff feedback interview: At the end of the intervention delivery phase (i.e. after both the initial and 6-month medication reviews are completed), an interview will be conducted with one member of practice staff (i.e. practice manager or receptionist) from each intervention arm practice (i.e. those involved in implementing the intervention within the practice). Practice staff will be interviewed via telephone as soon as possible after medication reviews have been completed with all recruited patients, using a semi-structured interview guide, at a time convenient to them. Practice staff will be asked about their views on the following:
- Acceptability of study procedures including patient screening and recruitment and support provided by the research team
- Experience of the PolyPrime intervention
- Weekly practice meetings
- Scheduling appointments
- Prompts/cues
- Acceptability of the intervention (questions based on TFA) (Table 1) [22].
Audio-recorded medication reviews: As outlined above (see GP and patient recruitment section), GPs and patients will be asked to consent to having the medication review discussions audio-recorded. Due to the current coronavirus restrictions in place, these medication reviews will be conducted either face-to-face, via the telephone or video-call. If possible, each recruited GP from the six intervention arm practices will be asked to audio-record one patient’s initial and 6-month follow-up medication review appointments. The GPs will be reminded by a member of the research team to undertake this activity for one of their recruited patients. Audio-recording equipment will be provided by the research team.
Quantitative analysis
Analysis in relation to study-specific data collection forms and patient questionnaires will use descriptive statistics (e.g. means, standard deviations) and will be conducted using SPSS (version 26.0). The data collected will be used to assess if the intervention is delivered and received as intended (i.e. intervention fidelity) and to assess the acceptability of the study procedures and medication reviews to patients.
Qualitative analysis – Feedback interviews
Analysis of the post-intervention feedback interviews will use a Framework analysis [29, 30], which will involve seven stages. The first stage will involve an in-depth familiarisation process. Coding of the transcripts will then take place in two phases. The second stage (first coding phase) will adopt a deductive approach using the TFA constructs [22] to frame the questions relating to the overall acceptability of the intervention in the GP and practice staff interviews (see Intervention acceptability section and Table 1). The third stage (second coding phase) will adopt an inductive approach, in which emerging themes will be identified. This will be followed by the development of a working analytical framework (Stage 4), applying the analytical framework (Stage 5), charting data into the framework matrix (Stage 6) and interpreting the data (Stage 7). All transcripts will be analysed independently by at least two members of the research team. Two sets of analysis will be undertaken, one for each professional group (i.e. GPs and practice staff).
Qualitative Data Analysis – Medication review appointments
Analysis of the medication review appointment transcripts will be conducted in a similar way to that outlined above. The second stage (first coding phase) will adopt a deductive approach using the BCT taxonomy [13] which will be used to assess if GPs delivered any additional BCTs during the patient recall process. The third stage (second coding phase) will adopt an inductive approach, in which any additional emerging themes will be identified.
Triangulation of quantitative and qualitative data
Once all quantitative and qualitative data have been analysed separately by the researchers, the results from all five data sets (GP feedback interviews, practice staff interviews, patient feedback questionnaires, medication review appointment recordings, study-specific data collection forms) will be compared. This will follow a triangulation protocol [31] involving six steps (Table 4). Step 1 will involve two researchers examining the interpretative summaries of all analyses to identify the key findings for each data set. The findings related to each research question (outlined above) from all five data sets will be sorted and separated into three files (one for each research question – fidelity, acceptability, mechanisms of action). Step 2 will involve researchers reviewing the contents of each file to identify the key themes discussed in each data set to create a unified list of themes. These themes will form the rows of a convergence coding matrix used to summarise similarities from the second step; each key finding will be compared across the five data sets to create the matrix. For each key finding, paired comparisons will be made to compare the data coming from each data set. The relationship between data will be marked as one of four categories: silence, dissonance (or disagreement), partial agreement and agreement (see Table 4). Comparisons will be labelled as not applicable to denote the source of data which has supplied a theme or when neither data set in a paired comparison contained data related to the finding. This will be followed by convergence assessment (Step 3) and completeness comparison (Step 4). The level of agreement between the two researchers with respect to the degree of convergence between data sets (in both meaning and prominence of key findings) will then be calculated (Step 5). A method established by Miles and Huberman will be used, whereby agreements are scored with 1 and disagreements scored with 0, and the percentage agreement calculated [32]. Miles and Huberman suggest that an inter-coder reliability of 80% agreement on level of convergence is acceptable agreement among multiple coders. Any disagreements will be resolved by consensus through discussion with another researcher. The triangulated results will then be presented to the wider research team for discussion and to make a final decision on the interpretation of the findings (Step 6).
Table 4: Triangulation Protocol
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Step
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Activity
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1. Sorting
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Sort findings from each data set to identify the key findings that address each research question of interest to determine areas of content overlap and divergence. A list of the key themes will be compiled and added to the convergence coding matrix
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2. Convergence coding
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Compare the findings to determine the degree of convergence of (a) essence of the meaning and prominence (e.g. the number of participants mentioning a theme) of the themes presented and (b) specific examples provided in relation to each theme. Characterise the degree and type of convergence using the following concurrence coding scheme within theme areas:
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Convergence coding scheme
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Agreement
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There is full agreement between the sets of results on both elements of comparison (e.g. meaning and prominence are the same and specific examples provided are the same)
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Partial agreement
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There is agreement on one but not both components (e.g. the meaning or prominence of themes is the same or specific examples provided are the same)
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Silence
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One set of results covers the theme or example, whereas the other set of results is silent on the theme or example
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Dissonance
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There is disagreement between the sets of results on both elements of comparison (e.g. meaning and prominence are different and specific examples provided are different)
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3. Convergence assessment
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Review convergence coding matrix to provide a global assessment of the level of convergence. Document when and where researchers have different perspectives on convergence or dissonance of findings
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4. Completeness comparison
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Compare the findings from the convergence coding matrix to create an overarching summary of the findings, highlighting both unique and similar contributions to each research question
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5. Researcher comparison
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Determine the degree of agreement among researchers on triangulated findings. Any disagreements will be resolved by consensus through discussion with another researcher
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6. Feedback
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Feedback of triangulated results to the wider research team for review and clarification
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Adapted from [31]
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Data management and monitoring
All participants (patients, GPs, practice staff and GP practices) will be given a unique study ID number and data will be anonymised/pseudonymised (e.g. study-specific data collection forms and interview transcripts). Personal data including consent forms, completed questionnaires or transcripts will be held in a locked filing cabinet, within a locked office on a secure keycode-protected floor of the School of Pharmacy, Queen’s University Belfast (QUB) or the School of Pharmacy and Pharmaceutical Sciences, TCD. Electronic data will be stored within the QUB or TCD network space and will be password-protected to ensure confidentiality. Interviews will be digitally recorded (with permission and written, informed consent), transcribed and checked for accuracy. Once transcripts have been checked for accuracy recordings will be deleted and transcriptions stored within QUB or TCD. All participant consent forms, questionnaires, study-specific data collection forms and transcripts stored at TCD will be transferred to QUB, in line with General Data Protection Regulation guidelines for transferral of data, upon study completion. This will be done via recorded delivery for hard copy data and encrypted email for electronic data. When the study has been completed, the forms and transcripts will be securely stored for five years and then destroyed. The investigators will conduct the study in compliance with the protocol given approval/favourable opinion by the relevant RECs. Changes to the protocol may require REC approval prior to implementation, except when modification is needed to eliminate an immediate hazard(s) to patients. The CI and trial team, in collaboration with the sponsor, will submit all protocol modifications to the RECs for review in accordance with the governing regulations. Protocol compliance will be monitored by the trial team who will undertake site visits to ensure that the trial protocol is adhered to and necessary paperwork (e.g. questionnaires, consent forms) is being completed appropriately. The findings of this process evaluation will be communicated to all participants, published in relevant journals and presented at conferences.