Barriers and Facilitators to Implementing Evidence for Improving Medication Adherence in Elderly Patients with Hypertension: a scoping review

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Improving medication adherence is one of the measures to effectively control blood pressure, and although there has been a great number of publications on how to improve medication adherence in elderly hypertensive patients, implementation in real practice remains a challenge. Moreover, little attention has been paid to what exactly are the factors that influence the implementation of the evidence. The purpose of this review is to provide a systematic overview of the barriers and facilitators that influence the implementation of evidence for improving medication adherence in the elderly hypertensive patient. Methods This review is based on Arksey and O'Malley methodology and searched six electronic databases. Two independent reviewers were involved in the screening and graphing of the data. Findings were synthesized and categorized using the five domains of the Consolidated Framework for Implementation Research (CFIR). Results A total of 15 studies were included in the final review. Barriers and facilitators were mapped to constructs in 14 of the five domains of the CFIR. The most frequently cited barriers were mapped to constructs within the "intervention characteristics" domain. Similarly, the most frequently mentioned facilitators were derived from the "intervention characteristics". Overall, the intervention content of the existing studies was not generalizable and accessible, whereas other factors such as family involvement in the “process” were effective in facilitating the implementation of the evidence. Conclusions This review identifies barriers and facilitators in the implementation of evidence about improving medication adherence in the elderly hypertensive patient. Future research should focus more on how to intervene with barriers and facilitators so that they can actually be implemented to promote improved medication adherence in the elderly hypertensive population. Medication adherence Elderly Hypertension Consolidated framework for implementation research Barriers Facilitators Scoping review Figures Figure 1 Figure 2 Background By 2050, the over-65 population is estimated to be 1.6 billion, with the population aged 80 and over increasing even faster( 1 ). Hypertension is a common-place disease in the elderly, the leading cause of cardiovascular disease and premature death worldwide, contributing to cardiac insufficiency, stroke, and chronic kidney disease( 2 , 3 ). A reasonably controlled lowering of blood pressure has been found to result in significant morbidity and mortality in the elderly( 4 , 5 ). Improving medication adherence leads to effective blood pressure control ( 6 – 8 ). Moreover, the evidence on improving medication adherence in elderly hypertensive patients is numerous( 9 – 11 ). However, the challenge of bringing these interventions to new situations is significant, the alarming fact that it can take up to 17 years for evidence-based practices to be published and implemented into practice, only 14% of the original research has ever been applied to patient care( 12 ), contributes to the fact that effective interventions are not applied in clinical practice in a timely way. Although many researchers realized this problem, showed a growing interest in research on how to translate knowledge into practice, the results were very superficial and progress was slow( 13 ). To work through this problem, implementation science was born, it is defined as “scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services and care”( 14 ). Implementation science is not to re-validate whether an evidence-based practices are effective in improving patient outcomes, but rather to enable the effective adoption and implementation of evidence-based practices in clinical and public health settings through contextualized implementation strategies. It has been shown that there has been a significant quantity of research on the implementation of science, and yet only 9% of the research on hypertension is conducted( 15 ). Accordingly, more attention should be focused on hypertension research. Identifying barriers and facilitators in the implementing research process is critical, in terms of matching the most effective implementation strategies in the upcoming work( 16 ). The Consolidated Framework for Implementation Research (CFIR) framework is frequently used in implementation research to identify potential barriers and facilitators( 17 – 20 ). In 2009, the CFIR framework was developed by Damschroder, using a snowball sampling method to extract and analyze the content of 19 theories and models, which were finally integrated into this practical and comprehensive theoretical framework( 21 ). CFIR includes 5 main dimensions: innovation, outer setting, inner setting, individuals and implementation process, it plays an architectural role in implementation research and can be utilized to find barriers and facilitators to the implementation process, which can have significant implications for future research( 19 , 20 ). Therefore, it would be meaningful to identify barriers and facilitators in the implementation of evidence for improving medication adherence in elderly hypertensive patients with the assistance of the CFIR framework, leads to the establishment of targeted implementation strategies to bridge the gap between evidence publication and implementation. Methods This research was guided by Arksey and O' Malley's( 22 ) framework for scoping reviews, written in a consistent format in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews(PRISMA-ScR)( 23 ), published in 2018. The process is executed in 5 steps: Identifying the research question; Identifying relevant studies; Study selection; Charting the data; Collating, summarizing and reporting the results. Step 1 Identifying the research question Our research questions have two components: What are the barriers and facilitators encountered in implementing evidence for improving medication adherence in elderly hypertensive patients in healthcare settings? How can the CFIR framework be used to classify the barriers and facilitators encountered in implementing evidence for improving medication adherence in elderly hypertensive patients? Step 2 Identifying relevant studies The following databases MEDLINE (PubMed), EMBASE, Web of Science (science and social science citation index), Cochrane Central Register of Controlled Trials (Central), CINAHL and PsycINFO were chosen and retrieved from inception to September 2023 for publications with no limit on language. A recursive search was performed on the references of all articles obtained. A combination of thematic and free word searches was used (see Table 1 ), and the screening of literature was carried out independently by two researchers each, with disagreements on inclusion or exclusion resolved by consulting a third expert to resolve differences. According to the "PCC principles: research participants, concept, and context " ( 24 ) ,we conducted a literature search for (i)participants: elderly hypertensive patients,(ii)concept: barriers and facilitators to implement the evidence for improving medication adherence,(iii)context: the study of hypertension in hospitals, nursing homes, communities, and so on. improving medication adherence. Table 1 Summary of the Search Strategy #1 elderly OR aged [MESH] #2 hypertension [MESH] OR “high blood pressure*” OR HTN OR HBP #3 Medication Adherence [MESH] OR “Drug Adherence” OR “Medication Nonadherence” OR “Medication Noncompliance” OR “Medication Non-Adherence” OR “Medication Non Adherence” OR “Medication Persistence” OR “Medication Compliance” OR “Medication Non-Compliance” OR “Medication Non Compliance” OR “Drug Compliance” #4 facilitat* OR promot* OR boost* OR enhenc* OR advanc* OR elevat* OR improv* OR increase* #5barrier* OR impact* OR influenc* OR problem* OR difficult* OR limit* OR restrict* OR confin* OR hinder* OR obstruct* OR obstacle* OR impediment* OR disincenti* #6 implement* OR actualiz* OR conduct* OR application* OR apply #7 (#1 AND #2 AND #3 AND (#4 OR #5) AND #6) Step 3 Study selection All search records were imported into Endnote and screened for duplicates. Literature screening and data extraction were carried out independently by JYZ and JJZ, and any disagreements were decided after discussion with XJZ. Firstly, the article titles and abstracts were initially screened for inclusion if they met the following criteria:(i) described interventions to improve medication adherence in elderly hypertensive patients, (ii) A description of barriers and facilitators to the intervention was included in the article, (iii) Published in English. Correspondingly, the exclusion criteria were (i) Failure to focus on improving medication adherence in elderly hypertensive patients, (ii) Research programs and studies that did not report on the implementation of facilitators and barriers, (iii) Unavailability of full text, critical reviews, protocol and viewpoint articles. Step 4 Charting the data Retrieved literature titles were imported into EndNote software to screen for duplicates. The initial screening of titles and abstracts was performed independently by 2 researchers according to inclusion and exclusion criteria, and those that potentially met the inclusion criteria were imported into the full-text annex for reading. Data information was extracted and checked, and in case of disagreement, it was adjudicated by a third person. Data extraction information mainly included: first author, year of publication, country, aims, study design, barriers, and facilitators. Step 5 summarising and reporting the results Facilitators and barriers were coded on the CFIR framework using a thematic approach. The steps were as follows: barriers and facilitators were extracted independently from each article by pairs; after extraction, barriers and facilitators were discussed for each article to reach consensus; each barrier or facilitator was coded independently by pairs under the CFIR constructs; results were discussed after independent coding was completed, and disagreements were harmonized; revised coding results were independently read and checked by pairs to ensure that all the facilitators and barriers were correctly mapped to the CFIR constructs; all information coded was summarized and categorized according to the categorized barriers and facilitators; all information coded was summarized and categorized according to the categorized barriers and facilitators. The revised coding results were independently read and checked by pairs to ensure that all facilitators and barriers were correctly mapped to the CFIR dimensions; all information coded was summarized, and the final version was finalized based on the summary of the barriers and facilitators, in consultation with experts and scholars in the field of implementation science. Results A total of 15 articles were reviewed and matched inclusion criteria (Figure 1). Among the studies focusing on the implementation of evidence for improving medication adherence in elderly hypertensive patients. 86.7% of the literature that matched the inclusion criteria was from studies conducted in the last 5 years. On the basis of the Data extraction instrument recommended by the JBI scoping review(25), the results were summarized using Microsoft Excel table to describe the characteristics of each research (Additional file 1.Table 2).The barriers and facilitators involved are mapped to the CFIR framework, as demonstrated by Table 3. To clearly demonstrate the distribution of barriers and facilitators in the implementation of evidence, the figure is plotted to show the number of articles for each structure in the specific dimension mentioned (Figure 2). Table 3 Barriers and Facilitators to Coding to the CFIR Framework Topic/Description Barriers(amounts) Facilitators(amounts) I.INTERVENTION CHARACTERISTICS A Intervention Source B Evidence Strength & Quality 1(26) C Relative advantage 1(27) 1(28) D Adaptability 3(29-31) E Trialability 1(32) F Complexity 1(27) 2(30, 33) G Design Quality and Packaging H Cost 1(34) 1(27) II.OUTER SETTING A Patient Needs & Resources B Cosmopolitanism C Peer Pressure D External Policy & Incentives III.INNER SETTING A Structural Characteristics B Networks & Communications C Culture D Implementation Climate 1 Tension for Change 2 Compatibility 3 Relative Priority 3(34-36) 4 Organizational Incentives & Rewards 5 Goals and Feedback 6 Learning Climate E Readiness for Implementation 1 Leadership Engagement 2 Available Resources 3 Access to knowledge and information 1(27) 2(29, 30) IV. CHARACTERISTICS OF INDIVIDUALS A Knowledge & Beliefs about the Intervention 2(26, 34) B Self-efficacy 1(37) C Individual Stage of Change D Individual Identification with Organization E Other Personal Attributes 4(26, 29, 30, 34) 1(29) V.PROCESS A Planning 1(10) B Engaging 1 Opinion Leaders 2 Formally appointed internal implementation leaders 3 Champions 4 External Change Agents 3(29, 38, 39) C Executing 1(26) D Reflecting & Evaluating Barriers Barriers were found to total 11, including complexity of the intervention, mental deterioration and language barriers in the elderly, financial constraints preventing the purchase of sphygmomanometers, lack of education on the disease and the effectiveness of blood pressure control, lack of training of healthcare professionals in the relevant knowledge, and inability of digital interventions to protect personal privacy. Based on the definitions of the 39 constructs of the CFIR framework, the barriers were mapped to the corresponding dimensions, and the results were mapped to 7 different constructs in 3 dimensions, including evidence strength & quality(n=1), relative advantage(n=1), complexity(n=1) and cost (n=1) under the dimension of intervention characteristics, access to knowledge and information(n=1) under the dimension of inner setting, knowledge & beliefs about the intervention(n=2)and other personal attributes(n=4) under the dimension of characteristic of individuals. Intervention characteristics Evidence Strength & Quality is defined as stakeholders’ perceptions of the quality and validity of evidence supporting the belief that the intervention will have desired outcomes. Unawareness of the effectiveness of current antihypertensive treatment is a barrier to the achievement of hypertension control(26), Clearly, there is a knowledge gap in the management of hypertension in elderly patients. Relative advantage is defined as stakeholders’ perception of the advantage of implementing the intervention versus an alternative solution. A location-sensing app created by a university or charity rather than a commercial company(27), As such, apps produced by universities or charities that provide interventions may be a barrier to preventing elderly patients from improving their medication adherence compared to commercial organizations. Complexity is defined as Perceived difficulty of implementation, reflected by duration, scope, radicalness, disruptiveness, centrality, and intricacy and number of steps required to implement. Over-complicating the digital intervention or overburdening the user, resulting in reduced intervention engagement(27), Therefore, the complexity of digital interventions makes it difficult for older people to understand the operation and ultimately makes it more difficult to land evidence. Cost is defined as Costs of the intervention and costs associated with implementing that intervention including investment, supply, and opportunity costs. Many patients were not using a sphygmomanometer regularly prior to the study because of financial limitations(34),the high cost of blood pressure measuring devices makes them unaffordable for some elderly hypertensive patients and is a barrier to getting evidence implemented. Inner setting Access to knowledge and information is defined as ease of access to digestible information and knowledge about the intervention and how to incorporate it into work tasks, comprehensive training for healthcare professionals which incorporate the principles of shared decision making and the skills to deliver the intervention in under 5 minutes(27), likewise, the unskilled and lack of training of medical staff in the process of evidence-based interventions creates a certain barrier factor. Characteristics of individuals Knowledge & beliefs about the intervention is defined as individuals’ attitudes toward and value placed on the intervention as well as familiarity with facts, truths, and principles related to the intervention. Knowledge gaps, lack of motivation, and intolerance of adverse events and negligence among elderly patients to improve medication adherence are barriers that prevent the implementation of interventions(26, 34). Other personal attributes are defined as a broad construct to include other personal traits such as tolerance of ambiguity, intellectual ability, motivation, values, competence, capacity, and learning style. Language barriers in elderly patients were also found to hinder the implementation of the evidence, leading to poor communication between healthcare professionals and them(29), as well as refusal to use smartphones because of their limited knowledge, lack of skills in using mobile phones, and fear of lack of privacy and mistrust(30, 34). Also, having dementia was considered to be a barrier factor(26). Facilitators Facilitating factors were found to include 24, including mobile apps developed by non-commercial companies, family involvement, personal cultural beliefs, nurses, pharmacists, community, implementation of scientific training for healthcare professionals, rigorous and diverse intervention programs, use of standardized theoretical frameworks, provision of patient-centered care, focus on bridging the knowledge gap of patients, targeted patient education. Facilitators are coded into the 4 constructs and 12 dimensions of the CFIR framework, relative advantage(n=1), adaptability(n=3), trialability(n=1), complexity(n=2), cost(n=1) under the dimension of intervention characteristics, relative priority(n=3), access to knowledge and information(n=2) under the dimension of inner setting, self-efficacy(n=1), other personal attributes(n=1) under the dimension of characteristic of individuals, planning(n=1), engaging(n=3),executing(n=1) under the dimension of process. Intervention characteristics By determining a patient's current level of health literacy, educational interventions can be tailored to specific individuals to address gaps related to practice issues in health literacy(26), This factor is summarized in relative advantage. Adaptability is defined as the degree to which an intervention can be adapted, tailored, refined, or reinvented to meet local needs. A bilingual hand book for rural Thai-Muslims with low levels of literacy and limited reading abilities(29), incorporate video chat features into mHealth apps, simplify smartphone technology for older adults with limited digital literacy(30), using of established theoretical frameworks, and structured interventions lead to a facilitating role(31). Trialability is defined as the ability to test the intervention on a small scale in the organization, and to be able to reverse course (undo implementation) if warranted. Pharmacy refill-adherence metrics can identify potential clinical adherence issues and facilitate targeted interventions, and pharmacists can then use this information to promote patient adherence. Complexity was mentioned in 2 studies, with easy-to-use mobile apps(30), multimodal interventions including individualized teaching on medication adherence and healthy lifestyles, leaflets on medication adherence and healthy lifestyles, weekly medication reminder boxes and follow up telephone reminders, as well as nurses contributing to improving medication adherence(33). Apps developed by universities or charities, rather than commercial companies, are also one of the contributing factors, and where this is mapped to cost(27). Inner setting Relative Priority is defined as individuals’ shared perception of the importance of the implementation within the organization. Pharmacists or pharmacy students identified and addressed patient barriers by asking questions over the phone to patients prescribed medications for hypertension, while pharmacist-led home-based interventions were highly effective in improving medication adherence(34-36). Educate all clinical nurses on the purpose and significance of the evidence-based implementation of improving medication adherence in elderly hypertensive patients and how to utilize the various tools to enable patients to receive extensive education and training in order to be able to use smartphone technology, these two points are categorized as access to knowledge and information. External change agents is defined as individuals who are affiliated with an outside entity who formally influence or facilitate intervention decisions in a desirable direction. Characteristic of individuals Self-efficacy is defined as individual belief in their own capabilities to execute courses of action to achieve implementation goals. Self-management interventions, namely cognitive-behavioral, self-efficacy, self-regulation, education, and self-care interventions, effectively promote the implementation of evidence on medication adherence in hypertensive elderly people(40). Working alongside cultural belief systems is an important step toward improving adherence regime, that personal cultural belief that belongs to the individual is mapped to other personal attributes. Process Planning is defined as the degree to which a scheme or method of behavior and tasks for implementing an intervention are developed in advance and the quality of those schemes or methods. To promote adherence to antihypertensive medication, tailored education is recommended for elderly hypertensive patients(10), advanced planning of what to teach is important. External change agents are defined as individuals who are affiliated with an outside entity who formally influence or facilitate intervention decisions in a desirable direction. Family member participation, combined with community management, are two approaches that can contribute well to the implementation of the evidence(29, 38, 39). Executing is defined as carrying out or accomplishing the implementation according to plan. Physicians should endeavor to educate patients about the importance of regular blood pressure measurement at home and focus on bridging the knowledge gap so that the evidence falls better on the ground(26). Discussion This article provides a scoping review of evidence implementation for improving medication adherence in older hypertensive patients through a synthesis of the evidence, with somewhat more facilitators mentioned than barriers. Therefore, the evidence can be maximized by strengthening the facilitators while avoiding the barriers in future work on evidence implementation. Clearly, from the data presented in Fig. 2, intervention characteristics are particularly critical to the implementation of the evidence, both the number of structures on the framework and the number of articles mentioned. Whether barriers or facilitators, the most salient dimensions when mapped to the CFIR framework is intervention characteristics, so the characteristics of the intervention are worthy of consideration. Looking at the number of structures that were mapped to the back of the framework, characteristic of individuals and process were placed at the same level, while the inner setting was ranked at the bottom. When considered in terms of barriers and facilitators, on the other hand, there are different perspectives. Barriers Throughout the entirety of the review, barriers were mapped most frequently to the dimension of intervention characteristics, but the construct of other personal attributes under the dimension of characteristic of individuals should not be overlooked. More attention should be devoted to improving the strength and quality of the evidence, exploiting the strengths of the evidence, and reducing the complexity of the evidence and its costs in the implementation of future studies to promote medication adherence in elderly hypertensive patients. Elderly hypertensive patients lack awareness of the benefits of improving medication adherence, and therefore future measures such as targeted health education can be used to increase their awareness( 41 ), thereby reducing the barriers to evidence-based implementation. At the same time, smartphones play an important role in managing the health of elderly people( 42 ), but the elderly are afraid of having their privacy exposed, they prefer APPs developed by professional organizations or universities to promote medication taking, and avoid APPs developed by commercial organizations, which may be effective in promoting evidence-based applications. Moreover, the content and usage of APPs should be simple and easy to use( 43 ), avoiding complications that may make the elderly, who are already not very skilled in APPs, even more reluctant to use them( 44 ). Since the elderly may not have enough available money to afford expensive sphygmomanometers considering their financial burden, it would be one of the good ways to promote the evidence down to the level of the government agencies if they can reduce the price of the sphygmomanometers sold or subsidize the purchase of the sphygmomanometers for the elderly hypertensive patients. In addition to the above, access to knowledge and information for medical staff in the inner setting should be strengthened and more training opportunities should be provided for them. The lack of training of the medical staff conducting the intervention leads to a lack of proficiency in the whole process of evidence-based interventions, and the application of evidence thus becomes a small gap. Therefore, after the intervention plan has been defined, the staff implementing the strategy should be systematically trained to master understanding the whole process. In addition, because of the lack of belief in change among elderly people and personal characteristics that cannot be avoided at this age, such as poor memory, a willingness to forget and poor learning ability( 45 ), the implementation of the evidence also turns out to be a hindrance. The lack of motivation to control blood pressure and even frequent forgetfulness to take medication are barriers to the implementation of interventions as elderly hypertensive patients experience a gradual decline in intelligence and even dementia as they age( 46 ), as well as insufficient reception, learning, and comprehension of new things, and even language barriers, resulting in an inability to express themselves correctly with medical staff. In summary, the most significant barriers analyzed in relation to the CFIR framework focused on intervention characteristics, followed by individual characteristics and, to a lesser extent, inner setting. In order to avoid the waste of evidence in the future, the design and implementation of intervention plans should focus on the complexity, effectiveness, advantages, and costs. Meanwhile, it should also focus on the training of the personnel involved in the intervention, and control the cost of the intervention, to prevent certain materials or instruments in the intervention from being too expensive and unaffordable to the patients, which will make the barriers bigger. Facilitators As opposed to barriers to implementation, there are a number of facilitators that can be referenced to accelerate the application and implementation of evidence. Intervention characteristics are overwhelmingly dominant in terms of facilitating. A very advantageous, well adapted and trialed, straightforward to implement and spending little money, it is extremely easy to promote the implementation of evidence. Before implementing the strategy, it is recommended that the health literacy of hypertensive patients be assessed( 10 , 47 , 48 ), this is also necessary for elderly patients with high blood pressure ,for patients with low literacy levels and poor reading skills, manuals suitable for the elderly that are simple and easy to understand can be produced( 49 ). In order to better improve medication adherence in the elderly through electronic information technology( 43 ), electronic interventions, including APPs, weekly medication reminder boxes, and follow up telephone text message reminders, etc. The APPs being mentioned should be developed by charities or university institutions, which on the one hand reduces the cost of use and protects privacy at the same time. If possible, it is recommended to include a video chat function in the APP, so that the interventionists can get in touch with the elderly in a timely manner. For pharmacies, refill-adherence metrics indicator can access the medication taken by older people, so if more attention can be paid to this indicator of pharmacy refill, it will be another very favorable facilitator in the process of evidence implementation. The pharmacist together with his students and nurses are favorable facilitators throughout the implementation of the evidence. Recognition and implementation of self-management among elderly hypertensive patients is an important factor influencing the implementation of the evidence, and good self-management can effectively contribute to the implementation of the evidence( 50 ). At the same time, one's cultural beliefs play a crucial role in the control of hypertension. Therefore, the application of evidence can be facilitated by enhancing self-management in older adults and respecting their cultural beliefs. Doctors play an equally important role in the implementation of evidence, and if they emphasized the benefits of improved medication adherence in controlling hypertension in elderly hypertensive patients, then this will make older people more willing to participate in the intervention process. The involvement of family members is also very significant, and family members of older hypertensive patients should be encouraged to join the intervention process together to promote the evidence being well applied to older adults( 51 ). The community actually plays a pivotal role in the overall implementation process, and all 3 roles can go a long way in making the evidence applicable. By coding the facilitators onto the CFIR framework, it was found that good intervention characteristics are likewise the factors that best facilitate the implementation of the evidence, and that the various factors throughout the implementation process are also facilitators if they are well mapped, and of course targeted interventions based on individual characteristics and external factors can likewise facilitate the implementation of the evidence. Limitations The limitations of this study are as follows, firstly the search was limited to English only, which resulted in a number of articles written in other languages not being found and included. Secondly, the study subjects included in this study were elderly hypertensive patients, and after searching and synthesising the results, a decision was made to include all of the literature where the vast majority of the study subjects were elderly patients, otherwise there would have been a minimal amount of literature carried out solely on elderly hypertensive patients. Thirdly, in future studies, implementation strategies will be developed to facilitate the translation of evidence into practice by addressing the barriers that have been identified. Conclusion The results of this review suggest that there are a number of barriers and facilitators to the implementation of evidence for improving medication adherence in the elderly hypertensive population. For most interventions, intervention characteristics were the most relevant barriers and the most relevant facilitators of contributing factors. Several implications of these findings for practice and research may facilitate the management of elderly hypertensive patients, reduce mortality, and improve the quality of life of those who are elderly. We found that an approach that promotes evidence implementation by increasing the ease of acceptance of intervention content and modalities, and involving family members of the elderly in all phases of the implementation process, may lead to better implementation results, and efforts to improve blood pressure in older adults may achieve the desired outcomes. At the same time, CFIR is a useful framework for effectively categorizing barriers and facilitators through which the greatest factors can be identified for intervention. It could be used extensively in future implementation studies to report facilitators and barriers. Abbreviations CFIR: Consolidated Framework for Implementation Research Declarations Ethics approval and consent to participate Not applicable. Consent for publication Not applicable Data availability All data generated or analysed during this study are included in this published article and its supplementary information files. Competing interests The authors declare that they have no competing interests. Funding This work was supported by the National Nature Science Foundation of China (Grant No. 72104044), the Natural Science Foundation of Liaoning Province (Grant No. 2022-BS-255) and the China Postdoctoral Science Foundation (Grant No.2023MD734243). Authors' contributions TS and XZ conceptualised the study and supervised the research team together. TS and JYZ determined the search methodology, JYZ and JJZ performed abstract review, full-text review, and data extraction, and XZ and YZ served as arbitrators. JYZ was a major contributor to the writing of the manuscript, XZ refined the manuscript, and all authors provided feedback and approved the final version. References Fund UNP. 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JBI Manual for Evidence Synthesis. 2022. Tsimtsiou Z, Kokkali S, Tatsioni A, Birka S, Papaioannou A, Dislian V, et al. Identifying patient-related barriers in hypertension control: a multi-centered, mixed-method study in Greek rural practices. Rural and Remote Health. 2020;20(4). Van Emmenis M, Jamison J, Kassavou A, Hardeman W, Naughton F, A'Court C, et al. Patient and practitioner views on a combined face-to-face and digital intervention to support medication adherence in hypertension: A qualitative study within primary care. BMJ Open. 2022;12(2). Ross T. Increasing Medication Adherence in Hypertensive Patients with Million HeartsRTM Health Literacy Program. Increasing Medication Adherence In Hypertensive Patients With Million Heartsrtm Health Literacy Program. 2018:1-. Perngmark P, Doloh N, Holroyd E. Family Participation to Promote Medication Adherence Among Thai-Muslim Older Adults With Hypertension: Action Research Study. J Transcult Nurs. 2022;33(3):381-7. Greer DB, Abel WM. Exploring Feasibility of mHealth to Manage Hypertension in Rural Black Older Adults: A Convergent Parallel Mixed Method Study. Patient Preference and Adherence. 2022;16:2135-48. Krousel-Wood M, Craig LS, Peacock E, Zlotnick E, O'Connell S, Bradford D, et al. Medication Adherence: Expanding the Conceptual Framework. Am J Hypertens. 2021;34(9):895-909. Dillon P, Smith SM, Gallagher P, Cousins G. The association between pharmacy refill-adherence metrics and healthcare utilisation: a prospective cohort study of older hypertensive adults. Int J Pharm Pract. 2019;27(5):459-67. Sheilini M, Hande HM, Prabhu MM, Pai MS, George A. Impact of multimodal interventions on medication nonadherence among elderly hypertensives: A randomized controlled study. Patient Preference and Adherence. 2019;13:549-59. Moultry AM, Pounds K, Poon IO. Managing medication adherence in elderly hypertensive patients through pharmacist home visits. Consultant Pharmacist. 2015;30(12):710-9. Stanton-Robinson C, Al-Jumaili AA, Jackson A, Catney C, Veach S, Witry MJ. Evaluation of community pharmacist-provided telephone interventions to improve adherence to hypertension and diabetes medications. J Am Pharm Assoc (2003). 2018;58(4s):S120-s4. Hedegaard U, Hallas J, Ravn-Nielsen LV, Kjeldsen LJ. Process- and patient-reported outcomes of a multifaceted medication adherence intervention for hypertensive patients in secondary care. Res Social Adm Pharm. 2016;12(2):302-18. Van Truong P, Wulan Apriliyasari R, Lin MY, Chiu HY, Tsai PS. Effects of self‐management programs on blood pressure, self‐efficacy, medication adherence and body mass index in older adults with hypertension: Meta‐analysis of randomized controlled trials. International Journal of Nursing Practice (John Wiley & Sons, Inc). 2021;27(2):1-12. Tankumpuan T, Anuruang S, Jackson D, Hickman OD, DiGiacomo M, Davidson PM. Improved adherence in older patients with hypertension: An observational study of a community-based intervention. International Journal of Older People Nursing. 2019;14(3). Son KJ, Son HR, Park B, Kim HJ, Kim CB. A Community-Based Intervention for Improving Medication Adherence for Elderly Patients with Hypertension in Korea. Int J Environ Res Public Health. 2019;16(5). Van Truong P, Wulan Apriliyasari R, Lin MY, Chiu HY, Tsai PS. Effects of self-management programs on blood pressure, self-efficacy, medication adherence and body mass index in older adults with hypertension: meta-analysis of randomized controlled trials. International journal of nursing practice. 2021;27(2):e12920. Woodham NS, Taneepanichskul S, Somrongthong R, Kitsanapun A, Sompakdee B. Effectiveness of a Multidisciplinary Approach Intervention to Improve Blood Pressure Control Among Elderly Hypertensive Patients in Rural Thailand: A Quasi-Experimental Study. Journal of Multidisciplinary Healthcare. 2020;13:571-80. Liang X, Xiong F, Xie F. The effect of smartphones on the self-rated health levels of the elderly. BMC Public Health. 2022;22(1):508. Jiménez-Chala EA, Durantez-Fernández C, Martín-Conty JL, Mohedano-Moriano A, Martín-Rodríguez F, Polonio-López B. Use of Mobile Applications to Increase Therapeutic Adherence in Adults: A Systematic Review. Journal of Medical Systems. 2022;46(12). Quaosar G, Hoque MR, Bao Y. Investigating Factors Affecting Elderly's Intention to Use m-Health Services: An Empirical Study. Telemed J E Health. 2018;24(4):309-14. Meng X, Li G, Jia Y, Liu Y, Shang B, Liu P, et al. Effects of dance intervention on global cognition, executive function and memory of older adults: a meta-analysis and systematic review. Aging Clin Exp Res. 2020;32(1):7-19. Cho MH, Han K, Lee S, Jeong SM, Yoo JE, Kim S, et al. Blood pressure and dementia risk by physical frailty in the elderly: a nationwide cohort study. Alzheimers Res Ther. 2023;15(1):56. Lou SP, Han D, Kuczmarski MF, Evans MK, Zonderman AB, Crews DC. Health Literacy, Numeracy, and Dietary Approaches to Stop Hypertension Accordance Among Hypertensive Adults. Health Educ Behav. 2023;50(1):49-57. Yazdanpanah Y, Saleh Moghadam AR, Mazlom SR, Ali Beigloo RH, Mohajer S. Effect of an Educational Program based on Health Belief Model on Medication Adherence in Elderly Patients with Hypertension. Journal of Evidence-based Care. 2019;9(1):52-62. Ge L, Heng BH, Yap CW. Understanding reasons and determinants of medication non-adherence in community-dwelling adults: a cross-sectional study comparing young and older age groups. BMC Health Serv Res. 2023;23(1):905. Van Truong P, Wulan Apriliyasari R, Lin MY, Chiu HY, Tsai PS. Effects of self-management programs on blood pressure, self-efficacy, medication adherence and body mass index in older adults with hypertension: Meta-analysis of randomized controlled trials. Int J Nurs Pract. 2021;27(2):e12920. Woodham N, Taneepanichskul S, Somrongthong R, Auamkul N. Medication adherence and associated factors among elderly hypertension patients with uncontrolled blood pressure in rural area, Northeast Thailand. Journal of Health Research. 2018;32(6):449-58. Table Table 2 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files SupplementaryMaterial1.docx Table 2 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4015978","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":279657795,"identity":"8bd6efc1-bec2-48b3-8a2b-886ce4d38e3b","order_by":0,"name":"Jingying Zhang","email":"","orcid":"","institution":"First Affiliated Hospital of Dalian Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jingying","middleName":"","lastName":"Zhang","suffix":""},{"id":279657796,"identity":"528dca23-1e07-4a7b-b04a-7718e56bc862","order_by":1,"name":"Jingjing Zhao","email":"","orcid":"","institution":"First Affiliated Hospital of Dalian 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08:31:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4015978/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4015978/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":52791219,"identity":"3f0a0832-8cfd-431b-b4b0-a744eb14f228","added_by":"auto","created_at":"2024-03-15 19:56:17","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":143107,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA Flow Diagram\u003c/p\u003e","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4015978/v1/2b24cd90039ba6189db29c85.png"},{"id":52789953,"identity":"93ae9d41-58a6-4223-8a5c-dbe82804341d","added_by":"auto","created_at":"2024-03-15 19:48:17","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":108118,"visible":true,"origin":"","legend":"\u003cp\u003eNumber of articles for each construct in the CFIR dimensions mention\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4015978/v1/262916b0217f6ba6da57fc95.png"},{"id":59399535,"identity":"2179c97c-b871-4a0e-a20d-6ab5c24be335","added_by":"auto","created_at":"2024-07-01 09:52:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":891305,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4015978/v1/2099b673-5c5b-46bc-9304-7f23d9825a70.pdf"},{"id":52789954,"identity":"177cb65b-67d6-4384-8019-636aee65051f","added_by":"auto","created_at":"2024-03-15 19:48:17","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":50305,"visible":true,"origin":"","legend":"\u003cp\u003eTable 2\u003c/p\u003e","description":"","filename":"SupplementaryMaterial1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4015978/v1/3db34ba8934f5dbc04d721e6.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Barriers and Facilitators to Implementing Evidence for Improving Medication Adherence in Elderly Patients with Hypertension: a scoping review","fulltext":[{"header":"Background","content":"\u003cp\u003eBy 2050, the over-65 population is estimated to be 1.6\u0026nbsp;billion, with the population aged 80 and over increasing even faster(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Hypertension is a common-place disease in the elderly, the leading cause of cardiovascular disease and premature death worldwide, contributing to cardiac insufficiency, stroke, and chronic kidney disease(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). A reasonably controlled lowering of blood pressure has been found to result in significant morbidity and mortality in the elderly(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Improving medication adherence leads to effective blood pressure control (\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Moreover, the evidence on improving medication adherence in elderly hypertensive patients is numerous(\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). However, the challenge of bringing these interventions to new situations is significant, the alarming fact that it can take up to 17 years for evidence-based practices to be published and implemented into practice, only 14% of the original research has ever been applied to patient care(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), contributes to the fact that effective interventions are not applied in clinical practice in a timely way. Although many researchers realized this problem, showed a growing interest in research on how to translate knowledge into practice, the results were very superficial and progress was slow(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo work through this problem, implementation science was born, it is defined as \u0026ldquo;scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services and care\u0026rdquo;(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Implementation science is not to re-validate whether an evidence-based practices are effective in improving patient outcomes, but rather to enable the effective adoption and implementation of evidence-based practices in clinical and public health settings through contextualized implementation strategies. It has been shown that there has been a significant quantity of research on the implementation of science, and yet only 9% of the research on hypertension is conducted(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Accordingly, more attention should be focused on hypertension research. Identifying barriers and facilitators in the implementing research process is critical, in terms of matching the most effective implementation strategies in the upcoming work(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Consolidated Framework for Implementation Research (CFIR) framework is frequently used in implementation research to identify potential barriers and facilitators(\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). In 2009, the CFIR framework was developed by Damschroder, using a snowball sampling method to extract and analyze the content of 19 theories and models, which were finally integrated into this practical and comprehensive theoretical framework(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). CFIR includes 5 main dimensions: innovation, outer setting, inner setting, individuals and implementation process, it plays an architectural role in implementation research and can be utilized to find barriers and facilitators to the implementation process, which can have significant implications for future research(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Therefore, it would be meaningful to identify barriers and facilitators in the implementation of evidence for improving medication adherence in elderly hypertensive patients with the assistance of the CFIR framework, leads to the establishment of targeted implementation strategies to bridge the gap between evidence publication and implementation.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis research was guided by Arksey and O' Malley's(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) framework for scoping reviews, written in a consistent format in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews(PRISMA-ScR)(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), published in 2018. The process is executed in 5 steps: Identifying the research question; Identifying relevant studies; Study selection; Charting the data; Collating, summarizing and reporting the results.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStep 1 Identifying the research question\u003c/h2\u003e \u003cp\u003eOur research questions have two components: What are the barriers and facilitators encountered in implementing evidence for improving medication adherence in elderly hypertensive patients in healthcare settings? How can the CFIR framework be used to classify the barriers and facilitators encountered in implementing evidence for improving medication adherence in elderly hypertensive patients?\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStep 2 Identifying relevant studies\u003c/h2\u003e \u003cp\u003eThe following databases MEDLINE (PubMed), EMBASE, Web of Science (science and social science citation index), Cochrane Central Register of Controlled Trials (Central), CINAHL and PsycINFO were chosen and retrieved from inception to September 2023 for publications with no limit on language. A recursive search was performed on the references of all articles obtained. A combination of thematic and free word searches was used (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), and the screening of literature was carried out independently by two researchers each, with disagreements on inclusion or exclusion resolved by consulting a third expert to resolve differences. According to the \"PCC principles: research participants, concept, and context \" (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) ,we conducted a literature search for (i)participants: elderly hypertensive patients,(ii)concept: barriers and facilitators to implement the evidence for improving medication adherence,(iii)context: the study of hypertension in hospitals, nursing homes, communities, and so on. improving medication adherence.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of the Search Strategy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#1 elderly OR aged [MESH]\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#2 hypertension [MESH] OR \u0026ldquo;high blood pressure*\u0026rdquo; OR HTN OR HBP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#3 Medication Adherence [MESH] OR \u0026ldquo;Drug Adherence\u0026rdquo; OR \u0026ldquo;Medication Nonadherence\u0026rdquo; OR \u0026ldquo;Medication Noncompliance\u0026rdquo; OR \u0026ldquo;Medication Non-Adherence\u0026rdquo; OR \u0026ldquo;Medication Non Adherence\u0026rdquo; OR \u0026ldquo;Medication Persistence\u0026rdquo; OR \u0026ldquo;Medication Compliance\u0026rdquo; OR \u0026ldquo;Medication Non-Compliance\u0026rdquo; OR \u0026ldquo;Medication Non Compliance\u0026rdquo; OR \u0026ldquo;Drug Compliance\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#4 facilitat* OR promot* OR boost* OR enhenc* OR advanc* OR elevat* OR improv* OR increase*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#5barrier* OR impact* OR influenc* OR problem* OR difficult* OR limit* OR restrict* OR confin* OR hinder* OR obstruct* OR obstacle* OR impediment* OR disincenti*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#6 implement* OR actualiz* OR conduct* OR application* OR apply\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#7 (#1 AND #2 AND #3 AND (#4 OR #5) AND #6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStep 3 Study selection\u003c/h2\u003e \u003cp\u003eAll search records were imported into Endnote and screened for duplicates. Literature screening and data extraction were carried out independently by JYZ and JJZ, and any disagreements were decided after discussion with XJZ. Firstly, the article titles and abstracts were initially screened for inclusion if they met the following criteria:(i) described interventions to improve medication adherence in elderly hypertensive patients, (ii) A description of barriers and facilitators to the intervention was included in the article, (iii) Published in English. Correspondingly, the exclusion criteria were (i) Failure to focus on improving medication adherence in elderly hypertensive patients, (ii) Research programs and studies that did not report on the implementation of facilitators and barriers, (iii) Unavailability of full text, critical reviews, protocol and viewpoint articles.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStep 4 Charting the data\u003c/h2\u003e \u003cp\u003eRetrieved literature titles were imported into EndNote software to screen for duplicates. The initial screening of titles and abstracts was performed independently by 2 researchers according to inclusion and exclusion criteria, and those that potentially met the inclusion criteria were imported into the full-text annex for reading. Data information was extracted and checked, and in case of disagreement, it was adjudicated by a third person. Data extraction information mainly included: first author, year of publication, country, aims, study design, barriers, and facilitators.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStep 5 summarising and reporting the results\u003c/h2\u003e \u003cp\u003eFacilitators and barriers were coded on the CFIR framework using a thematic approach. The steps were as follows: barriers and facilitators were extracted independently from each article by pairs; after extraction, barriers and facilitators were discussed for each article to reach consensus; each barrier or facilitator was coded independently by pairs under the CFIR constructs; results were discussed after independent coding was completed, and disagreements were harmonized; revised coding results were independently read and checked by pairs to ensure that all the facilitators and barriers were correctly mapped to the CFIR constructs; all information coded was summarized and categorized according to the categorized barriers and facilitators; all information coded was summarized and categorized according to the categorized barriers and facilitators. The revised coding results were independently read and checked by pairs to ensure that all facilitators and barriers were correctly mapped to the CFIR dimensions; all information coded was summarized, and the final version was finalized based on the summary of the barriers and facilitators, in consultation with experts and scholars in the field of implementation science.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 15 articles were reviewed and matched inclusion criteria (Figure 1).\u0026nbsp;Among the studies focusing on the implementation of evidence for improving medication adherence in elderly hypertensive patients.\u0026nbsp;86.7% of the literature that matched the inclusion criteria was from studies conducted in the last 5 years. On the basis of the Data extraction instrument recommended by the JBI scoping review(25), the results were summarized using Microsoft Excel table to describe the characteristics of each research (Additional file 1.Table 2).The barriers and facilitators involved are mapped to the CFIR framework, as demonstrated by Table 3. To clearly demonstrate the distribution of barriers and facilitators in the implementation of evidence, the figure is plotted to show the number of articles for each structure in the specific dimension mentioned (Figure 2).\u003c/p\u003e\n\u003cp\u003eTable 3 Barriers and Facilitators to Coding to the CFIR Framework\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"554\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.54792043399638%\" valign=\"top\"\u003e\n \u003cp\u003eTopic/Description\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003eBarriers(amounts)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.018083182640144%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eFacilitators(amounts)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eI.INTERVENTION\u0026nbsp;CHARACTERISTICS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eA \u0026nbsp;Intervention Source\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eB \u0026nbsp;Evidence Strength \u0026amp; Quality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e1(26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eC \u0026nbsp;Relative advantage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e1(27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e1(28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eD \u0026nbsp; \u0026nbsp; Adaptability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e3(29-31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eE \u0026nbsp; \u0026nbsp; Trialability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e1(32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eF \u0026nbsp; \u0026nbsp; Complexity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e1(27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e2(30, 33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eG \u0026nbsp;Design Quality and Packaging\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eH \u0026nbsp;Cost\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e1(34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e1(27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eII.OUTER\u0026nbsp;SETTING\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eA \u0026nbsp;Patient Needs \u0026amp; Resources\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eB \u0026nbsp; \u0026nbsp; Cosmopolitanism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eC \u0026nbsp;Peer Pressure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eD \u0026nbsp; \u0026nbsp; External Policy \u0026amp; Incentives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eIII.INNER SETTING\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eA \u0026nbsp; Structural Characteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eB \u0026nbsp; Networks \u0026amp; Communications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eC \u0026nbsp; Culture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eD \u0026nbsp; Implementation Climate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003e1 \u0026nbsp; \u0026nbsp; \u0026nbsp; Tension for Change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003e2 \u0026nbsp; \u0026nbsp; \u0026nbsp; Compatibility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003e3 \u0026nbsp; \u0026nbsp; \u0026nbsp; Relative Priority\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e3(34-36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003e4 \u0026nbsp; \u0026nbsp; \u0026nbsp; Organizational Incentives \u0026amp; Rewards\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003e5 Goals and Feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003e6 Learning Climate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eE \u0026nbsp;Readiness for Implementation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003e1 Leadership\u0026nbsp;Engagement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003e2 Available\u0026nbsp;Resources\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003e3 Access\u0026nbsp;to\u0026nbsp;knowledge\u0026nbsp;and\u0026nbsp;information\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e1(27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e2(29, 30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eIV. CHARACTERISTICS\u0026nbsp;OF\u0026nbsp;INDIVIDUALS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eA \u0026nbsp;Knowledge \u0026amp; Beliefs about the Intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e2(26, 34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eB \u0026nbsp;Self-efficacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e1(37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eC \u0026nbsp;Individual Stage of Change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eD \u0026nbsp;Individual Identification with Organization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eE \u0026nbsp;Other Personal Attributes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e4(26, 29, 30, 34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e1(29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eV.PROCESS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eA \u0026nbsp; \u0026nbsp; Planning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e1(10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eB \u0026nbsp; \u0026nbsp; Engaging\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003e1 Opinion\u0026nbsp;Leaders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003e2 Formally\u0026nbsp;appointed\u0026nbsp;internal implementation leaders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003e3 Champions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003e4 External\u0026nbsp;Change\u0026nbsp;Agents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e3(29, 38, 39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eC \u0026nbsp; \u0026nbsp; Executing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e1(26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.458483754512635%\" valign=\"top\"\u003e\n \u003cp\u003eD \u0026nbsp;Reflecting \u0026amp; Evaluating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.3971119133574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.96389891696751%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.18050541516245489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eBarriers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBarriers were found to total 11, including complexity of the intervention, mental deterioration and language barriers in the elderly, financial constraints preventing the purchase of sphygmomanometers, lack of education on the disease and the effectiveness of blood pressure control, lack of training of healthcare professionals in the relevant knowledge, and inability of digital interventions to protect personal privacy. Based on the definitions of the 39 constructs of the CFIR framework, the barriers were mapped to the corresponding dimensions, and the results were mapped to 7 different constructs in 3 dimensions, including evidence strength \u0026amp; quality(n=1), relative advantage(n=1),\u0026nbsp;complexity(n=1) and\u0026nbsp;cost\u0026nbsp;(n=1) under the dimension of intervention characteristics,\u0026nbsp;access to knowledge and information(n=1) under the dimension of inner setting, knowledge \u0026amp; beliefs about the intervention(n=2)and\u0026nbsp;other personal attributes(n=4) under the dimension of characteristic of individuals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntervention characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEvidence Strength \u0026amp; Quality is defined as stakeholders\u0026rsquo; perceptions of the quality and validity of evidence supporting the belief that the intervention will have desired outcomes. Unawareness of the effectiveness of current antihypertensive treatment is a barrier to the achievement of hypertension control(26), Clearly, there is a knowledge gap in the management of hypertension in elderly patients. Relative advantage is defined as stakeholders\u0026rsquo; perception of the advantage of implementing the intervention versus an alternative solution. A location-sensing app created by a university or charity rather than a commercial company(27), As such, apps produced by universities or charities that provide interventions may be a barrier to preventing elderly patients from improving their medication adherence compared to commercial organizations. Complexity is defined as Perceived difficulty of implementation, reflected by duration, scope, radicalness, disruptiveness, centrality, and intricacy and number of steps required to implement. Over-complicating the digital intervention or overburdening the user, resulting in reduced intervention engagement(27), Therefore, the complexity of digital interventions makes it difficult for older people to understand the operation and ultimately makes it more difficult to land evidence. Cost is defined as Costs of the intervention and costs associated with implementing that intervention including investment, supply, and opportunity costs. Many patients were not using a sphygmomanometer regularly prior to the study because of financial limitations(34),the high cost of blood pressure measuring devices makes them unaffordable for some elderly hypertensive patients and is a barrier to getting evidence implemented.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInner setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccess to knowledge and information is defined as ease of access to digestible information and knowledge about the intervention and how to incorporate it into work tasks, comprehensive training for healthcare professionals which incorporate the principles of shared decision making and the skills to deliver the intervention in under 5 minutes(27), likewise, the unskilled and lack of training of medical staff in the process of evidence-based interventions creates a certain barrier factor.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCharacteristics of individuals\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKnowledge\u0026nbsp;\u0026amp;\u0026nbsp;beliefs\u0026nbsp;about\u0026nbsp;the intervention\u0026nbsp;is defined as individuals\u0026rsquo; attitudes toward and value placed on the intervention as well as familiarity with facts, truths, and principles related to the intervention. Knowledge gaps, lack of motivation, and intolerance of adverse events and negligence among elderly patients to improve medication adherence are barriers that prevent the implementation of interventions(26, 34).\u0026nbsp;Other personal attributes are defined as a broad construct to include other personal traits such as tolerance of ambiguity, intellectual ability, motivation, values, competence, capacity, and learning style.\u0026nbsp;Language barriers in elderly patients were also found to hinder the implementation of the evidence, leading to poor communication between healthcare professionals and them(29), as well as refusal to use smartphones because of their limited knowledge, lack of skills in using mobile phones, and fear of lack of privacy and mistrust(30, 34). Also, having dementia was considered to be a barrier factor(26).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFacilitators\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFacilitating factors were found to include 24, including mobile apps developed by non-commercial companies, family involvement, personal cultural beliefs, nurses, pharmacists, community, implementation of scientific training for healthcare professionals, rigorous and diverse intervention programs, use of standardized theoretical frameworks, provision of patient-centered care, focus on bridging the knowledge gap of patients, targeted patient education.\u0026nbsp;Facilitators are coded into the 4 constructs and 12 dimensions of the CFIR framework,\u0026nbsp;relative\u0026nbsp;advantage(n=1), adaptability(n=3), trialability(n=1), complexity(n=2),\u0026nbsp;cost(n=1)\u0026nbsp;under the dimension of intervention characteristics,\u0026nbsp;relative priority(n=3), access\u0026nbsp;to\u0026nbsp;knowledge\u0026nbsp;and\u0026nbsp;information(n=2)\u0026nbsp;under the dimension of inner setting,\u0026nbsp;self-efficacy(n=1), other\u0026nbsp;personal\u0026nbsp;attributes(n=1)\u0026nbsp;under the dimension of characteristic of individuals, planning(n=1), engaging(n=3),executing(n=1)\u0026nbsp;under the dimension of process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntervention characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBy determining a patient\u0026apos;s current level of health literacy, educational interventions can be tailored to specific individuals to address gaps related to practice issues in health literacy(26), This factor is summarized in\u0026nbsp;relative\u0026nbsp;advantage.\u0026nbsp;Adaptability is defined as the degree to which an intervention can be adapted, tailored, refined, or reinvented to meet local needs. A bilingual hand book for rural Thai-Muslims with low levels of literacy and limited reading abilities(29), incorporate video chat features into mHealth apps, simplify smartphone technology for older adults with limited digital literacy(30), using of established theoretical frameworks, and structured interventions lead to a facilitating role(31).\u0026nbsp;Trialability\u0026nbsp;is defined as\u0026nbsp;the ability to test the intervention on a small scale in the organization, and to be able to reverse course (undo implementation) if warranted.\u0026nbsp;Pharmacy refill-adherence metrics can identify potential clinical adherence issues and facilitate targeted interventions, and pharmacists can then use this information to promote patient adherence.\u0026nbsp;Complexity was mentioned in 2 studies, with easy-to-use mobile apps(30), multimodal interventions including individualized teaching on medication adherence and healthy lifestyles, leaflets on medication adherence and healthy lifestyles, weekly medication reminder boxes and follow up telephone reminders, as well as nurses contributing to improving medication adherence(33).\u0026nbsp;Apps developed by universities or charities, rather than commercial companies, are also one of the contributing factors, and where this is mapped to cost(27).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInner setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRelative Priority is defined as individuals\u0026rsquo; shared perception of the importance of the implementation within the organization.\u0026nbsp;Pharmacists or pharmacy students identified and addressed patient barriers by asking questions over the phone to patients prescribed medications for hypertension, while pharmacist-led home-based interventions were highly effective in improving medication adherence(34-36).\u0026nbsp;Educate all clinical nurses on the purpose and significance of the evidence-based implementation of improving medication adherence in elderly hypertensive patients and how to utilize the various tools to enable patients to receive extensive education and training in order to be able to use smartphone technology,\u0026nbsp;these two points are categorized as\u0026nbsp;access\u0026nbsp;to\u0026nbsp;knowledge\u0026nbsp;and\u0026nbsp;information.\u0026nbsp;External change agents\u0026nbsp;is defined as\u0026nbsp;individuals who are affiliated with an outside entity who formally influence or facilitate intervention decisions in a desirable direction.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCharacteristic of individuals\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSelf-efficacy\u0026nbsp;is defined as\u0026nbsp;individual belief in their own capabilities to execute courses of action to achieve implementation goals.\u0026nbsp;Self-management interventions, namely cognitive-behavioral, self-efficacy, self-regulation, education, and self-care interventions,\u0026nbsp;effectively promote the implementation of evidence on medication adherence in hypertensive elderly people(40).\u0026nbsp;Working alongside cultural belief systems is an important step toward improving adherence regime, that personal cultural belief that belongs to the individual is mapped to\u0026nbsp;other\u0026nbsp;personal\u0026nbsp;attributes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcess\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePlanning is defined as the degree to which a scheme or method of behavior and tasks for implementing an intervention are developed in advance and the quality of those schemes or methods. To promote adherence to antihypertensive medication, tailored education is recommended for elderly hypertensive patients(10), advanced planning of what to teach is important. External change agents are defined as individuals who are affiliated with an outside entity who formally influence or facilitate intervention decisions in a desirable direction. Family member participation, combined with community management, are two approaches that can contribute well to the implementation of the evidence(29, 38, 39). Executing is defined as carrying out or accomplishing the implementation according to plan. Physicians should endeavor to educate patients about the importance of regular blood pressure measurement at home and focus on bridging the knowledge gap so that the evidence falls better on the ground(26). \u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis article provides a scoping review of evidence implementation for improving medication adherence in older hypertensive patients through a synthesis of the evidence, with somewhat more facilitators mentioned than barriers. Therefore, the evidence can be maximized by strengthening the facilitators while avoiding the barriers in future work on evidence implementation. Clearly, from the data presented in Fig.\u0026nbsp;2, intervention characteristics are particularly critical to the implementation of the evidence, both the number of structures on the framework and the number of articles mentioned. Whether barriers or facilitators, the most salient dimensions when mapped to the CFIR framework is intervention characteristics, so the characteristics of the intervention are worthy of consideration. Looking at the number of structures that were mapped to the back of the framework, characteristic of individuals and process were placed at the same level, while the inner setting was ranked at the bottom. When considered in terms of barriers and facilitators, on the other hand, there are different perspectives.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eBarriers\u003c/h2\u003e \u003cp\u003eThroughout the entirety of the review, barriers were mapped most frequently to the dimension of intervention characteristics, but the construct of other personal attributes under the dimension of characteristic of individuals should not be overlooked. More attention should be devoted to improving the strength and quality of the evidence, exploiting the strengths of the evidence, and reducing the complexity of the evidence and its costs in the implementation of future studies to promote medication adherence in elderly hypertensive patients. Elderly hypertensive patients lack awareness of the benefits of improving medication adherence, and therefore future measures such as targeted health education can be used to increase their awareness(\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e), thereby reducing the barriers to evidence-based implementation. At the same time, smartphones play an important role in managing the health of elderly people(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e), but the elderly are afraid of having their privacy exposed, they prefer APPs developed by professional organizations or universities to promote medication taking, and avoid APPs developed by commercial organizations, which may be effective in promoting evidence-based applications. Moreover, the content and usage of APPs should be simple and easy to use(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e), avoiding complications that may make the elderly, who are already not very skilled in APPs, even more reluctant to use them(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Since the elderly may not have enough available money to afford expensive sphygmomanometers considering their financial burden, it would be one of the good ways to promote the evidence down to the level of the government agencies if they can reduce the price of the sphygmomanometers sold or subsidize the purchase of the sphygmomanometers for the elderly hypertensive patients. In addition to the above, access to knowledge and information for medical staff in the inner setting should be strengthened and more training opportunities should be provided for them. The lack of training of the medical staff conducting the intervention leads to a lack of proficiency in the whole process of evidence-based interventions, and the application of evidence thus becomes a small gap. Therefore, after the intervention plan has been defined, the staff implementing the strategy should be systematically trained to master understanding the whole process. In addition, because of the lack of belief in change among elderly people and personal characteristics that cannot be avoided at this age, such as poor memory, a willingness to forget and poor learning ability(\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e), the implementation of the evidence also turns out to be a hindrance. The lack of motivation to control blood pressure and even frequent forgetfulness to take medication are barriers to the implementation of interventions as elderly hypertensive patients experience a gradual decline in intelligence and even dementia as they age(\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e), as well as insufficient reception, learning, and comprehension of new things, and even language barriers, resulting in an inability to express themselves correctly with medical staff. In summary, the most significant barriers analyzed in relation to the CFIR framework focused on intervention characteristics, followed by individual characteristics and, to a lesser extent, inner setting. In order to avoid the waste of evidence in the future, the design and implementation of intervention plans should focus on the complexity, effectiveness, advantages, and costs. Meanwhile, it should also focus on the training of the personnel involved in the intervention, and control the cost of the intervention, to prevent certain materials or instruments in the intervention from being too expensive and unaffordable to the patients, which will make the barriers bigger.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eFacilitators\u003c/h2\u003e \u003cp\u003eAs opposed to barriers to implementation, there are a number of facilitators that can be referenced to accelerate the application and implementation of evidence. Intervention characteristics are overwhelmingly dominant in terms of facilitating. A very advantageous, well adapted and trialed, straightforward to implement and spending little money, it is extremely easy to promote the implementation of evidence. Before implementing the strategy, it is recommended that the health literacy of hypertensive patients be assessed(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e), this is also necessary for elderly patients with high blood pressure ,for patients with low literacy levels and poor reading skills, manuals suitable for the elderly that are simple and easy to understand can be produced(\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). In order to better improve medication adherence in the elderly through electronic information technology(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e), electronic interventions, including APPs, weekly medication reminder boxes, and follow up telephone text message reminders, etc. The APPs being mentioned should be developed by charities or university institutions, which on the one hand reduces the cost of use and protects privacy at the same time. If possible, it is recommended to include a video chat function in the APP, so that the interventionists can get in touch with the elderly in a timely manner. For pharmacies, refill-adherence metrics indicator can access the medication taken by older people, so if more attention can be paid to this indicator of pharmacy refill, it will be another very favorable facilitator in the process of evidence implementation. The pharmacist together with his students and nurses are favorable facilitators throughout the implementation of the evidence. Recognition and implementation of self-management among elderly hypertensive patients is an important factor influencing the implementation of the evidence, and good self-management can effectively contribute to the implementation of the evidence(\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). At the same time, one's cultural beliefs play a crucial role in the control of hypertension. Therefore, the application of evidence can be facilitated by enhancing self-management in older adults and respecting their cultural beliefs. Doctors play an equally important role in the implementation of evidence, and if they emphasized the benefits of improved medication adherence in controlling hypertension in elderly hypertensive patients, then this will make older people more willing to participate in the intervention process. The involvement of family members is also very significant, and family members of older hypertensive patients should be encouraged to join the intervention process together to promote the evidence being well applied to older adults(\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). The community actually plays a pivotal role in the overall implementation process, and all 3 roles can go a long way in making the evidence applicable. By coding the facilitators onto the CFIR framework, it was found that good intervention characteristics are likewise the factors that best facilitate the implementation of the evidence, and that the various factors throughout the implementation process are also facilitators if they are well mapped, and of course targeted interventions based on individual characteristics and external factors can likewise facilitate the implementation of the evidence.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe limitations of this study are as follows, firstly the search was limited to English only, which resulted in a number of articles written in other languages not being found and included. Secondly, the study subjects included in this study were elderly hypertensive patients, and after searching and synthesising the results, a decision was made to include all of the literature where the vast majority of the study subjects were elderly patients, otherwise there would have been a minimal amount of literature carried out solely on elderly hypertensive patients. Thirdly, in future studies, implementation strategies will be developed to facilitate the translation of evidence into practice by addressing the barriers that have been identified.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe results of this review suggest that there are a number of barriers and facilitators to the implementation of evidence for improving medication adherence in the elderly hypertensive population. For most interventions, intervention characteristics were the most relevant barriers and the most relevant facilitators of contributing factors. Several implications of these findings for practice and research may facilitate the management of elderly hypertensive patients, reduce mortality, and improve the quality of life of those who are elderly. We found that an approach that promotes evidence implementation by increasing the ease of acceptance of intervention content and modalities, and involving family members of the elderly in all phases of the implementation process, may lead to better implementation results, and efforts to improve blood pressure in older adults may achieve the desired outcomes. At the same time, CFIR is a useful framework for effectively categorizing barriers and facilitators through which the greatest factors can be identified for intervention. It could be used extensively in future implementation studies to report facilitators and barriers.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCFIR: Consolidated Framework for Implementation Research\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article and its supplementary information files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the National Nature Science Foundation of China (Grant No. 72104044),\u0026nbsp;the Natural Science Foundation of Liaoning Province (Grant No. 2022-BS-255) and the China Postdoctoral Science Foundation (Grant No.2023MD734243).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTS and XZ conceptualised the study and supervised the research team together. TS and JYZ determined the search methodology, JYZ and JJZ performed abstract review, full-text review, and data extraction, and XZ and YZ served as arbitrators. JYZ was a major contributor to the writing of the manuscript, XZ refined the manuscript, and all authors provided feedback and approved the final version.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFund UNP. State of World Population 2023: United Nations; 2023.\u003c/li\u003e\n\u003cli\u003eMills KT, Stefanescu A, He J. The global epidemiology of hypertension. Nature Reviews Nephrology. 2020;16(4):223-37.\u003c/li\u003e\n\u003cli\u003eWang C, Yuan Y, Zheng MY, Pan A, Wang M, Zhao MX, et al. Association of Age of Onset of Hypertension With Cardiovascular Diseases and Mortality. Journal of the American College of Cardiology. 2020;75(23):2921-30.\u003c/li\u003e\n\u003cli\u003eArmas Rojas N, Dobell E, Lacey B, Varona-P\u0026eacute;rez P, Burrett JA, Lorenzo-V\u0026aacute;zquez E, et al. 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International Journal of Nursing Practice (John Wiley \u0026amp; Sons, Inc). 2021;27(2):1-12.\u003c/li\u003e\n\u003cli\u003eTankumpuan T, Anuruang S, Jackson D, Hickman OD, DiGiacomo M, Davidson PM. Improved adherence in older patients with hypertension: An observational study of a community-based intervention. International Journal of Older People Nursing. 2019;14(3).\u003c/li\u003e\n\u003cli\u003eSon KJ, Son HR, Park B, Kim HJ, Kim CB. A Community-Based Intervention for Improving Medication Adherence for Elderly Patients with Hypertension in Korea. Int J Environ Res Public Health. 2019;16(5).\u003c/li\u003e\n\u003cli\u003eVan Truong P, Wulan Apriliyasari R, Lin MY, Chiu HY, Tsai PS. Effects of self-management programs on blood pressure, self-efficacy, medication adherence and body mass index in older adults with hypertension: meta-analysis of randomized controlled trials. 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Effect of an Educational Program based on Health Belief Model on Medication Adherence in Elderly Patients with Hypertension. Journal of Evidence-based Care. 2019;9(1):52-62.\u003c/li\u003e\n\u003cli\u003eGe L, Heng BH, Yap CW. Understanding reasons and determinants of medication non-adherence in community-dwelling adults: a cross-sectional study comparing young and older age groups. BMC Health Serv Res. 2023;23(1):905.\u003c/li\u003e\n\u003cli\u003eVan Truong P, Wulan Apriliyasari R, Lin MY, Chiu HY, Tsai PS. Effects of self-management programs on blood pressure, self-efficacy, medication adherence and body mass index in older adults with hypertension: Meta-analysis of randomized controlled trials. Int J Nurs Pract. 2021;27(2):e12920.\u003c/li\u003e\n\u003cli\u003eWoodham N, Taneepanichskul S, Somrongthong R, Auamkul N. Medication adherence and associated factors among elderly hypertension patients with uncontrolled blood pressure in rural area, Northeast Thailand. Journal of Health Research. 2018;32(6):449-58.\u003c/li\u003e\n\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003eTable 2 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Medication adherence, Elderly, Hypertension, Consolidated framework for implementation research, Barriers, Facilitators, Scoping review","lastPublishedDoi":"10.21203/rs.3.rs-4015978/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4015978/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eWith the seriousness of global aging, hypertension has become a major health hazard for the elderly. Improving medication adherence is one of the measures to effectively control blood pressure, and although there has been a great number of publications on how to improve medication adherence in elderly hypertensive patients, implementation in real practice remains a challenge. Moreover, little attention has been paid to what exactly are the factors that influence the implementation of the evidence. The purpose of this review is to provide a systematic overview of the barriers and facilitators that influence the implementation of evidence for improving medication adherence in the elderly hypertensive patient.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis review is based on Arksey and O'Malley methodology and searched six electronic databases. Two independent reviewers were involved in the screening and graphing of the data. Findings were synthesized and categorized using the five domains of the Consolidated Framework for Implementation Research (CFIR).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 15 studies were included in the final review. Barriers and facilitators were mapped to constructs in 14 of the five domains of the CFIR. The most frequently cited barriers were mapped to constructs within the \"intervention characteristics\" domain. Similarly, the most frequently mentioned facilitators were derived from the \"intervention characteristics\". Overall, the intervention content of the existing studies was not generalizable and accessible, whereas other factors such as family involvement in the \u0026ldquo;process\u0026rdquo; were effective in facilitating the implementation of the evidence.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis review identifies barriers and facilitators in the implementation of evidence about improving medication adherence in the elderly hypertensive patient. Future research should focus more on how to intervene with barriers and facilitators so that they can actually be implemented to promote improved medication adherence in the elderly hypertensive population.\u003c/p\u003e","manuscriptTitle":"Barriers and Facilitators to Implementing Evidence for Improving Medication Adherence in Elderly Patients with Hypertension: a scoping review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-15 19:48:12","doi":"10.21203/rs.3.rs-4015978/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"183b1c00-47df-46a0-89d4-a8de42f5f9f6","owner":[],"postedDate":"March 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-01T09:44:18+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-15 19:48:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4015978","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4015978","identity":"rs-4015978","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}