Henna Hasson

Fidelity and moderating factors in complex interventions: a case study of a continuum of care program for frail elderly people in health and social care

BackgroundPrior studies measuring fidelity of complex interventions have mainly evaluated adherence, and not taken factors affecting adherence into consideration. A need for studies that clarify the concept of fidelity and the function of factors moderating fidelity has been emphasized. The aim of the study was to systematically evaluate implementation fidelity and possible factors influencing fidelity of a complex care continuum intervention for frail elderly people.MethodsThe intervention was a systematization of the collaboration between a nurse with geriatric expertise situated at the emergency department, the hospital ward staff, and a multi-professional team with a case manager in the municipal care services for older people. Implementation was evaluated between September 2008 and May 2010 with observations of work practices, stakeholder interviews, and document analysis according to a modified version of The Conceptual Framework for Implementation Fidelity.ResultsA total of 16 of the 18 intervention components were to a great extent delivered as planned, while some new components were added to the model. No changes in the frequency or duration of the 18 components were observed, but the dose of the added components varied over time. Changes in fidelity were caused in a complex, interrelated fashion by all the moderating factors in the framework, i.e., context, staff and participant responsiveness, facilitation, recruitment, and complexity.DiscussionThe Conceptual Framework for Implementation Fidelity was empirically useful and included comprehensive measures of factors affecting fidelity. Future studies should focus on developing the framework with regard to how to investigate relationships between the moderating factors and fidelity over time.Trial registrationClinicalTrials.gov, NCT01260493.

Post‐stroke depression and functional independence: a conundrum

Brown C, Hasson H, Thyselius V, Almborg A‐H. Post‐stroke depression and functional independence: a conundrum.
Acta Neurol Scand: 2012: 126: 45–51.
© 2011 John Wiley & Sons A/S.

Barriers in implementation of evidence-based practice: Supported employment in Swedish context

PURPOSE The aim of this paper is to identify initial barriers influencing implementation of supported employment (SE). SE, according to the individual placement and support (IPS) approach, has been recognised as an evidence-based method to help people with severe mental illness to find regular employment. DESIGN/METHODOLOGY/APPROACH A systematic implementation evaluation of the first randomised controlled SE (IPS) trial in Sweden was conducted in August 2008 and August 2009. Data were collected on a regular basis from SE employment specialists, process heads, clients and representatives from mental health care units and vocational services (social insurance and public employment offices) using interviews, non-participant observations and document analysis. FINDINGS SE employment specialists reported that existing regulations for social insurance and employment regulations presented major obstacles to implementation. Difficulties were reported in cooperation with handling officers at the vocational services. Scepticism towards persons with mental illness was common and employers expected to receive subsidies if they hired a person with mental illness. SE participants expressed fear of losing their social benefits. ORIGINALITY/VALUE The results illuminate a collision between an innovative evidence-based practice and the existing systems for social benefits and work rehabilitation.

Older people's views of quality of care: a randomised controlled study of continuum of care

AIMS AND OBJECTIVES To analyse frail older peoples views of quality of care when receiving a comprehensive continuum of care intervention, compared with those of people receiving the usual care (control group). The intervention included early geriatric assessment, case management, interprofessional collaboration, support for relatives and organising of care-planning meetings in older peoples own homes. BACKGROUND Prior studies indicate that tailored/individualised care planning conducted by a case manager/coordinator often led to greater satisfaction with care planning among older people. However, there is no obvious evidence of any effects of continuum of care interventions on older peoples views of quality of care. DESIGN Randomised controlled study. METHODS Items based on a validated questionnaire were used in face-to-face interviews to assess older peoples views of quality of care at three, six and 12 months after baseline. RESULTS Older people receiving a comprehensive continuum of care intervention perceived higher quality of care on items about care planning (p ≤ 0·005), compared with those receiving the usual care. In addition, they had increased knowledge of whom to contact about care/service, after three and 12 months (p < 0·03). CONCLUSIONS The study gives evidence of the advantages of a combination of components such as organising care-planning meetings in older peoples own homes, case management and interprofessional teamwork. RELEVANCE TO CLINICAL PRACTICE The results have implications for policymakers, managers and professionals in the area of health and social care for older people to meet individual needs of frail older people.

Functions of behavior change interventions when implementing multi-professional teamwork at an emergency department: a comparative case study.

BackgroundWhile there is strong support for the benefits of working in multi-professional teams in health care, the implementation of multi-professional teamwork is reported to be complex and challenging. Implementation strategies combining multiple behavior change interventions are recommended, but the understanding of how and why the behavior change interventions influence staff behavior is limited. There is a lack of studies focusing on the functions of different behavior change interventions and the mechanisms driving behavior change. In this study, applied behavior analysis is used to analyze the function and impact of different behavior change interventions when implementing multi-professional teamwork.MethodsA comparative case study design was applied. Two sections of an emergency department implemented multi-professional teamwork involving changes in work processes, aimed at increasing inter-professional collaboration. Behavior change interventions and staff behavior change were studied using observations, interviews and document analysis. Using a hybrid thematic analysis, the behavior change interventions were categorized according to the DCOM® model. The functions of the behavior change interventions were then analyzed using applied behavior analysis.ResultsThe two sections used different behavior change interventions, resulting in a large difference in the degree of staff behavior change. The successful section enabled staff performance of teamwork behaviors with a strategy based on ongoing problem-solving and frequent clarification of directions. Managerial feedback initially played an important role in motivating teamwork behaviors. Gradually, as staff started to experience positive outcomes of the intervention, motivation for teamwork behaviors was replaced by positive task-generated feedback.ConclusionsThe functional perspective of applied behavior analysis offers insight into the behavioral mechanisms that describe how and why behavior change interventions influence staff behavior. The analysis demonstrates how enabling behavior change interventions, managerial feedback and task-related feedback interact in their influence on behavior and have complementary functions during different stages of implementation.

Strategies to facilitate implementation and sustainability of large system transformations : a case study of a national program for improving quality of care for elderly people

BackgroundLarge-scale change initiatives stimulating change in several organizational systems in the health and social care sector are challenging both to lead and evaluate. There is a lack of systematic research that can enrich our understanding of strategies to facilitate large system transformations in this sector. The purpose of this study was to examine the characteristics of core activities and strategies to facilitate implementation and change of a national program aimed at improving life for the most ill elderly people in Sweden. The program outcomes were also addressed to assess the impact of these strategies.MethodsA longitudinal case study design with multiple data collection methods was applied. Archival data (n = 795), interviews with key stakeholders (n = 11) and non-participant observations (n = 23) were analysed using content analysis. Outcome data was obtained from national quality registries.ResultsThis study presents an approach for implementing a large national change program that is characterized by initial flexibility and dynamism regarding content and facilitation strategies and a growing complexity over time requiring more structure and coordination. The description of activities and strategies show that the program management team engaged a variety of stakeholders and actor groups and accordingly used a palate of different strategies. The main strategies used to influence change in the target organisations were to use regional improvement coaches, regional strategic management teams, national quality registries, financial incentives and annually revised agreements. Interactive learning sessions, intense communication, monitor and measurements, and active involvement of different experts and stakeholders, including elderly people, complemented these strategies. Program outcomes showed steady progress in most of the five target areas, less so for the target of achieving coordinated care.ConclusionsThere is no blue-print on how to approach the challenging task of leading large scale change programs in complex contexts, but our conclusion is that more attention has to be given to the multidimensional strategies that program management need to consider. This multidimensionality comprises different strategies depending on types of actors, system levels, contextual factors, program progress over time, program content, types of learning and change processes, and the conditions for sustainability.

Investigating variations in implementation fidelity of an organizational-level occupational health intervention.

BackgroundThe workplace has been suggested as an important arena for health promotion, but little is known about how the organizational setting influences the implementation of interventions.PurposeThe aims of this study are to evaluate implementation fidelity in an organizational-level occupational health intervention and to investigate possible explanations for variations in fidelity between intervention units.MethodThe intervention consisted of an integration of health promotion, occupational health and safety, and a system for continuous improvements (Kaizen) and was conducted in a quasi-experimental design at a Swedish hospital. Implementation fidelity was evaluated with the Conceptual Framework for Implementation Fidelity and implementation factors used to investigate variations in fidelity with the Framework for Evaluating Organizational-level Interventions. A multi-method approach including interviews, Kaizen notes, and questionnaires was applied.ResultsImplementation fidelity differed between units even though the intervention was introduced and supported in the same way. Important differences in all elements proposed in the model for evaluating organizational-level interventions, i.e., context, intervention, and mental models, were found to explain the differences in fidelity.ConclusionImplementation strategies may need to be adapted depending on the local context. Implementation fidelity, as well as pre-intervention implementation elements, is likely to affect the implementation success and needs to be assessed in intervention research. The high variation in fidelity across the units indicates the need for adjustments to the type of designs used to assess the effects of interventions. Thus, rather than using designs that aim to control variation, it may be necessary to use those that aim at exploring and explaining variation, such as adapted study designs.

Promoting employee health by integrating health protection, health promotion, and continuous improvement: a longitudinal quasi-experimental intervention study.

Objective:To test the effects of integrating health protection and health promotion with a continuous improvement system (Kaizen) on proximal employee outcomes (health promotion, integration, and Kaizen) and distal outcomes (workability, productivity, self-rated health and self-rated sickness absence). Methods:Twelve units in a county hospital in Sweden were randomized to control or intervention groups using a quasiexperimental study design. All staff (approximately 500) provided self-ratings in questionnaires at baseline, and a 12- and 24-month follow-up (response rate, 79% to 87.5%). Result:There was a significant increase in the proximal outcomes over time in the intervention group compared with the control group, and a trend toward improvement in the distal outcomes workability and productivity. Conclusions:Integration seems to promote staff engagement in health protection and promotion, as well as to improve their understanding of the link between work and health.

Alignment for Achieving a Healthy Organization

Modern working life is characterized by change and competiveness. It is also characterized by a drift away from low-skilled work to more complex jobs and increased social interaction. This means that the human resources employees and their skills, competencies, engagement and motivation are the greatest asset of many organizations. This has implications for how an organization can be healthy, i.e. create an environment that will contribute to employee health, wellbeing and motivation as well as achieve business outcomes. In this chapter, we will draw on theories from work and organizational psychology and behavioral psychology, and our own research, to describe what we believe to be the fundament of a healthy organization. We will do this by introducing the concept of alignment, which will be used to illuminate the healthy organization. Alignment can be described as the lining up of different aspects of what is going on in an organization so that they create a common thread. This cuts across different layers and processes in the organization; thus vertical, horizontal and diagonal alignments will be described. In the second part, we will use the framework of alignment to illuminate why occupational health interventions need to be integrated with the organizations strategy and systems in order to create sustainable change. Implications of alignment for participatory approaches, intervention fit, program theories, the role of management and more will be discussed. In the third part, we will describe the implications of our view of an aligned, healthy organization for designing and evaluating interventions in organizations. This includes arguing for changing the roles and responsibilities of researchers and practitioners, and how this change can be beneficial to the organization as well as the quality of the research. (Less)

Evidence-informed policy formulation and implementation: a comparative case study of two national policies for improving health and social care in Sweden

BackgroundEvidence has come to play a central role in health policymaking. However, policymakers tend to use other types of information besides research evidence. Most prior studies on evidence-informed policy have focused on the policy formulation phase without a systematic analysis of its implementation. It has been suggested that in order to fully understand the policy process, the analysis should include both policy formulation and implementation. The purpose of the study was to explore and compare two policies aiming to improve health and social care in Sweden and to empirically test a new conceptual model for evidence-informed policy formulation and implementation.MethodsTwo concurrent national policies were studied during the entire policy process using a longitudinal, comparative case study approach. Data was collected through interviews, observations, and documents. A Conceptual Model for Evidence-Informed Policy Formulation and Implementation was developed based on prior frameworks for evidence-informed policymaking and policy dissemination and implementation. The conceptual model was used to organize and analyze the data.ResultsThe policies differed regarding the use of evidence in the policy formulation and the extent to which the policy formulation and implementation phases overlapped. Similarities between the cases were an emphasis on capacity assessment, modified activities based on the assessment, and a highly active implementation approach relying on networks of stakeholders. The Conceptual Model for Evidence-Informed Policy Formulation and Implementation was empirically useful to organize the data.ConclusionsThe policy actors’ roles and functions were found to have a great influence on the choices of strategies and collaborators in all policy phases. The Conceptual Model for Evidence-Informed Policy Formulation and Implementation was found to be useful. However, it provided insufficient guidance for analyzing actors involved in the policy process, capacity-building strategies, and overlapping policy phases. A revised version of the model that includes these aspects is suggested.