Siw Carlfjord

Key factors influencing adoption of an innovation in primary health care: a qualitative study based on implementation theory

BackgroundBridging the knowledge-to-practice gap in health care is an important issue that has gained interest in recent years. Implementing new methods, guidelines or tools into routine care, however, is a slow and unpredictable process, and the factors that play a role in the change process are not yet fully understood. There is a number of theories concerned with factors predicting successful implementation in various settings, however, this issue is insufficiently studied in primary health care (PHC). The objective of this article was to apply implementation theory to identify key factors influencing the adoption of an innovation being introduced in PHC in Sweden.MethodsA qualitative study was carried out with staff at six PHC units in Sweden where a computer-based test for lifestyle intervention had been implemented. Two different implementation strategies, implicit or explicit, were used. Sixteen focus group interviews and two individual interviews were performed. In the analysis a theoretical framework based on studies of implementation in health service organizations, was applied to identify key factors influencing adoption.ResultsThe theoretical framework proved to be relevant for studies in PHC. Adoption was positively influenced by positive expectations at the unit, perceptions of the innovation being compatible with existing routines and perceived advantages. An explicit implementation strategy and positive opinions on change and innovation were also associated with adoption. Organizational changes and staff shortages coinciding with implementation seemed to be obstacles for the adoption process.ConclusionWhen implementation theory obtained from studies in other areas was applied in PHC it proved to be relevant for this particular setting. Based on our results, factors to be taken into account in the planning of the implementation of a new tool in PHC should include assessment of staff expectations, assessment of the perceived need for the innovation to be implemented, and of its potential compatibility with existing routines. Regarding context, we suggest that implementation concurrent with other major organizational changes should be avoided. The choice of implementation strategy should be given thorough consideration.

Implementation of a neuromuscular training programme in female adolescent football: 3-year follow-up study after a randomised controlled trial

Background Neuromuscular training (NMT) has been shown to reduce anterior cruciate ligament injury rates in highly structured clinical trials. However, there is a paucity of studies that evaluate implementation of NMT programmes in sports. Aim To evaluate the implementation of an NMT programme in female adolescent football 3 years after a randomised controlled trial (RCT). Methods Cross-sectional follow-up after an RCT using the Reach, Effectiveness, Adoption, Implementation, and Maintenance Sports Setting Matrix (RE-AIM SSM) framework. Questionnaires were sent to the Swedish Football Association (FA), to eight district FAs and coaches (n=303) that participated in the RCT in 2009, and coaches who did not participate in the RCT but were coaching female adolescent football teams during the 2012 season (n=496). Results Response rates were 100% among the FAs, 57% among trial coaches and 36% among currently active coaches. The reach of the intervention was high, 99% of trial coaches (control group) and 91% of current coaches were familiar with the programme. The adoption rate was 74% among current coaches, but programme modifications were common among coaches. No district FA had formal policies regarding implementation, and 87% of current coaches reported no club routines for programme use. Maintenance was fairly high; 82% of trial coaches from the intervention group and 68% from the control group still used the programme. Conclusions Reach and adoption of the programme was high among coaches. However, this study identified low programme fidelity and lack of formal policies for its implementation and use in clubs and district FAs.

Computerized lifestyle intervention in routine primary health care: Evaluation of usage on provider and responder levels

OBJECTIVE The aim of this study was to evaluate the use of a computerized concept for lifestyle intervention in routine primary health care (PHC). METHODS Nine PHC units were equipped with computers providing a lifestyle test and tailored printed advice regarding alcohol consumption and physical activity. Patients were referred by staff, and performed the test anonymously. Data were collected over a period of 1 year. RESULTS During the study period 3,065 tests were completed, representing 5.7% of the individuals visiting the PHC units during the period. There were great differences between the units in the number of tests performed and in the proportion of patients referred. One-fifth of the respondents scored for hazardous alcohol consumption, and one-fourth reported low levels of physical activity. The majority of respondents found the test easy to perform, and a majority of those referred to the test found referral positive. CONCLUSION The computerized test can be used for screening and intervention regarding lifestyle behaviours in PHC. Responders are positive to the test and to referral. PRACTICE IMPLICATIONS A more widespread implementation of computerized lifestyle tests could be a beneficial complement to face-to-face interventions in PHC.

Leadership in evidence-based practice: a systematic review

PURPOSE This study aims to systematically review published empirical research on leadership as a determinant for the implementation of evidence-based practice (EBP) and to investigate leadership conceptualization and operationalization in this field. DESIGN/METHODOLOGY/APPROACH A systematic review with narrative synthesis was conducted. Relevant electronic bibliographic databases and reference lists of pertinent review articles were searched. To be included, a study had to involve empirical research and refer to both leadership and EBP in health care. Study quality was assessed with a structured instrument based on study design. FINDINGS A total of 17 studies were included. Leadership was mostly viewed as a modifier for implementation success, acting through leadership support. Yet, there was definitional imprecision as well as conceptual inconsistency, and studies seemed to inadequately address situational and contextual factors. Although referring to an organizational factor, the concept was mostly analysed at the individual or group level. RESEARCH LIMITATIONS/IMPLICATIONS The concept of leadership in implementation science seems to be not fully developed. It is unclear whether attempts to tap the concept of leadership in available instruments truly capture and measure the full range of the diverse leadership elements at various levels. Research in implementation science would benefit from a better integration of research findings from other disciplinary fields. Once a more mature concept has been established, researchers in implementation science could proceed to further elaborate operationalization and measurement. ORIGINALITY/VALUE Although the relevance of leadership in implementation science has been acknowledged, the conceptual base of leadership in this field has received only limited attention.

Referral to an electronic screening and brief alcohol intervention in primary health care in Sweden: impact of staff referral to the computer

The aim of this paper was to evaluate whether primary health care staffs referral of patients to perform an electronic screening and brief intervention (e-SBI) for alcohol use had a greater impact on change in alcohol consumption after 3 month, compared to patients who performed the test on their own initiative. Staff-referred responders reported reduced weekly alcohol consumption with an average decrease of 8.4 grams. In contrast, self-referred responders reported an average increase in weekly alcohol consumption of 2.4 grams. Staff-referred responders reported a 49% reduction of average number of heavy episodic drinking (HED) occasions per month. The corresponding reduction for self-referred responders was 62%. The differences between staff- and self-referred patient groups in the number who moved from risky drinking to nonrisky drinking at the followup were not statistically significant. Our results indicate that standalone computers with touchscreens that provide e-SBIs for risky drinking have the same effect on drinking behaviour in both staff-referred patients and self-referred patients.

Implementation of a computerized alcohol advice concept in routine emergency care

BACKGROUND There is a growing body of evidence for computer-generated advice for many health behaviours. This study evaluated the implementation of a computerized concept to provide tailored advice on alcohol in a Swedish emergency department (ED). AIM The aim was to evaluate the usage of the concept over 12 months: participation rate among the ED population; representativeness of the participants; and participation development over time. METHODS The target population was defined as all patients aged 18-69 years given a card from ED triage staff with a request to conduct a computerized test about their alcohol use. After completing the 5-10-min programme, the patient received a printout, containing personalised alcohol habit feedback, as calculated by the computer from the patients answers. Data for this study were primarily obtained from the computer programme and ED logs. RESULTS Forty-one percent of the target population completed the computerized test and received tailored alcohol advice. The number of patients who used the concept showed a slight decreasing trend during the first half of the year, leveling off for the second half of the year. CONCLUSION A computerized concept for provision of alcohol advice can be implemented in an ED without unrealistic demands on staff and with limited external support to attain sustainability.

Applying the RE-AIM framework to evaluate two implementation strategies used to introduce a tool for lifestyle intervention in Swedish primary health care

The aim of this study was to evaluate two implementation strategies for the introduction of a lifestyle intervention tool in primary health care (PHC), applying the RE-AIM framework to assess outcome. A computer-based tool for lifestyle intervention was introduced in PHC. A theory-based, explicit, implementation strategy was used at three centers, and an implicit strategy with a minimum of implementation efforts at three others. After 9 months a questionnaire was sent to staff members (n= 159) and data from a test database and county council registers were collected. The RE-AIM framework was applied to evaluate outcome in terms of reach, effectiveness, adoption and implementation. The response rate for the questionnaire was 73%. Significant differences in outcome were found between the strategies regarding reach, effectiveness and adoption, in favor of the explicit implementation strategy. Regarding the dimension implementation, no differences were found according to the implementation strategy. A theory-based implementation strategy including a testing period before using a new tool in daily practice seemed to be more successful than a strategy in which the tool was introduced and immediately used for patients.

Asthma and COPD in primary health care, quality according to national guidelines : A cross-sectional and a retrospective study

BackgroundIn recent decades international and national guidelines have been formulated to ensure that patients suffering from specific diseases receive evidence-based care. In 2004 the National Swedish Board of Health and Welfare (SoS) published guidelines concerning the management of patients with asthma and COPD. The guidelines identify quality indicators that should be fulfilled. The aim of this study was to survey structure and process indicators, according to the asthma and COPD guidelines, in primary health care, and to identify correlations between structure and process quality results.MethodsA cross-sectional study of existing structure by using a questionnaire, and a retrospective study of process quality based on a review of measures documented in asthma and COPD medical records. All 42 primary health care centres in the county council of Östergötland, Sweden, were included.ResultsAll centres showed high quality regarding structure, although there was a large difference in time reserved for Asthma and COPD Nurse Practice (ACNP). The difference in reserved time was reflected in process quality results. The time needed to reach the highest levels of spirometry and current smoking habit documentation was between 1 and 1 1/2 hours per week per 1000 patients registered at the centre. Less time resulted in fewer patients examined with spirometry, and fewer medical records with smoking habits documented. More time did not result in higher levels, but in more frequent contact with each patient. In the COPD group more time resulted in higher levels of pulse oximetry and weight registration.ConclusionTo provide asthma and COPD patients with high process quality in primary care according to national Swedish guidelines, at least one hour per week per 1000 patients registered at the primary health care centre should be reserved for ACNP.

Staff perceptions of addressing lifestyle in primary health care: a qualitative evaluation 2 years after the introduction of a lifestyle intervention tool

BackgroundPreventive services and health promotion in terms of lifestyle counselling provided through primary health care (PHC) has the potential to reduce morbidity and mortality in the population. Health professionals in general are positive about and willing to develop a health-promoting and/or preventive role. A number of obstacles hindering PHC staff from addressing lifestyle issues have been identified, and one facilitator is the use of modern technology. When a computer-based tool for lifestyle intervention (CLT) was introduced at a number of PHC units in Sweden, this provided an opportunity to study staff perspectives on the subject. The aim of this study was to explore PHC staff’s perceptions of handling lifestyle issues, including the consultation situation as well as the perceived usefulness of the CLT.MethodsA qualitative study was conducted after the CLT had been in operation for 2 years. Six focus group interviews, one at each participating unit, including a total of 30 staff members with different professions participated. The interviews were designed to capture perceptions of addressing lifestyle issues, and of using the CLT. Interview data were analysed using manifest content analysis.ResultsTwo main themes emerged from the interviews: a challenging task and confidence in handling lifestyle issues. The first theme covered the categories responsibilities and emotions, and the second theme covered the categories first contact, existing tools, and role of the CLT. Staff at the units showed commitment to health promotion/prevention, and saw that patients, caregivers, managers and politicians all have responsibilities regarding the issue. They expressed confidence in handling lifestyle-related conditions, but to a lesser extent had routines for general screening of lifestyle habits, and found addressing alcohol the most problematic issue. The CLT, intended to facilitate screening, was viewed as a complement, but was not considered an important tool for health promotion/prevention.ConclusionAdditional resources, for example in terms of manpower, may help to build the structures necessary for the health promotion/prevention task. Committed leaders could enhance the engagement among staff. Cooperation in multi-professional teams seems to be important, and methods or tools perceived by staff as compatible have a potential to be successfully implemented. Economic incentives rewarding quantity rather than quality appear to be frustrating to PHC staff.

Improvement of Physical Activity by a Kiosk-based Electronic Screening and Brief Intervention in Routine Primary Health Care: Patient-Initiated Versus Staff-Referred

Background Interactive behavior change technology (eg, computer programs, Internet websites, and mobile phones) may facilitate the implementation of lifestyle behavior interventions in routine primary health care. Effective, fully automated solutions not involving primary health care staff may offer low-cost support for behavior change. Objectives We explored the effectiveness of an electronic screening and brief intervention (e-SBI) deployed through a stand-alone information kiosk for promoting physical activity among sedentary patients in routine primary health care. We further tested whether its effectiveness differed between patients performing the e-SBI on their own initiative and those referred to it by primary health care staff. Methods The e-SBI screens for the physical activity level, motivation to change, attitudes toward performing the test, and physical characteristics and provides tailored feedback supporting behavior change. A total of 7863 patients performed the e-SBI from 2007 through 2009 in routine primary health care in Östergötland County, Sweden. Of these, 2509 were considered not sufficiently physically active, and 311 of these 2509 patients agreed to participate in an optional 3-month follow-up. These 311 patients were included in the analysis and were further divided into two groups based on whether the e-SBI was performed on the patient´s own initiative (informed by posters in the waiting room) or if the patient was referred to it by staff. A physical activity score representing the number of days being physically active was compared between baseline e-SBI and the 3-month follow-up. Based on physical activity recommendations, a score of 5 was considered the cutoff for being sufficiently physically active. Results In all, 137 of 311 patients (44%) were sufficiently physically active at the 3-month follow-up. The proportion becoming sufficiently physically active was 16/55 (29%), 40/101 (40%), and 81/155 (52%) for patients with a physical activity score at baseline of 0, 1 to 2, and 3 to 4, respectively. The patient-initiated group and staff-referred group had similar mean physical activity scores at baseline (2.1, 95% confidence interval [CI] 1.8-2.3, versus 2.3, 95% CI 2.1-2.5) and at follow-up, (4.1, 95% CI 3.4-4.7, vs 4.2, 95% CI 3.7-4.8). Conclusions Among the sedentary patients in primary health care who participated in the follow-up, the e-SBI appeared effective at promoting short-term improvement of physical activity for about half of them. The results were similar when the e-SBI was patient-initiated or staff-referred. The e-SBI may be a low-cost complement to lifestyle behavior interventions in routine primary health care and could work as a stand-alone technique not requiring the involvment of primary health care staff.