Using organization theory to understand the determinants of effective implementation of worksite health promotion programs

Which worksite supports for healthy weight do employees use?

This paper explores factors associated with employee use of available supports for improving nutrition and activity behaviors. A cross-sectional telephone-survey assessed presence and use of available program, facility, and policy supports. Logistic regression was used to explore associations between job characteristics (e.g., supervising others) and use of available supports, adjusting for demographic characteristics. After adjustment, most supports were associated with at least one job-related factor. Participants supervising others were more likely to utilize eight supports including personal services for fitness, indoor exercise and shower facilities, and flextime for physical activity. The programs and facilities associated with the most factors were health fairs (e.g., increased likelihood with increased hours worked/week) and indoor exercise and shower facilities (e.g., increased likelihood with increased flexibility at work), respectively. Policies were associated with fewer factors. Since use of many programs and facilities differed based on job-related factors, employers might target supports based on job-related factors.

FUEL Your Life: A Translation of the Diabetes Prevention Program to Worksites

Purpose.

To evaluate the effectiveness of FUEL Your Life, a translation of the Diabetes Prevention Program for worksites.

Design.

A randomized control group design was conducted in five worksites of a large transportation company. Measures were collected pretest, posttest (6 months), and follow-up (12 months).

Setting.

Railroad maintenance facilities of Union Pacific Railroad.

Subjects.

Participants consisted of 362 workers (227 treatment, 135 control).

Intervention.

FUEL Your Life was translated from the Diabetes Prevention Program to better fit within the context of the worksite. The primary difference was the use of peer health coaches to provide social support and reinforcement and an occupational nurse to provide lesson content (six sessions of 10 minutes) to participants instead of the lifestyle coaches employed by the Diabetes Prevention Program, resulting in a less structured meeting schedule.

Measures.

The primary outcomes were weight and body mass index (BMI), with secondary outcomes including eating behaviors, physical activity, and social support.

Analysis.

Latent growth modeling was used to measure changes in the outcomes over time.

Results.

Participants in the intervention group maintained weight/BMI (–.1 pounds/–.1 BMI), whereas the control participants gained weight/BMI (+2.6 pounds/+.3 BMI), resulting in a statistically significant difference between groups. Fifty-five percent of intervention participants lost some weight, whereas only 35% of the control group lost weight.

Conclusions.

FUEL Your Life, a low intensity intervention, was not effective for promoting weight loss, but was effective for helping workers maintain weight over a 12-month period.

Advancing heart health in North Carolina primary care: the Heart Health NOW study protocol

BACKGROUND

The objective of Heart Health NOW (HHN) is to determine if primary care practice support-a comprehensive evidence-based quality improvement strategy involving practice facilitation, academic detailing, technology support, and regional learning collaboratives-accelerates widespread dissemination and implementation of evidence-based guidelines for cardiovascular disease (CVD) prevention in small- to medium-sized primary care practices and, additionally, increases practices' capacity to incorporate other evidence-based clinical guidelines in the future.

METHODS/DESIGN

HHN is a stepped wedge, stratified, cluster randomized trial to evaluate the effect of primary care practice support on evidence-based CVD prevention, organizational change process measures, and patient outcomes. Each practice will start the trial as a control, receive the intervention at a randomized time point, and then enter a maintenance period 12 months after the start of the intervention. The intervention will be randomized to practices in one of four strata defined by region of the state (east or west) and degree of practice readiness for change. Seventy-five practices in each region with a high degree of readiness will be randomized 1:1:1 in blocks of 3 sometime prior to month 8 to receive the intervention at month 9, 11, or 12. An additional 75 practices within each region that have a low degree of readiness or are recruited later will be randomized 1:1 in blocks of 2 prior to month 13 to receive the intervention at month 14 or 16. The sites will be ordered within each strata based on time of enrollment with the blocking based on this ordering. Evaluation will examine the effect of primary care practice support on (1) practice-level delivery of evidence-based CVD prevention, (2) patient-level health outcomes, (3) practice-level implementation of clinical and organizational changes that support delivery of evidence-based CVD prevention, and (4) practice-level capacity to implement future evidence-based clinical guidelines.

DISCUSSION

Results will indicate whether primary care practice support is an effective strategy for widespread dissemination and implementation of evidence-based clinical guidelines in primary care practices. Discernible reductions in cardiovascular risk in 300 practices covering over an estimated 900,000 adult patients would likely lead to prevention of thousands of cardiovascular events within 10 years.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02585557.

Implementing tobacco use treatment guidelines in community health centers in Vietnam

Background

Vietnam has a smoking prevalence that is the second highest among Southeast Asian countries (SEACs). According to the World Health Organization (WHO), most reductions in mortality from tobacco use in the near future will be achieved through helping current users quit. Yet, largely due to a lack of research on strategies for implementing WHO-endorsed treatment guidelines in primary care settings, services to treat tobacco dependence are not readily available to smokers in low middle-income countries (LMICs) like Vietnam. The objective of this study is to conduct a cluster randomized controlled trial that compares the effectiveness of two system-level strategies for implementing evidence-based guidelines for the treatment of tobacco use in 26 public community health centers (CHCs) in Vietnam.

Methods/Design

The current study will use a cluster-randomized design and multiple data sources (patient exit interviews, provider and village health worker (VHW) surveys, and semi-structured provider/VHW interviews) to study the process of adapting and implementing clinical practice guidelines in Vietnam and theory-driven mechanisms hypothesized to explain the comparative effectiveness of the two strategies for implementation. CHCs will be randomly assigned to either of the following: (1) training plus clinical reminder system (TC) or (2) TC + referral to a VHW (TCR) for three in person counseling sessions. The primary outcome is provider adherence to tobacco use treatment guidelines. The secondary outcome is 6-month biochemically verified smoking abstinence.

Discussion

The proposed implementation strategies draw on evidence-based approaches and a growing literature that supports the effectiveness of integrating community health workers as members of the health care team to improve access to preventive services. We hypothesize that the value of these implementation strategies is additive and that incorporating a referral resource that allows providers to delegate the task of offering counseling (TCR) will be superior to TC alone in improving delivery of cessation assistance to smokers. The findings of this research have potential to guide large-scale adoption of promising strategies for implementing and disseminating tobacco use treatment guidelines throughout the public health system in Vietnam and will serve as a model for similar action in other LMICs.

Trial registration

NCT01967654

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0328-8) contains supplementary material, which is available to authorized users.

Worksite Tobacco Prevention: A Randomized, Controlled Trial of Adoption, Dissemination Strategies, and Aggregated Health-Related Outcomes across Companies

Evidence based public health requires knowledge about successful dissemination of public health measures. This study analyses (a) the changes in worksite tobacco prevention (TP) in the Canton of Zurich, Switzerland, between 2007 and 2009; (b1) the results of a multistep versus a "brochure only" dissemination strategy; (b2) the results of a monothematic versus a comprehensive dissemination strategy that aim to get companies to adopt TP measures; and (c) whether worksite TP is associated with health-related outcomes. A longitudinal design with randomized control groups was applied. Data on worksite TP and health-related outcomes were gathered by a written questionnaire (baseline n = 1627; follow-up n = 1452) and analysed using descriptive statistics, nonparametric procedures, and ordinal regression models. TP measures at worksites improved slightly between 2007 and 2009. The multistep dissemination was superior to the "brochure only" condition. No significant differences between the monothematic and the comprehensive dissemination strategies were observed. However, improvements in TP measures at worksites were associated with improvements in health-related outcomes. Although dissemination was approached at a mass scale, little change in the advocated adoption of TP measures was observed, suggesting the need for even more aggressive outreach or an acceptance that these channels do not seem to be sufficiently effective.

Health Behaviors and Overweight in Nursing Home Employees: Contribution of Workplace Stressors and Implications for Worksite Health Promotion

BACKGROUND

Many worksite health promotion programs ignore the potential influence of working conditions on unhealthy behaviors.

METHODS

A study of nursing home employees (56% nursing aides) utilized a standardized questionnaire. We analyzed the cross-sectional associations between workplace stressors and obesity, cigarette smoking, and physical inactivity.

RESULTS

Of 1506 respondents, 20% reported exposure to three or more workplace stressors (physical or organizational), such as lifting heavy loads, low decision latitude, low coworker support, regular night work, and physical assault. For each outcome, the prevalence ratio was between 1.5 and 2 for respondents with four or five job stressors. Individuals under age 40 had stronger associations between workplace stressors and smoking and obesity.

CONCLUSIONS

Workplace stressors were strongly associated with smoking, obesity, and physical inactivity, even among the lowest-status workers. Current working conditions affected younger workers more than older workers. Although this study is cross-sectional, it has other strengths, including the broad range of work stressors studied. Strenuous physical work and psychosocial strain are common among low-wage workers such as nursing home aides. Workplace health promotion programs may be more effective if they include measures to reduce stressful work environment features, so that working conditions support rather than interfere with employee health.

Enriching Patient-Centered Medical Homes Through Peer Support

Peer supporters are recognized by various designations-community health workers, promotores de salud, lay health advisers-and are community members who work for pay or as volunteers in association with health care systems or nonprofit community organizations and often share ethnicity, language, and socioeconomic status with the mentees that they serve. Although emerging evidence demonstrates the efficacy of peer support at the community level, the adoption and implementation of this resource into patient-centered medical homes (PCMHs) is still under development. To accelerate that integration, this article addresses three major elements of peer support interventions: the functions and features of peer support, a framework and programmatic strategies for implementation, and fiscal models that would support the sustained viability of peer support programs within PCMHs. Key functions of peer support include assistance in daily management of health-related behaviors, social and emotional support, linkage to clinical care, and longitudinal or ongoing support. An organizational model of innovation implementation provides a useful framework for determining how to implement and evaluate peer support programs in PCMHs. Programmatic strategies that can be useful in developing peer support programs within PCMHs include peer coaching or mentoring, group self-management training, and programs designed around the telephone and information technology. Fiscal models for peer support programs include linkages with hospital or health care systems, service- or community-based nonprofit organizations, and partnerships between health care systems and community groups. Peer support promises to enrich PCMHs by activating patients in their self-care, providing culturally sensitive outreach, and opening the way for partnerships with community-based organizations.

Adoption of Evidence-Based Interventions in Local Health Departments: "1-2-3 Pap NC"

Descriptions of barriers and facilitators to adoption of evidence-based interventions in local health departments (LHDs) are limited. This study was conducted by the North Carolina Public Health Practice-Based Research Network to identify factors associated with adoption of an evidence-based human papillomavirus video intervention, "1-2-3 Pap NC," in North Carolina LHDs. A sequential mixed-method study design was used. Data from the 2013 National Profile of Local Health Departments were used to test associations between LHD characteristics and adoption of the intervention. Qualitative, key stakeholder interviews with LHD directors provided the context for quantitative data. Data collection and analysis continued from March 3, 2014, to September 15, 2014. Overall, 28% of North Carolina health jurisdictions (33 of 100 counties) implemented the intervention. Of the three channels used to deliver the intervention to clients, most LHDs opted to show the video in the exam room (42%), followed by website/other social media (36%) and video loop in the lobby/waiting room (22%). In logistic regression, gender of the director (female) was significantly and positively associated with adoption of the intervention (AOR=4.44, p<0.05). Being a first-time director was marginally significant (AOR=0.28, p=0.074), suggesting first-time directors were less likely to adopt. Qualitative results suggested that aspects of communication (awareness and positive attitudes) and agency directors' evaluation of resources, balanced against intervention complexity and flexibility, competing priorities, and mandates, influenced adoption. Adoption of evidence-based interventions by LHDs is critical to improve population health. Practice-based research can contribute to understanding facilitators and modifying barriers to this process.

An organizational readiness intervention and randomized controlled trial to test strategies for implementing substance use disorder treatment into primary care: SUMMIT study protocol

BACKGROUND

Millions of people who need treatment for substance use disorders (SUD) do not receive it. Evidence-based practices for treating SUD exist, and some are appropriate for delivery outside of specialty care settings. Primary care is an opportune setting in which to deliver SUD treatment because many individuals see their primary care providers at least once a year. Further, the Patient Protection and Affordable Care Act (PPACA) increases coverage for SUD treatment and is increasing the number of individuals seeking primary care services. In this article, we present the protocol for a study testing the effects of an organizational readiness and service delivery intervention on increasing the uptake of SUD treatment in primary care and on patient outcomes.

METHODS/DESIGN

In a randomized controlled trial, we test the combined effects of an organizational readiness intervention consisting of implementation tools and activities and an integrated collaborative care service delivery intervention based on the Chronic Care Model on service system (patient-centered care, utilization of substance use disorder treatment, utilization of health care services and adoption and sustainability of evidence-based practices) and patient (substance use, consequences of use, health and mental health, and satisfaction with care) outcomes. We also use a repeated measures design to test organizational changes throughout the study, such as acceptability, appropriateness and feasibility of the practices to providers, and provider intention to adopt the practices. We use provider focus groups, provider and patient surveys, and administrative data to measure outcomes.

DISCUSSION

The present study responds to critical gaps in health care services for people with substance use disorders, including the need for greater access to SUD treatment and greater uptake of evidence-based practices in primary care. We designed a multi-level study that combines implementation tools to increase organizational readiness to adopt and sustain evidence-based practices (EBPs) and tests the effectiveness of a service delivery intervention on service system and patient outcomes related to SUD services.

TRIAL REGISTRATION

Current controlled trials: NCT01810159.

Hiding in plain sight: communication theory in implementation science

Background

Poor communication among healthcare professionals is a pressing problem, contributing to widespread barriers to patient safety. The word “communication” means to share or make common. In the literature, two communication paradigms dominate: (1) communication as a transactional process responsible for information exchange, and (2) communication as a transformational process responsible for causing change. Implementation science has focused on information exchange attributes while largely ignoring transformational attributes of communication. In this paper, we debate the merits of encompassing both paradigms.

Discussion

We conducted a two-staged literature review searching for the concept of communication in implementation science to understand how communication is conceptualized. Twenty-seven theories, models, or frameworks were identified; only Rogers’ Diffusion of Innovations theory provides a definition of communication and includes both communication paradigms. Most models (notable exceptions include Diffusion of Innovations, The Ottawa Model of Research Use, and Normalization Process Theory) describe communication as a transactional process. But thinking of communication solely as information transfer or exchange misrepresents reality. We recommend that implementation science theories (1) propose and test the concept of shared understanding when describing communication, (2) acknowledge that communication is multi-layered, identify at least a few layers, and posit how identified layers might affect the development of shared understanding, (3) acknowledge that communication occurs in a social context, providing a frame of reference for both individuals and groups, (4) acknowledge the unpredictability of communication (and healthcare processes in general), and (5) engage with and draw on work done by communication theorists.

Summary

Implementation science literature has conceptualized communication as a transactional process (when communication has been mentioned at all), thereby ignoring a key contributor to implementation intervention success. When conceptualized as a transformational process, the focus of communication moves to shared understanding and is grounded in human interactions and the way we go about constructing knowledge. Instead of hiding in plain sight, we suggest explicitly acknowledging the role that communication plays in our implementation efforts. By using both paradigms, we can investigate when communication facilitates implementation, when it does not, and how to improve it so that our implementation and clinical interventions are embraced by clinicians and patients alike.

Strategies of active dissemination of workplace health promotion

Purpose

– A growing body of literature provides evidence for the efficacy of workplace health promotion (WHP). However, little is known about effective dissemination strategies for WHP interventions. The purpose of this paper is to describe how a WHP agency in Zurich, Switzerland, used bulk mailings, information events, telephone marketing and free initial consultations for the large-scale geographic marketing of WHP services, with a focus on tobacco prevention (TP).

Design/methodology/approach

– To analyze the number of companies responding positively to solicitation, examine the predictors of positive responses and explore the reasons for negative responses, the authors used both quantitative (e.g. a standardized questionnaire) and qualitative (telephone interviews) methods.

Findings

– The results show that except for telephone marketing (69 percent), the success rates of dissemination activities were very low (3-9 percent). Predictors for a positive response were institutionalization of WHP, the representative’s personal concern about TP, and problems with environmental tobacco smoke within the company. The most prominent reason for a negative response was that the companies had already implemented TP measures by themselves and needed no further external support.

Practical implications

– It is suggested that TP was the wrong emphasis for a WHP program to be disseminated at that particular time, because a law on protection from passive smoking was introduced in Switzerland shortly afterwards.

Originality/value

– The study examines dissemination strategies under real-life consulting conditions. It builds on on a large sample of companies and uses both quantitative and qualitative research methods. It reports specific numbers and success rates of marketing activities and thereby contributes to the knowledge about an important issue for intervention planning in the field of WHP.

Assessing Organizational Readiness for a Participatory Occupational Health/Health Promotion Intervention in Skilled Nursing Facilities

The long-term care sector is characterized by high morbidity and employee turnover, along with associated costs. Effective health protection and health promotion are important to improve physical and psychosocial well-being of caregivers. Assessment of organizational readiness for change is an essential precursor to the successful implementation of workplace programs addressing work climate, structure of tasks and relationships, and other issues that may be perceived as challenging by some within the institution. This study qualitatively assessed readiness of five skilled nursing facilities for a participatory occupational health/health promotion intervention. Selection criteria were developed to screen for program feasibility and ability to conduct prospective evaluations, and information was collected from managers and employees (interviews and focus groups). Three centers were selected for the program, and the first year of formative evaluation and intervention experience was then reviewed to evaluate and modify our selection criteria after the fact. Lessons learned include adding assessment of communication and the structure of problem solving to our selection criteria, improving methods to assess management support in a concrete (potentially nonverbal) form, and obtaining a stated financial commitment and resources to enable the team to function. Assessment of organizational readiness for change is challenging, although necessary to implement effective and sustainable health promotion programs in specific organizations.

Context and implementation: A concept analysis towards conceptual maturity

Context and implementation of health interventions have received increasing attention over the past decade, in particular with respect to their influence on the effectiveness and reach of complex interventions. The underlying concepts are both considered partially mature, limiting their operationalization in research and practice. We conducted systematic literature searches and pragmatic utility (PU) concept analyses to provide a state-of-the-art assessment of the concepts of "context" and "implementation" in the health sciences to create a common understanding for their use within systematic reviews and HTA. We performed two separate searches, one for context (EMBASE, MEDLINE) and the other for implementation (Google Scholar) to identify relevant models, theories and frameworks. 17 publications on context and 35 articles on implementation met our inclusion criteria. PU concept analysis comprises three guiding principles: selection of the literature, organization and structuring of the literature, and asking analytic questions of the literature. Both concepts were analyzed according to four features of conceptual maturity, i.e., consensual definitions, clear characteristics, fully described preconditions and outcomes, and delineated boundaries. Context and implementation are highly intertwined, with both concepts influencing and interacting with each other. Context is defined as a set of characteristics and circumstances that surround the implementation effort. Implementation is conceptualized as a planned and deliberately initiated effort with the intention to put an intervention into practice. The concept of implementation presents largely consensual definitions and relatively well-defined boundaries, while distinguishing features, preconditions and outcomes are not yet fully articulated. In contrast, definitions of context vary widely, and boundaries with neighbouring concepts, such as setting and environment, are blurred; characteristics, preconditions and outcomes are ill-defined. Therefore, the maturity of both concepts should be further improved to facilitate operationalization in systematic reviews and HTAs.

Exploring health facilities' experiences in implementing the free health-care policy (FHCP) in Nepal: how did organizational factors influence the implementation of the user-fee abolition policy?

BACKGROUND

This article presents an Asian experience of abolishing health-care user fees: Nepal's universal free health-care policy, implemented in 2008. Based on doctoral fieldwork between August 2008 and April 2009, the paper analyses primary-care facilities' and central and district health systems' experiences with the policy. It makes a unique contribution to existing evidence because it explicitly applies organizational theory within a carefully designed, rigorous, multiple case-study analysis to deepen our understanding of the organizational and 'people' factors in the successful removal of user fees.

METHODS

The cases were two pairs of primary-care facilities in one district, paired for comparison of the facilities' experiences with the policy in relation to its effects on health care utilization. Data collection methods included document reviews; key informant interviews at district and central levels; in-depth, semi-structured interviews and group interviews at case facilities. (Data on indicators of utilization and quality changes over time were also collected and will be published separately). Using key elements of Nadler and Tushman's 'Organizational Congruence' model, a degree-of-fit analysis tested the study's initial propositions and yielded generalizations for contexts in and outside Nepal.

RESULTS

The study found that Nepal's key implementation challenges were similar to Africa's: insufficient or delayed inputs of drugs and compensation; insufficient workforce and the resulting reduced quality of services that hampered facilities' relationships with their clients and health providers' attitudes. However, the Nepalese case facilities with (1) good intra- and inter-facility relationships, (2) adequate staffing, (3) well-oriented providers and (4) previously trained, better-informed and skilled health management committees experienced higher utilization and better-quality indicators over time.

CONCLUSIONS

Through its detailed analysis of Nepal's experience in removing user fees, the study highlights the importance of addressing the 'people' and 'organizational' factors in health-policy development and implementation.

Our Choice/Nuestra Opción: the Imperial County, California, Childhood Obesity Research Demonstration study (CA-CORD)

BACKGROUND

Despite recent declines among young children, obesity remains a public health burden in the United States, including among Latino/Hispanic children. The determining factors are many and are too complex to fully address with interventions that focus on single factors, such as parenting behaviors or school policies. In this article, we describe a multisector, multilevel intervention to prevent and control childhood obesity in predominantly Mexican-origin communities in Southern California, one of three sites of the CDC-funded Childhood Obesity Research Demonstration (CA-CORD) study.

METHODS

CA-CORD is a partnership between a university-affiliated research institute, a federally qualified health center, and a county public health department. We used formative research, advisory committee members' recommendations, and previous research to inform the development of the CA-CORD project. Our theory-informed multisector, multilevel intervention targets improvements in four health behaviors: fruit, vegetable, and water consumption; physical activity; and quality sleep. Intervention partners include 1200 families, a federally qualified health center (including three clinics), 26 early care and education centers, two elementary school districts (and 20 elementary schools), three community recreation centers, and three restaurants. Intervention components in these sectors target changes in behaviors, policies, systems, and the social and physical environment. Evaluation activities include assessment of the primary outcome, BMI z-score, at baseline, 12-, and 18-months post-baseline, and sector evaluations at baseline, 12, and 24 months.

CONCLUSIONS

Identifying feasible and effective strategies to prevent and control childhood obesity has the potential to effect real changes in children's current and future health status.

Evaluation protocol to assess an integrated framework for the implementation of the Childhood Obesity Research Demonstration project at the California (CA-CORD) and Massachusetts (MA-CORD) sites

BACKGROUND

The long-term success of child obesity prevention and control efforts depends not only on the efficacy of the approaches selected, but also on the strategies through which they are implemented and sustained. This study introduces the Multilevel Implementation Framework (MIF), a conceptual model of factors affecting the implementation of multilevel, multisector interventions, and describes its application to the evaluation of two of three state sites (CA and MA) participating in the Childhood Obesity Research Demonstration (CORD) project.

METHODS/DESIGN

A convergent mixed-methods design is used to document intervention activities and identify determinants of implementation effectiveness at the CA-CORD and MA-CORD sites. Data will be collected from multiple sectors and at multiple levels of influence (e.g., delivery system, academic-community partnership, and coalition). Quantitative surveys will be administered to coalition members and staff in participating delivery systems. Qualitative, semistructured interviews will be conducted with project leaders and key informants at multiple levels (e.g., leaders and frontline staff) within each delivery system. Document analysis of project-related materials and in vivo observations of training sessions will occur on an ongoing basis. Specific constructs assessed will be informed by the MIF. Results will be shared with project leaders and key stakeholders for the purposes of improving processes and informing sustainability discussions and will be used to test and refine the MIF.

CONCLUSIONS

Study findings will contribute to knowledge about how to coordinate and implement change strategies within and across sectors in ways that effectively engage diverse stakeholders, minimize policy resistance, and maximize desired intervention outcomes.

Determining the predictors of innovation implementation in healthcare: a quantitative analysis of implementation effectiveness

BACKGROUND

The failure rates for implementing complex innovations in healthcare organizations are high. Estimates range from 30% to 90% depending on the scope of the organizational change involved, the definition of failure, and the criteria to judge it. The innovation implementation framework offers a promising approach to examine the organizational factors that determine effective implementation. To date, the utility of this framework in a healthcare setting has been limited to qualitative studies and/or group level analyses. Therefore, the goal of this study was to quantitatively examine this framework among individual participants in the National Cancer Institute's Community Clinical Oncology Program using structural equation modeling.

METHODS

We examined the innovation implementation framework using structural equation modeling (SEM) among 481 physician participants in the National Cancer Institute's Community Clinical Oncology Program (CCOP). The data sources included the CCOP Annual Progress Reports, surveys of CCOP physician participants and administrators, and the American Medical Association Physician Masterfile.

RESULTS

Overall the final model fit well. Our results demonstrated that not only did perceptions of implementation climate have a statistically significant direct effect on implementation effectiveness, but physicians' perceptions of implementation climate also mediated the relationship between organizational implementation policies and practices (IPP) and enrollment (p <0.05). In addition, physician factors such as CCOP PI status, age, radiological oncologists, and non-oncologist specialists significantly influenced enrollment as well as CCOP organizational size and structure, which had indirect effects on implementation effectiveness through IPP and implementation climate.

CONCLUSIONS

Overall, our results quantitatively confirmed the main relationship postulated in the innovation implementation framework between IPP, implementation climate, and implementation effectiveness among individual physicians. This finding is important, as although the model has been discussed within healthcare organizations before, the studies have been predominately qualitative in nature and/or at the organizational level. In addition, our findings have practical applications. Managers looking to increase implementation effectiveness of an innovation should focus on creating an environment that physicians perceive as encouraging implementation. In addition, managers should consider instituting specific organizational IPP aimed at increasing positive perceptions of implementation climate. For example, IPP should include specific expectations, support, and rewards for innovation use.

Stage 1 of the meaningful use incentive program for electronic health records: a study of readiness for change in ambulatory practice settings in one integrated delivery system

Background

Meaningful Use (MU) provides financial incentives for electronic health record (EHR) implementation. EHR implementation holds promise for improving healthcare delivery, but also requires substantial changes for providers and staff. Establishing readiness for these changes may be important for realizing potential EHR benefits. Our study assesses whether provider/staff perceptions about the appropriateness of MU and their departments’ ability to support MU-related changes are associated with their reported readiness for MU-related changes.

Methods

We surveyed providers and staff representing 47 ambulatory practices within an integrated delivery system. We assessed whether respondent’s role and practice-setting type (primary versus specialty care) were associated with reported readiness for MU (i.e., willingness to change practice behavior and ability to document actions for MU) and hypothesized predictors of readiness (i.e., perceived appropriateness of MU and department support for MU). We then assessed associations between reported readiness and the hypothesized predictors of readiness.

Results

In total, 400 providers/staff responded (response rate approximately 25%). Individuals working in specialty settings were more likely to report that MU will divert attention from other patient-care priorities (12.6% vs. 4.4%, p = 0.019), as compared to those in primary-care settings. As compared to advanced-practice providers and nursing staff, physicians were less likely to have strong confidence in their department’s ability to solve MU implementation problems (28.4% vs. 47.1% vs. 42.6%, p = 0.023) and to report strong willingness to change their work practices for MU (57.9% vs. 83.3% vs. 82.0%, p < 0.001). Finally, provider/staff perceptions about whether MU aligns with departmental goals (OR = 3.99, 95% confidence interval (CI) = 2.13 to 7.48); MU will divert attention from other patient-care priorities (OR = 2.26, 95% CI = 1.26 to 4.06); their department will support MU-related change efforts (OR = 3.99, 95% CI = 2.13 to 7.48); and their department will be able to solve MU implementation problems (OR = 2.26, 95% CI = 1.26 to 4.06) were associated with their willingness to change practice behavior for MU.

Conclusions

Organizational leaders should gauge provider/staff perceptions about appropriateness and management support of MU-related change, as these perceptions might be related to subsequent implementation.

Determinants of survivorship care plan use in US cancer programs

Cancer programs are increasingly required to use survivorship care plans (SCPs). Compliance with SCP use requirements will be evaluated at the cancer program level. Cancer program-level determinants of SCP use may suggest strategies for compliance. The objective of this study was to describe SCP use and identify its cancer program-level determinants. We surveyed employees knowledgeable about survivorship practices in cancer programs throughout the USA with a wide range of annual incident cancers, program types, and cancer care quality improvement organization memberships (81/100 response rate). We used descriptive statistics to describe SCP use and bivariate statistics to identify its cancer program-level determinants. Most respondents (56 %) reported that SCPs were not used. In programs reporting use, SCP use is restricted primarily to breast (82 %) and colorectal (55 %) cancer survivors, and few providers use SCPs. When developed, SCPs seldom reach survivors and their primary care providers. Most respondents (78 %) reported beginning to use SCPs because of requirements. Frequently cited barriers included insufficient resources (76 %), perceived difficulty using SCPs (29 %), and lack of advocacy for SCP use from influential people (24 %). SCP use was positively associated with academic program type (p = .009) and membership in the National Cancer Institute's Community Cancer Centers Program (p = .009) and negatively associated with freestanding program type (p = .02). SCP use in the US cancer programs is highly inconsistent. Many cancer programs plan to implement SCPs to comply with SCP use requirements. Support specifically intended to facilitate SCP use may be more effective than non-specific resources.

Following through: the consistency of survivorship care plan use in United States cancer programs

The Institute of Medicine suggests that consistent survivorship care plan (SCP) use involves developing and delivering SCPs to all cancer survivors and their primary care providers (PCPs). We describe the consistency of SCP use in US cancer programs and assess its relationship with cancer-program-level determinants. We surveyed employees knowledgeable about survivorship practices in cancer programs reporting current SCP use (n = 36, 81 % response rate). We operationalized consistent SCP use as whether SCPs were (1) developed for ≥75 % survivors, (2) delivered to ≥75 % survivors, (3) delivered to ≥75 % PCPs, and (4) all of the above. We use descriptive statistics to report SCP use consistency and evaluate associations using Fisher's exact and Wilcoxon rank sum tests. SCPs were developed for ≥75 % survivors in five programs (15 %), eight (25 %) delivered ≥75 % SCPs to survivors, seven (23 %) delivered ≥75 % SCPs to PCPs, and only one program (4 %) met all three criteria. We found relationships between SCP use consistency and geographic region (p = .05), initiating SCP use in response to survivors' requests (p = .03), and membership in the National Cancer Institute's National Community Cancer Centers Program (p = .01). SCP use is highly inconsistent. Survivors and cancer care quality improvement organizations may play a key role in improving the consistency of SCP use in US cancer programs. Survivors can initiate SCP use. Cancer care quality improvement organizations can specify how cancer programs' compliance with SCP guidelines will be assessed. Future research should identify mechanisms underlying the relationships that we found.

Implementation of new clinical programs in the VHA healthcare system: the importance of early collaboration between clinical leadership and research

Collaboration between policy, research, and clinical partners is crucial to achieving proven quality care. The Veterans Health Administration has expended great efforts towards fostering such collaborations. Through this, we have learned that an ideal collaboration involves partnership from the very beginning of a new clinical program, so that the program is designed in a way that ensures quality, validity, and puts into place the infrastructure necessary for a reliable evaluation. This paper will give an example of one such project, the Lung Cancer Screening Demonstration Project (LCSDP). We will outline the ways that clinical, policy, and research partners collaborated in design, planning, and implementation in order to create a sustainable model that could be rigorously evaluated for efficacy and fidelity. We will describe the use of the Donabedian quality matrix to determine the necessary characteristics of a quality program and the importance of the linkage with engineering, information technology, and clinical paradigms to connect the development of an on-the-ground clinical program with the evaluation goal of a learning healthcare organization. While the LCSDP is the example given here, these partnerships and suggestions are salient to any healthcare organization seeking to implement new scientifically proven care in a useful and reliable way.

Assessing organizational capacity for achieving meaningful use of electronic health records

BACKGROUND

Health care institutions are scrambling to manage the complex organizational change required for achieving meaningful use (MU) of electronic health records (EHR). Assessing baseline organizational capacity for the change can be a useful step toward effective planning and resource allocation.

PURPOSE

The aim of this article is to describe an adaptable method and tool for assessing organizational capacity for achieving MU of EHR. Data on organizational capacity (people, processes, and technology resources) and barriers are presented from outpatient clinics within one integrated health care delivery system; thus, the focus is on MU requirements for eligible professionals, not eligible hospitals.

METHODS

We conducted 109 interviews with representatives from 46 outpatient clinics.

FINDINGS

Most clinics had core elements of the people domain of capacity in place. However, the process domain was problematic for many clinics, specifically, capturing problem lists as structured data and having standard processes for maintaining the problem list in the EHR. Also, nearly half of all clinics did not have methods for tracking compliance with their existing processes. Finally, most clinics maintained clinical information in multiple systems, not just the EHR. The most common perceived barriers to MU for eligible professionals included EHR functionality, changes to workflows, increased workload, and resistance to change.

PRACTICE IMPLICATIONS

Organizational capacity assessments provide a broad institutional perspective and an in-depth clinic-level perspective useful for making resource decisions and tailoring strategies to support the MU change effort for eligible professionals.

Leadership networks in Catholic parishes: implications for implementation research in health

Through two case studies of Catholic parishes in Massachusetts, this study explores the implications of leader-centered versus distributed leadership in Catholic parishes for the implementation of evidence-based health interventions. The two parishes involved in the study differ from each other in several ways. In the first, parishioners are less engaged in leadership activities at the decision-making level in the parish. A small group of lay volunteers work with the parish priest and other ordained leaders on parish activities. In the second parish, a large and active lay volunteer leadership have forged an organizational structure that allows more independence from the pastor's direct oversight. In this parish, lay volunteer leaders are the prime drivers of organizational programs and events. In 2012-2013, three types of networks were assessed at each parish: discussion, collaboration, and outside-of-parish ties. The contrasts between each parish include differences in density of collaboration, in frequency of discussion, and network centrality of the respective parish priests. We further identified key actors in the network structures at each parish. We discuss the implications of these findings for understanding organizational capacity in the context of health program implementation.

School health promotion providers' roles in practice and theory: results from a case study

BACKGROUND

Implementation is critical to the success of health promotion (HP) in schools, but little is known about how schools can best be assisted during this process. This article focuses on Austrian HP providers and aspects their roles incorporate.

OBJECTIVE

To investigate the providers' role in the practice of HP implementation and how it differs from its official description. On the basis of these findings, implications are suggested.

METHODS

The data were gathered within the framework of an explorative case study of complex HP interventions. We draw on four interviews with HP organisation staff, five documents from the providers' organisations and seven interviews with school staff from three schools.

RESULTS

In practice, providers took up different responsibilities, e.g., acting as emotional support to school staff and supporting the documentation of projects, guided more by the schools' needs than by the programmes they are helping to implement. Providers focused mostly on the implementation of single activities and did little to emphasize the necessity of organisational change.

POLICY IMPLICATIONS

Our findings suggest that providers' background in health should be complemented by a deeper understanding of the importance of organisational change to further support HP implementation.

The role of advocacy coalitions in a project implementation process: the example of the planning phase of the At Home/Chez Soi project dealing with homelessness in Montreal

This study analyzed the planning process (summer 2008 to fall 2009) of a Montreal project that offers housing and community follow-up to homeless people with mental disorders, with or without substance abuse disorders. With the help of the Advocacy Coalition Framework (ACF), advocacy groups that were able to navigate a complex intervention implementation process were identified. In all, 25 people involved in the Montreal At Home/Chez Soi project were surveyed through interviews (n=18) and a discussion group (n=7). Participant observations and documentation (minutes and correspondence) were also used for the analysis. The start-up phase of the At Home/Chez may be broken down into three separate periods qualified respectively as "honeymoon;" "clash of cultures;" and "acceptance & commitment". In each of the planning phases of the At Home/Chez Soi project in Montreal, at least two advocacy coalitions were in confrontation about their specific belief systems concerning solutions to address the recurring homelessness social problem, while a third, more moderate one contributed in rallying most key actors under specified secondary aspects. The study confirms the importance of policy brokers in achieving compromises acceptable to all advocacy coalitions.

Translating evidence-based interventions for implementation: Experiences from Project HEAL in African American churches

BACKGROUND

Community-based approaches have been increasing in the effort to raise awareness and early detection for cancer and other chronic disease. However, many times, such interventions are tested in randomized trials, become evidence-based, and then fail to reach further use in the community. Project HEAL (Health through Early Awareness and Learning) is an implementation trial that aims to compare two strategies of implementing evidence-based cancer communication interventions in African American faith-based organizations.

METHOD

This article describes the community-engaged process of transforming three evidence-based cancer communication interventions into a coherent, branded strategy for training community health advisors with two delivery mechanisms. Peer community health advisors receive training through either a traditional classroom approach (with high technical assistance/support) or a web-based training portal (with low technical assistance/support).

RESULTS

We describe the process, outline the intervention components, report on the pilot test, and conclude with lessons learned from each of these phases. Though the pilot phase showed feasibility, it resulted in modifications to data collection protocols and team and community member roles and expectations.

CONCLUSIONS

Project HEAL offers a promising strategy to implement evidence-based interventions in community settings through the use of technology. There could be wider implications for chronic disease prevention and control.

Organizational factors as predictors of tobacco cessation pharmacotherapy adoption in addiction treatment programs

OBJECTIVES

This study investigated 3 organizational factors (ie, counseling staff clinical skills, absence of treatment program obstacles, and policy-related incentives) as predictors of tobacco cessation pharmacotherapy (TCP) adoption (comprised of the 9 available TCPs) in addiction treatment programs using the innovation implementation effectiveness framework.

METHODS

Data were obtained in 2010 from a random sample of 1006 addiction treatment program administrators located across the United States using structured telephone interviews.

RESULTS

According to program administrator reports, TCP is adopted in approximately 30% of treatment programs. Negative binomial regression results show that fewer treatment program obstacles and more policy-related incentives are related to greater adoption of TCP. Counter to prediction, clinical skills are unrelated to TCP adoption.

CONCLUSIONS

Our findings suggest that organizational factors, on the basis of established theoretical frameworks, merit further examination as facilitators of the adoption of diverse TCP in addiction treatment programs.

Developing and implementing a service charter for an integrated regional stroke service: an exploratory case study

BACKGROUND

Based on practices in commercial organizations and public services, healthcare organizations are using service charters to inform patients about the quality of service they can expect and to increase patient-centeredness. In the Netherlands, an integrated regional stroke service involving five organizations has developed and implemented a single service charter. The purpose of this study is to determine the organizational enablers for the effective development and implementation of this service charter.

METHODS

We have conducted an exploratory qualitative study using Grounded Theory to determine the organizational enablers of charter development and implementation. Individual semi-structured interviews were held with all members of the steering committee and the taskforce responsible for the service charter. In these twelve interviews, participants were retrospectively asked for their opinions of the enablers. Interview transcripts have been analysed using Glaser's approach of substantive coding consisting of open and selective coding in order to develop a framework of these enablers. A tabula rasa approach was used without any preconceived frameworks used in the coding process.

RESULTS

We have determined seven categories of enablers formed of a total of 27 properties. The categories address a broad spectrum of enablers dealing with the basic foundations for cooperation, the way to manage the project's organization and the way to implement the service charter. In addition to the enablers within each individual organization, enablers that reflect the whole chain seem to be important for the effective development and implementation of this service charter. Strategic alignment of goals within the chain, trust between organizations, willingness to cooperate and the extent of process integration are all important properties.

CONCLUSIONS

This first exploratory study into the enablers of the effective development and implementation was based on a single case study in the Netherlands. This is the only integrated care chain using a single service charter that we could find. Nevertheless, the results of our explorative study provide an initial framework for the development and implementation of service charters in integrated care settings. This research contributes to the literature on service charters, on patient-centeredness in integrated care and on the implementation of innovations.

The roles of users personal characteristics and organisational support in the attitude towards using ERP systems in a Spanish public hospital

Enterprise resources planning (ERP) systems enable central and integrative control over all processes throughout an organisation by ensuring one data entry point and the use of a common database. T his paper analyses the attitude of healthcare personnel towards the use of an ERP system in a Spanish public hospital, identifying influencing factors. This research is based on a regression analysis of latent variables using the optimisation technique of partial least squares. We propose a research model including possible relationships among different constructs using the technology acceptance model. Our results show that the personal characteristics of potential users are key factors in explaining attitude towards using ERP systems.

Evaluation of a worksite wellness program designed to reduce cardiovascular risks

We evaluated a multifactorial worksite wellness program designed to improve lifestyle and reduce cardiovascular risks at a small professional services company. Program participation (N = 60 employees) consisted of an enrollment session, a 6-month period of wellness program activities, and a disenrollment session. Lifestyle and biometric measures were obtained at enrollment and disenrollment. Over 6-months, percentage of dietary fat intake decreased (P < .01); daily fruit and vegetable servings and fiber intake increased (P = .02); systolic and diastolic blood pressure decreased (P = .04 and 0.01, respectively), and high-density lipoprotein increased (P < .01). This worksite wellness program achieved meaningful improvements in dietary intake and reduction in cardiovascular risks.

Organizational readiness for implementing change: a psychometric assessment of a new measure

Background

Organizational readiness for change in healthcare settings is an important factor in successful implementation of new policies, programs, and practices. However, research on the topic is hindered by the absence of a brief, reliable, and valid measure. Until such a measure is developed, we cannot advance scientific knowledge about readiness or provide evidence-based guidance to organizational leaders about how to increase readiness. This article presents results of a psychometric assessment of a new measure called Organizational Readiness for Implementing Change (ORIC), which we developed based on Weiner’s theory of organizational readiness for change.

Methods

We conducted four studies to assess the psychometric properties of ORIC. In study one, we assessed the content adequacy of the new measure using quantitative methods. In study two, we examined the measure’s factor structure and reliability in a laboratory simulation. In study three, we assessed the reliability and validity of an organization-level measure of readiness based on aggregated individual-level data from study two. In study four, we conducted a small field study utilizing the same analytic methods as in study three.

Results

Content adequacy assessment indicated that the items developed to measure change commitment and change efficacy reflected the theoretical content of these two facets of organizational readiness and distinguished the facets from hypothesized determinants of readiness. Exploratory and confirmatory factor analysis in the lab and field studies revealed two correlated factors, as expected, with good model fit and high item loadings. Reliability analysis in the lab and field studies showed high inter-item consistency for the resulting individual-level scales for change commitment and change efficacy. Inter-rater reliability and inter-rater agreement statistics supported the aggregation of individual level readiness perceptions to the organizational level of analysis.

Conclusions

This article provides evidence in support of the ORIC measure. We believe this measure will enable testing of theories about determinants and consequences of organizational readiness and, ultimately, assist healthcare leaders to reduce the number of health organization change efforts that do not achieve desired benefits. Although ORIC shows promise, further assessment is needed to test for convergent, discriminant, and predictive validity.

Embedding care management in the medical home: a case study

INTRODUCTION

Care managers are playing increasingly significant roles in the redesign of primary care and in the evolution of patient-centered medical homes (PCMHs), yet their adoption within day-to-day practice remains uneven and approaches for implementation have been minimally reported. We introduce a strategy for incorporating care management into the operations of a PCMH and assess the preliminary effectiveness of this approach.

METHODS

A case study of the University of North Carolina at Chapel Hill Family Medicine Center used an organizational model of innovation implementation to guide the parameters of implementation and evaluation. Two sources were used to determine the effectiveness of the implementation strategy: data elements from the care management informatics system in the health record and electronic survey data from the Family Medicine Center providers and care staff.

RESULTS

A majority of physicians (75%) and support staff (82%) reported interactions with the care manager, primarily via face-to-face, telephone, or electronic means, primarily for facilitating referrals for behavioral health services and assistance with financial and social and community-based resources. Trend line suggests an absolute decrease of 8 emergency department visits per month for recipients of care management services and an absolute decrease of 7.5 inpatient admissions per month during the initial 2-year implementation period.

DISCUSSION

An organizational model of innovation implementation is a potentially effective approach to guide the process of incorporating care management services into the structure and workflows of PCMHs.

More extensive implementation of the chronic care model is associated with better lipid control in diabetes

OBJECTIVE

Chronic disease collaboratives help practices redesign care delivery. The North Carolina Improving Performance in Practice program provides coaches to guide implementation of 4 key practice changes: registries, planned care templates, protocols, and self-management support. Coaches rate progress using the Key Drivers Implementation Scales (KDIS). This study examines whether higher KDIS scores are associated with improved diabetes outcomes.

METHODS

We analyzed clinical and KDIS data from 42 practices. We modeled whether higher implementation scores at year 1 of participation were associated with improved diabetes measures during year 2. Improvement was defined as an increase in the proportion of patients with hemoglobin A1C values <9%, blood pressure values <130/80 mmHg, and low-density lipoprotein (LDL) levels <100 mg/dL.

RESULTS

Statistically significant improvements in the proportion of patients who met the LDL threshold were noted with higher "registry" and "protocol" KDIS scores. For hemoglobin A1C and blood pressure values, none of the odds ratios were statistically significant.

CONCLUSIONS

Practices that implement key changes may achieve improved patient outcomes in LDL control among their patients with diabetes. Our data confirm the importance of registry implementation and protocol use as key elements of improving patient care. The KDIS tool is a pragmatic option for measuring practice changes that are rooted in the Chronic Care Model.

What is actually measured in process evaluations for worksite health promotion programs: a systematic review

Background

Numerous worksite health promotion program (WHPPs) have been implemented the past years to improve employees’ health and lifestyle (i.e., physical activity, nutrition, smoking, alcohol use and relaxation). Research primarily focused on the effectiveness of these WHPPs. Whereas process evaluations provide essential information necessary to improve large scale implementation across other settings. Therefore, this review aims to: (1) further our understanding of the quality of process evaluations alongside effect evaluations for WHPPs, (2) identify barriers/facilitators affecting implementation, and (3) explore the relationship between effectiveness and the implementation process.

Methods

Pubmed, EMBASE, PsycINFO, and Cochrane (controlled trials) were searched from 2000 to July 2012 for peer-reviewed (randomized) controlled trials published in English reporting on both the effectiveness and the implementation process of a WHPP focusing on physical activity, smoking cessation, alcohol use, healthy diet and/or relaxation at work, targeting employees aged 18-65 years.

Results

Of the 307 effect evaluations identified, twenty-two (7.2%) published an additional process evaluation and were included in this review. The results showed that eight of those studies based their process evaluation on a theoretical framework. The methodological quality of nine process evaluations was good. The most frequently reported process components were dose delivered and dose received. Over 50 different implementation barriers/facilitators were identified. The most frequently reported facilitator was strong management support. Lack of resources was the most frequently reported barrier. Seven studies examined the link between implementation and effectiveness. In general a positive association was found between fidelity, dose and the primary outcome of the program.

Conclusions

Process evaluations are not systematically performed alongside effectiveness studies for WHPPs. The quality of the process evaluations is mostly poor to average, resulting in a lack of systematically measured barriers/facilitators. The narrow focus on implementation makes it difficult to explore the relationship between effectiveness and implementation. Furthermore, the operationalisation of process components varied between studies, indicating a need for consensus about defining and operationalising process components.

Factors in adoption of a fire department wellness program: champ-and-chief model

OBJECTIVE

To identify and evaluate determinants of fire departments' wellness program adoption.

METHODS

The Promoting Healthy Lifestyles: Alternative Models' Effects fire service wellness program was offered for free to all medium-sized fire departments in Oregon and Washington. An invitation to participate was mailed to key fire department decision makers (chief, union president, and wellness officer). These key decision makers from 12 sites that adopted the program and 24 matched nonadopting sites were interviewed and results were analyzed to define adoption determinants.

RESULTS

Three adoption requirements were identified: (1) mailer connection, (2) local firefighter wellness champion, and (3) willing fire chief, whereas a fourth set of organizational factors had little or no impact on adoption including previous and ongoing wellness activities, financial pressures, and resistance to change.

CONCLUSIONS

Findings identified determinants of medium-sized fire service wellness program adoption.

Prevention of low back pain and its consequences among nurses' aides in elderly care: a stepped-wedge multi-faceted cluster-randomized controlled trial

BACKGROUND

A high prevalence of low back pain has persisted over the years despite extensive primary prevention initiatives among nurses' aides. Many single-faceted interventions addressing just one aspect of low back pain have been carried out at workplaces, but with low success rate. This may be due to the multi-factorial origin of low back pain. Participatory ergonomics, cognitive behavioral training and physical training have previously shown promising effects on prevention and rehabilitation of low back pain. Therefore, the main aim of this study is to examine whether a multi-faceted workplace intervention consisting of participatory ergonomics, physical training and cognitive behavioral training can prevent low back pain and its consequences among nurses' aides. External resources for the participating workplace and a strong commitment from the management and the organization support the intervention.

METHODS/DESIGN

To overcome implementation barriers within usual randomized controlled trial designed workplace interventions, this study uses a stepped-wedge cluster-randomized controlled trial design with 4 groups. The intervention is delivered to the groups at random along four successive time periods three months apart. The intervention lasts three months and integrates participatory ergonomics, physical training and cognitive behavioral training tailored to the target group. Local physiotherapists and occupational therapists conduct the intervention after having received standardized training. Primary outcomes are low back pain and its consequences measured monthly by text messages up to three months after initiation of the intervention.

DISCUSSION

Intervention effectiveness trials for preventing low back pain and its consequences in workplaces with physically demanding work are few, primarily single-faceted, with strict adherence to a traditional randomized controlled trial design that may hamper implementation and compliance, and have mostly been unsuccessful. By using a stepped wedge design, and obtain high management commitment and support we intend to improve implementation and aim to establish the effectiveness of a multi-faceted intervention to prevent low back pain. This study will potentially provide knowledge of prevention of low back pain and its consequences among nurses' aides. Results are expected to be published in 2015-2016.

TRIAL REGISTRATION

The study is registered as ISRCTN78113519.

Climate for innovation, 12-step orientation, and tobacco cessation treatment

This study examined the relationship between (1) three indicators of climate for innovation (clinician skills, absence of program obstacles, policy-related incentives) and adoption extensiveness of both behavioral treatments for tobacco cessation (TC) and system-level support for TC in substance use disorder treatment programs, (2) a program's 12-step treatment orientation and adoption extensiveness, and (3) whether 12-step treatment orientation moderates the relationship between climate for innovation and adoption extensiveness. Data were obtained from a random sample of 1006 program administrators. Hierarchical regression results showed that both absence of program obstacles and policy-related incentives are positively related to adoption extensiveness. Twelve-step treatment orientation is neither related to adoption extensiveness nor a moderator of the relationship between climate for innovation and adoption extensiveness. Although the adoption of both behavioral treatments for TC and system-level support for TC is not extensive, we conclude that a 12-step treatment orientation neither hampers nor promotes adoption extensiveness.

A multilevel model of organizational health culture and the effectiveness of health promotion

PURPOSE

Organizational health culture is a health-oriented core characteristic of the organization that is shared by all members. It is effective in regulating health-related behavior for employees and could therefore influence the effectiveness of health promotion efforts among organizations and employees. This study applied a multilevel analysis to verify the effects of organizational health culture on the organizational and individual effectiveness of health promotion.

DESIGN

At the organizational level, we investigated the effect of organizational health culture on the organizational effectiveness of health promotion. At the individual level, we adopted a cross-level analysis to determine if organizational health culture affects employee effectiveness through the mediating effect of employee health behavior.

SETTING

The study setting consisted of the workplaces of various enterprises.

SUBJECTS

We selected 54 enterprises in Taiwan and surveyed 20 full-time employees from each organization, for a total sample of 1011 employees.

MEASURES

We developed the Organizational Health Culture Scale to measure employee perceptions and aggregated the individual data to formulate organization-level data. Organizational effectiveness of health promotion included four dimensions: planning effectiveness, production, outcome, and quality, which were measured by scale or objective indicators. The Health Promotion Lifestyle Scale was adopted for the measurement of health behavior. Employee effectiveness was measured subjectively in three dimensions: self-evaluated performance, altruism, and happiness.

ANALYSIS

Following the calculation of descriptive statistics, hierarchical linear modeling (HLM) was used to test the multilevel hypotheses.

RESULTS

Organizational health culture had a significant effect on the planning effectiveness (β = .356, p < .05) and production (β = .359, p < .05) of health promotion. In addition, results of cross-level moderating effect analysis by HLM demonstrated that the effects of organizational health culture on three dimensions of employee effectiveness were completely mediated by health behavior.

CONCLUSION

The construct connections established in this multilevel model will help in the construction of health promotion theories. The findings remind business executives that organizational health culture and employee health behavior help improve employee effectiveness.

Finding theory- and evidence-based alternatives to fear appeals: Intervention Mapping

Fear arousal-vividly showing people the negative health consequences of life-endangering behaviors-is popular as a method to raise awareness of risk behaviors and to change them into health-promoting behaviors. However, most data suggest that, under conditions of low efficacy, the resulting reaction will be defensive. Instead of applying fear appeals, health promoters should identify effective alternatives to fear arousal by carefully developing theory- and evidence-based programs. The Intervention Mapping (IM) protocol helps program planners to optimize chances for effectiveness. IM describes the intervention development process in six steps: (1) assessing the problem and community capacities, (2) specifying program objectives, (3) selecting theory-based intervention methods and practical applications, (4) designing and organizing the program, (5) planning, adoption, and implementation, and (6) developing an evaluation plan. Authors who used IM indicated that it helped in bringing the development of interventions to a higher level.

Organizational factors associated with readiness to implement and translate a primary care based telemedicine behavioral program to improve blood pressure control: the HTN-IMPROVE study

Background

Hypertension is prevalent and often sub-optimally controlled; however, interventions to improve blood pressure control have had limited success.

Objectives

Through implementation of an evidence-based nurse-delivered self-management phone intervention to facilitate hypertension management within large complex health systems, we sought to answer the following questions: What is the level of organizational readiness to implement the intervention? What are the specific facilitators, barriers, and contextual factors that may affect organizational readiness to change?

Study design

Each intervention site from three separate Veterans Integrated Service Networks (VISNs), which represent 21 geographic regions across the US, agreed to enroll 500 participants over a year with at least 0.5 full time equivalent employees of nursing time. Our mixed methods approach used a priori semi-structured interviews conducted with stakeholders (n = 27) including nurses, physicians, administrators, and information technology (IT) professionals between 2010 and 2011. Researchers iteratively identified facilitators and barriers of organizational readiness to change (ORC) and implementation. Additionally, an ORC survey was conducted with the stakeholders who were (n = 102) preparing for program implementation.

Results

Key ORC facilitators included stakeholder buy-in and improving hypertension. Positive organizational characteristics likely to impact ORC included: other similar programs that support buy-in, adequate staff, and alignment with the existing site environment; improved patient outcomes; is positive for the professional nurse role, and is evidence-based; understanding of the intervention; IT infrastructure and support, and utilization of existing equipment and space.

The primary ORC barrier was unclear long-term commitment of nursing. Negative organizational characteristics likely to impact ORC included: added workload, competition with existing programs, implementation length, and limited available nurse staff time; buy-in is temporary until evidence shows improved outcomes; contacting patients and the logistics of integration into existing workflow is a challenge; and inadequate staffing is problematic. Findings were complementary across quantitative and qualitative analyses.

Conclusions

The model of organizational change identified key facilitators and barriers of organizational readiness to change and successful implementation. This study allows us to understand the needs and challenges of intervention implementation. Furthermore, examination of organizational facilitators and barriers to implementation of evidence-based interventions may inform dissemination in other chronic diseases.