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Zurynski Y, Ludlow K, Testa L, Augustsson H, Herkes-Deane J, Hutchinson K, Lamprell G, McPherson E, Carrigan A, Ellis LA, Dharmayani PNA, Smith CL, Richardson L, Dammery G, Singh N, Braithwaite J. Built to last? Barriers and facilitators of healthcare program sustainability: a systematic integrative review. Implement Sci 2023; 18:62. [PMID: 37957669 PMCID: PMC10641997 DOI: 10.1186/s13012-023-01315-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 10/08/2023] [Indexed: 11/15/2023] Open
Abstract
OBJECTIVE To identify barriers and facilitators associated with the sustainability of implemented and evaluated improvement programs in healthcare delivery systems. DATA SOURCES AND STUDY SETTING Six academic databases were searched to identify relevant peer-reviewed journal articles published in English between July 2011 and June 2022. Studies were included if they reported on healthcare program sustainability and explicitly identified barriers to, and facilitators of, sustainability. STUDY DESIGN A systematic integrative review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Study quality was appraised using Hawker's Quality Assessment Tool. DATA COLLECTION/EXTRACTION METHODS A team of reviewers screened eligible studies against the inclusion criteria and extracted the data independently using a purpose-designed Excel spreadsheet. Barriers and facilitators were extracted and mapped to the Integrated Sustainability Framework (ISF). Frequency counts of reported barriers/facilitators were performed across the included studies. RESULTS Of the 124 studies included in this review, almost half utilised qualitative designs (n = 52; 41.9%) and roughly one third were conducted in the USA (n = 43; 34.7%). Few studies (n = 29; 23.4%) reported on program sustainability beyond 5 years of program implementation and only 16 of them (55.2%) defined sustainability. Factors related to the ISF categories of inner setting (n = 99; 79.8%), process (n = 99; 79.8%) and intervention characteristics (n = 72; 58.1%) were most frequently reported. Leadership/support (n = 61; 49.2%), training/support/supervision (n = 54; 43.5%) and staffing/turnover (n = 50; 40.3%) were commonly identified barriers or facilitators of sustainability across included studies. Forty-six (37.1%) studies reported on the outer setting category: funding (n = 26; 56.5%), external leadership by stakeholders (n = 16; 34.8%), and socio-political context (n = 14; 30.4%). Eight studies (6.5%) reported on discontinued programs, with factors including funding and resourcing, poor fit, limited planning, and intervention complexity contributing to discontinuation. CONCLUSIONS This review highlights the importance of taking into consideration the inner setting, processes, intervention characteristics and outer setting factors when sustaining healthcare programs, and the need for long-term program evaluations. There is a need to apply consistent definitions and implementation frameworks across studies to strengthen evidence in this area. TRIAL REGISTRATION https://bmjopen.bmj.com/content/7/11/e018568 .
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Affiliation(s)
- Yvonne Zurynski
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109.
- NHMRC Partnership Centre for Health System Sustainability, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia.
| | - Kristiana Ludlow
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Luke Testa
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
| | - Hanna Augustsson
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Solna, Sweden
| | - Jessica Herkes-Deane
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
| | - Karen Hutchinson
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
| | - Gina Lamprell
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
| | - Elise McPherson
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
| | - Ann Carrigan
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
| | - Louise A Ellis
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
- NHMRC Partnership Centre for Health System Sustainability, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia
| | - Putu Novi Arfirsta Dharmayani
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
- NHMRC Partnership Centre for Health System Sustainability, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia
| | - Carolynn L Smith
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
- NHMRC Partnership Centre for Health System Sustainability, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia
| | - Lieke Richardson
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
| | - Genevieve Dammery
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
- NHMRC Partnership Centre for Health System Sustainability, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia
| | - Nehal Singh
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
| | - Jeffrey Braithwaite
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia, Level 6, 75 Talavera Rd, NSW, 2109
- NHMRC Partnership Centre for Health System Sustainability, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia
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Reardon CM, Damschroder L, Opra Widerquist MA, Arasim M, Jackson GL, White B, Cutrona SL, Fix GM, Gifford AL, DeLaughter K, King HA, Henderson B, Vega R, Nevedal AL. Sustainment of diverse evidence-informed practices disseminated in the Veterans Health Administration (VHA): initial development and piloting of a pragmatic survey tool. Implement Sci Commun 2023; 4:6. [PMID: 36647162 PMCID: PMC9842210 DOI: 10.1186/s43058-022-00386-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/18/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND There are challenges associated with measuring sustainment of evidence-informed practices (EIPs). First, the terms sustainability and sustainment are often falsely conflated: sustainability assesses the likelihood of an EIP being in use in the future while sustainment assesses the extent to which an EIP is (or is not) in use. Second, grant funding often ends before sustainment can be assessed. The Veterans Health Administration (VHA) Diffusion of Excellence (DoE) program is one of few large-scale models of diffusion; it seeks to identify and disseminate practices across the VHA system. The DoE sponsors "Shark Tank" competitions, in which leaders bid on the opportunity to implement a practice with approximately 6 months of implementation support. As part of an ongoing evaluation of the DoE, we sought to develop and pilot a pragmatic survey tool to assess sustainment of DoE practices. METHODS In June 2020, surveys were sent to 64 facilities that were part of the DoE evaluation. We began analysis by comparing alignment of quantitative and qualitative responses; some facility representatives reported in the open-text box of the survey that their practice was on a temporary hold due to COVID-19 but answered the primary outcome question differently. As a result, the team reclassified the primary outcome of these facilities to Sustained: Temporary COVID-Hold. Following this reclassification, the number and percent of facilities in each category was calculated. We used directed content analysis, guided by the Consolidated Framework for Implementation Research (CFIR), to analyze open-text box responses. RESULTS A representative from forty-one facilities (64%) completed the survey. Among responding facilities, 29/41 sustained their practice, 1/41 partially sustained their practice, 8/41 had not sustained their practice, and 3/41 had never implemented their practice. Sustainment rates increased between Cohorts 1-4. CONCLUSIONS The initial development and piloting of our pragmatic survey allowed us to assess sustainment of DoE practices. Planned updates to the survey will enable flexibility in assessing sustainment and its determinants at any phase after adoption. This assessment approach can flex with the longitudinal and dynamic nature of sustainment, including capturing nuances in outcomes when practices are on a temporary hold. If additional piloting illustrates the survey is useful, we plan to assess the reliability and validity of this measure for broader use in the field.
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Affiliation(s)
- Caitlin M. Reardon
- grid.413800.e0000 0004 0419 7525Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, USA
| | - Laura Damschroder
- grid.413800.e0000 0004 0419 7525Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, USA
| | - Marilla A. Opra Widerquist
- grid.413800.e0000 0004 0419 7525Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, USA
| | - Maria Arasim
- grid.413800.e0000 0004 0419 7525Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, USA
| | - George L. Jackson
- grid.512153.1Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, USA ,grid.26009.3d0000 0004 1936 7961Department of Population Health Sciences, Duke University, Durham, USA ,grid.26009.3d0000 0004 1936 7961Division of General Internal Medicine, Duke University, Durham, USA ,grid.26009.3d0000 0004 1936 7961Department of Family Medicine & Community Health, Duke University, Durham, USA
| | - Brandolyn White
- grid.512153.1Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, USA
| | - Sarah L. Cutrona
- Center for Healthcare Organization & Implementation Research (CHOIR), Bedford & Boston VA Medical Centers, Bedford, USA ,Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, USA ,grid.168645.80000 0001 0742 0364Division of General Internal Medicine, University of Massachusetts Medical School, Worcester, USA
| | - Gemmae M. Fix
- Center for Healthcare Organization & Implementation Research (CHOIR), Bedford & Boston VA Medical Centers, Bedford, USA ,grid.189504.10000 0004 1936 7558Section of General Internal Medicine, Boston University School of Medicine, Boston, USA
| | - Allen L. Gifford
- Center for Healthcare Organization & Implementation Research (CHOIR), Bedford & Boston VA Medical Centers, Bedford, USA ,grid.189504.10000 0004 1936 7558Section of General Internal Medicine, Boston University School of Medicine, Boston, USA ,grid.189504.10000 0004 1936 7558Department of Health Law, Policy & Management, Boston University, Boston, USA
| | - Kathryn DeLaughter
- Center for Healthcare Organization & Implementation Research (CHOIR), Bedford & Boston VA Medical Centers, Bedford, USA ,Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, USA
| | - Heather A. King
- grid.512153.1Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, USA ,grid.26009.3d0000 0004 1936 7961Department of Population Health Sciences, Duke University, Durham, USA ,grid.26009.3d0000 0004 1936 7961Division of General Internal Medicine, Duke University, Durham, USA
| | - Blake Henderson
- grid.239186.70000 0004 0481 9574Innovation Ecosystem, United States Veterans Health Administration, Washington, D.C., USA
| | - Ryan Vega
- grid.239186.70000 0004 0481 9574Innovation Ecosystem, United States Veterans Health Administration, Washington, D.C., USA
| | - Andrea L. Nevedal
- grid.413800.e0000 0004 0419 7525Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, USA
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Karman E, Wilson KS, Mugo C, Slyker JA, Guthrie BL, Bukusi D, Inwani I, John-Stewart GC, Wamalwa D, Kohler PK. Training Exposure and Self-Rated Competence among HIV Care Providers Working with Adolescents in Kenya. J Int Assoc Provid AIDS Care 2020; 19:2325958220935264. [PMID: 32588709 PMCID: PMC7322818 DOI: 10.1177/2325958220935264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 05/20/2020] [Accepted: 05/26/2020] [Indexed: 11/17/2022] Open
Abstract
Lack of health care worker (HCW) training is a barrier to implementing youth-friendly services. We examined training coverage and self-reported competence, defined as knowledge, abilities, and attitudes, of HCWs caring for adolescents living with HIV (ALWH) in Kenya. Surveys were conducted with 24 managers and 142 HCWs. Competence measures were guided by expert input and Kalamazoo II Consensus items. Health care workers had a median of 3 (interquartile range [IQR]: 1-6) years of experience working with ALWH, and 40.1% reported exposure to any ALWH training. Median overall competence was 78.1% (IQR: 68.8-84.4). In multivariable linear regression analyses, more years caring for ALWH and any prior training in adolescent HIV care were associated with significantly higher self-rated competence. Training coverage for adolescent HIV care remains suboptimal. Targeting HCWs with less work experience and training exposure may be a useful and efficient approach to improve quality of youth-friendly HIV services.
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Affiliation(s)
- Elizabeth Karman
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Kate S. Wilson
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Cyrus Mugo
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Paediatrics and Child Health/Kenyatta National Hospital, University of Nairobi, Kenya
| | - Jennifer A. Slyker
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Brandon L. Guthrie
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - David Bukusi
- VCT and HIV Prevention Unit/Youth Centre, Kenyatta National Hospital, Nairobi, Kenya
| | - Irene Inwani
- Department of Paediatrics and Child Health/Kenyatta National Hospital, University of Nairobi, Kenya
| | - Grace C. John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Dalton Wamalwa
- Department of Paediatrics and Child Health/Kenyatta National Hospital, University of Nairobi, Kenya
| | - Pamela K. Kohler
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, WA, USA
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Zakumumpa H, Kiweewa FM, Khuluza F, Kitutu FE. "The number of clients is increasing but the supplies are reducing": provider strategies for responding to chronic antiretroviral (ARV) medicines stock-outs in resource-limited settings: a qualitative study from Uganda. BMC Health Serv Res 2019; 19:312. [PMID: 31092245 PMCID: PMC6521347 DOI: 10.1186/s12913-019-4137-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 04/30/2019] [Indexed: 11/18/2022] Open
Abstract
Background Despite the increasing frequency of ARV medicines stock-outs in Sub-Saharan Africa, there is little research inquiring into the mitigation strategies devised by frontline health facilities. Many previous studies have focused on ‘upstream’ or national-level drivers of ARVs stock-outs with less empirical attention devoted ‘down-stream’ or at the facility-level. The objective of this study was to examine the strategies devised by health facilities in Uganda to respond to the chronic stock-outs of ARVs. Methods This was a qualitative research design nested within a larger mixed-methods study. We purposively selected 16 health facilities from across Uganda (to achieve diversity with regard to; level of care (primary/ tertiary), setting (rural/urban) and geographic sub-region (northern/ central/western). We conducted 76 Semi-structured interviews with ART clinic managers, clinicians and pharmacists in the selected health facilities supplemented by on-site observations and documentary reviews. Data were analyzed by coding and thematic analyses. Results Participants reported that facility-level contributors to stock-outs include untimely orders of drugs from suppliers and inaccurate quantification of ARV medicine needs due to a paucity of ART program data. Internal stock management solutions for mitigating stock-outs which emerged include the substitution of ARV medicines which were out of stock, overstocking selected medicines and the use of recently expired drugs. The external solutions for mitigating stock-outs which were identified include ‘borrowing’ of ARVs from peer-providers, re-distributing stock across regions and upward referrals of patients. Systemic drivers of stock-outs were identified. These include the supply of drugs with a short shelf life, oversupply and undersupply of ARV medicines and migration pressures on the available ARVs stock at case-study facilities. Conclusion Health facilities devised internal stock management strategies and relied on peer-provider networks for ARV medicines during stock-out events. Our study underscores the importance of devising interventions aimed at improving Uganda’s medicines supply chain systems in the quest to reduce the frequency of ARV medicines stock-outs at the front-line level of service delivery. Further research is recommended on the effect of substituting ARV medicines on patient outcomes. Electronic supplementary material The online version of this article (10.1186/s12913-019-4137-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Henry Zakumumpa
- Makerere University, School of Public Health, Kampala, Uganda.
| | | | - Felix Khuluza
- Pharmacy Department, University of Malawi, Blantyre, Malawi
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