Understanding the factors influencing the implementation of participatory interventions to improve care coordination. An analytical framework based on an evaluation in Latin America

The impact of research on health education/health literacy on policymaking in Latin America and the Caribbean Region

Background

In this study, we addressed the gap between health research and policymaking in Latin America and the Caribbean (LAC), focusing on health education/health literacy. Despite growing research, translating findings into effective policies needs to be improved. We explored the factors that make research on health education and health literacy to be referenced and mentioned in policy documents in LAC (and in Peru). We proposed a model based on the hypothesis that the relationship between research and policymaking depends on the research strength of scientific evidence, timing, and social media activity.

Methods

A mixed-methods approach was employed, combining quantitative and qualitative data analysis. Quantitative data sources included multidisciplinary databases, altmetric data, and citations of policy documents. For data analysis, we obtained descriptive statistics to identify patterns and then verified the association between variables using χ2. The negative binomial regression was used to test the empirical model introduced above. Quantitative analysis was complemented by analysis of responses to a set of open questions from a sample of Peruvian health policymakers.

Results

We found that timing, strength of evidence, and social media activity were significant predictors of research cited in policy documents. Policy documents tended to rely more on qualitative evidence. A positive correlation between timing and cites in policy documents highlighted the importance of timely dissemination, whereas social media activity, while having an impact, had a relatively minor effect. Peruvian policymakers' responses emphasized the role of political context, the relevance of results, and policymakers' commitment to incorporating research into policies.

Conclusion

Strength of evidence, social media engagement, and publication timing are key predictors of citations for health education/literacy research in LAC policy documents. However, qualitative findings highlight challenges, including some distrust in research findings, together with limited access to relevant research. The findings offer opportunities to enhance evidence-informed health education/health literacy policy decisions.

Implications

To increase the influence on health policymakers, researchers should prioritize the timely dissemination of solid evidence, considering both traditional and digital platforms. Policymakers should focus on the quality and relevance of evidence when formulating policies.

Investigating Factors Influencing Medical Practitioners' Resistance to and Adoption of Internet Hospitals in China: Mixed Methods Study

BACKGROUND

The swift shift toward internet hospitals has relied on the willingness of medical practitioners to embrace new systems and workflows. Low engagement or acceptance by medical practitioners leads to difficulties in patient access. However, few investigations have focused on barriers and facilitators of adoption of internet hospitals from the perspective of medical practitioners.

OBJECTIVE

This study aims to identify both enabling and inhibiting predictors associated with resistance and behavioral intentions of medical practitioners to use internet hospitals by combining the conservation of resources theory with the Unified Theory of Acceptance and Use of Technology and technostress framework.

METHODS

A mixed methods research design was conducted to qualitatively identify the factors that enable and inhibit resistance and behavioral intention to use internet hospitals, followed by a quantitative survey-based study that empirically tested the effects of the identified factors. The qualitative phase involved conducting in-depth interviews with 16 experts in China from June to August 2022. Thematic analysis was performed using the qualitative data analysis software NVivo version 10 (QSR International). On the basis of the findings and conceptual framework gained from the qualitative interviews, a cross-sectional, anonymous, web-based survey of 593 medical practitioners in 28 provincial administrative regions of China was conducted. The data collected were analyzed using the partial least squares method, with the assistance of SPSS 27.0 (IBM Corp) and Mplus 7.0 (Muthen and Muthen), to measure and validate the proposed model.

RESULTS

On the basis of qualitative results, this study identified 4 facilitators and inhibitors, namely performance expectancy, social influence, work overload, and role ambiguity. Of the 593 medical practitioners surveyed in the quantitative research, most were female (n=364, 61.4%), had a middle title (n=211, 35.6%) or primary title (n=212, 35.8%), and had an average use experience of 6 months every year. By conducting structural equation modeling, we found that performance expectancy (β=-.55; P<.001) and work overload (β=.16; P=.005) had the most significant impact on resistance to change. Resistance to change fully mediated the influence of performance expectancy and partially mediated the influences of social influence (variance accounted for [VAF]=43.3%; P=.002), work overload (VAF=37.2%; P=.03), and role ambiguity (VAF=12.2%; P<.001) on behavioral intentions to use internet hospitals. In addition, this study found that the sex, age, professional title, and use experience of medical practitioners significantly moderated the aforementioned influencing mechanisms.

CONCLUSIONS

This study investigated the factors that facilitate or hinder medical practitioners' resistance to change and their behavioral intentions to use internet hospitals. The findings suggest that policy makers avoid the resistance and further promote the adoption of internet hospitals by ensuring performance expectancy and social influence and eliminating work overload and role ambiguity.

Lessons learnt from the process of designing care coordination interventions through participatory action research in public healthcare networks of six Latin American countries

BACKGROUND

The participation of health professionals in designing interventions is considered vital to effective implementation, yet in areas such as clinical coordination is rarely promoted and evaluated. This study, part of Equity-LA II, aims to analyse the design process of interventions to improve clinical coordination, taking a participatory-action-research (PAR) approach, in healthcare networks of Argentina, Brazil, Chile, Colombia, Mexico and Uruguay. This participatory process was planned in four phases, led by a local steering committee (LSC): (1) dissemination of problem analysis results and creation of professionals' platform, (2) selection of problems and intervention (3) intervention design and planning (4) adjustments after evaluation of first implementation stage.

METHODS

A descriptive qualitative study based on documentary analysis, using a topic guide, was conducted in each intervention network. Documents produced regarding the intervention design process were selected. Thematic content analysis was conducted, generating mixed categories taken from the topic guide and identified from data. Main categories were LSC characteristics, type of design process (phases, participants' roles, methods) and associated difficulties, coordination problems and interventions selected.

RESULTS

LSCs of similar composition (managers, professionals and researchers) were established, with increasing membership in Chile and high turnover in Argentina, Colombia and Mexico. Following results dissemination and selection of problems and interventions (more participatory in Chile and Colombia: 200-479 participants), the interventions were designed and planned, resulting in three different types of processes: (1) short initial design with adjustments after first implementation stage, in Colombia, Brazil and Mexico; (2) longer, more participatory process, with multiple cycles of action/reflection and pilot tests, in Chile; (3) open-ended design for ongoing adaptation, in Argentina and Uruguay. Professionals' time and the political cycle were the main barriers to participation. The clinical coordination problem selected was limited communication between primary and secondary care doctors. To address it, through discussions guided by context and feasibility criteria, interventions based on mutual feedback were selected.

CONCLUSIONS

As expected in a flexible PAR process, its rollout differed across countries in participation and PAR cycles. Results show that PAR can help to design interventions adapted to context and offers lessons that can be applied in other contexts.

Improving equity in access to early diagnosis of cancer in different healthcare systems of Latin America: protocol for the EquityCancer-LA implementation-effectiveness hybrid study

INTRODUCTION

Healthcare fragmentation, a main cause for delay in cancer diagnosis and treatment, contributes to high mortality in Latin America (LA), particularly among disadvantaged populations. This research focuses on integrated care interventions, which have been limitedly implemented in the region. The objective is to evaluate the contextual effectiveness of scaling-up an integrated care intervention to improve early diagnosis of frequent cancers in healthcare networks of Chile, Colombia and Ecuador.

METHODS AND ANALYSIS

This research is two pronged: (A) quasi-experimental design (controlled before and after) with an intervention and a control healthcare network in each LA country, using an implementation-effectiveness hybrid approach to assess the intervention process, effectiveness and costs; and (B) case study design to analyse access to diagnosis of most frequent cancers. Focusing on the most vulnerable socioeconomic population, it develops in four phases: (1) analysis of delays and barriers to early diagnosis (baseline); (2) intervention adaptation and implementation (primary care training, fast-track referral pathway and patient information); (3) intracountry evaluation of intervention and (4) cross-country analysis. Baseline and evaluation studies adopt mixed-methods qualitative (semistructured individual interviews) and quantitative (patient questionnaire survey) methods. For the latter, a sample size of 174 patients with cancer diagnosis per healthcare network and year was calculated to detect a proportions difference of 15%, before and after intervention (α=0.05; β=0.2) in a two-sided test. A participatory approach will be used to tailor the intervention to each context, led by a local steering committee (professionals, managers, policy makers, patients and researchers).

ETHICS AND DISSEMINATION

This study complies with international and national legal stipulations on ethics. It was approved by each country's ethical committee and informed consent will be obtained from participants. Besides the coproduction of knowledge with key stakeholders, it will be disseminated through strategies such as policy briefs, workshops, e-tools and scientific papers.

Relational Continuity of Chronic Patients with Primary and Secondary Care Doctors: A Study of Public Healthcare Networks of Six Latin American Countries

Despite relational continuity (RC) with the doctor being key to care quality for chronic patients, particularly in fragmented healthcare systems, like many in Latin America (LA), little is known about RC and its attributes, particularly regarding specialists. Aim: We aim to analyse chronic patients' perceptions of RC with primary (PC) and secondary (SC) care doctors, and record changes between 2015 and 2017 in the public healthcare networks of six LA countries. An analysis of two cross-sectional studies applying the CCAENA questionnaire to chronic patients (N = 4881) was conducted in Argentina, Brazil, Chile, Colombia, Mexico, and Uruguay. The dependent variables of RC with PC and SC doctors were: consistency, trust, effective communication, and synthetic indexes based on RC attributes. Descriptive and multivariate analyses were performed. Although the RC index was high in 2015, especially in PC in all countries, and at both levels in Argentina and Uruguay, low perceived consistency of PC and SC doctors in Colombia and Chile and of SC doctors in Mexico revealed important areas for improvement. In 2017 the RC index of SC doctors increased in Chile and Mexico, while SC doctors' consistency in Colombia decreased. This study reveals important gaps in achieving RC with doctors, particularly in SC, which requires further structural and organisational reforms.

Evaluating the effectiveness of care coordination interventions designed and implemented through a participatory action research process: Lessons learned from a quasi-experimental study in public healthcare networks in Latin America

Background

Despite increasing recommendations for health professionals to participate in intervention design and implementation to effect changes in clinical practice, little is known about this strategy’s effectiveness. This study analyses the effectiveness of interventions designed and implemented through participatory action research (PAR) processes in healthcare networks of Brazil, Chile, Colombia, Mexico and Uruguay to improve clinical coordination across care levels, and offers recommendations for future research.

Methods

The study was quasi-experimental. Two comparable networks, one intervention (IN) and one control (CN), were selected in each country. Baseline (2015) and evaluation (2017) surveys of a sample of primary and secondary care doctors (174 doctors/network/year) were conducted using the COORDENA^® questionnaire. Most of the interventions chosen were based on joint meetings, promoting cross-level clinical agreement and communication for patient follow-up. Outcome variables were: a) intermediate: interactional and organizational factors; b) distal: experience of cross-level clinical information coordination, of clinical management coordination and general perception of coordination between levels. Poisson regression models were estimated.

Results

A statistically significant increase in some of the interactional factors (intermediate outcomes) -knowing each other personally and mutual trust- was observed in Brazil and Chile INs; and in some organizational factors -institutional support- in Colombia and Mexico. Compared to CNs in 2017, INs of Brazil, Chile, Colombia and Mexico showed significant differences in some factors. In distal outcomes, care consistency items improved in Brazil, Colombia and Uruguay INs; and patient follow-up improved in Chile and Mexico. General perception of clinical coordination increased in Brazil, Colombia and Mexico INs. Compared to CNs in 2017, only Brazil showed significant differences.

Conclusions

Although more research is needed, results show that PAR-based interventions improved some outcomes regarding clinical coordination at network level, with differences between countries. However, a PAR process is, by definition, slow and gradual, and longer implementation periods are needed to achieve greater penetration and quantifiable changes. The participatory and flexible nature of interventions developed through PAR processes poses methodological challenges (such as defining outcomes or allocating individuals to different groups in advance), and requires a comprehensive mixed-methods approach that simultaneously evaluates effectiveness and the implementation process to better understand its outcomes.

Implementing COVID-19 Surveillance Through Inter-Organizational Coordination: A Qualitative Study of Three Cities in Colombia

Introducing comprehensive surveillance is recommended as an urgent public health measure to control and mitigate the spread of coronavirus disease 2019 (COVID-19) worldwide. However, its implementation has proven challenging as it requires inter-organizational coordination among multiple healthcare stakeholders. The purpose of this study was to examine the role of soft and hard mechanisms in the implementation of inter-organizational coordination strategies for COVID-19 surveillance within Colombia, drawing on evidence from the cities of Bogotá, Cali and Cartagena. The study used a case study approach to understand the perspectives of local and national authorities, insurance companies and health providers in the implementation of inter-organizational coordination strategies for COVID-19 surveillance. Eighty-one semi-structured interviews were conducted between June and November 2020. The data were analysed by codes and categorized using New NVivo software. The study identified inter-organizational coordination strategies that were implemented to provide COVID-19 surveillance in the three cities. Both soft (e.g. trust and shared purpose) and hard mechanisms (e.g. formal agreements and regulations) acted as mediators for collaboration and helped to address existing structural barriers in the provision of health services. The findings suggest that soft and hard mechanisms contributed to promoting change among healthcare system stakeholders and improved inter-organizational coordination for disease surveillance. The findings contribute to evidence regarding practices to improve coordinated surveillance of disease, including the roles of new forms of financing and contracting between insurers and public and private health service providers, logistics regarding early diagnosis in infectious disease and the provision of health services at the community level regardless of insurance affiliation. Our research provides evidence to improve disease surveillance frameworks in fragmented health systems contributing to public health planning and health system improvement.

Assessing the Impact of Clinical Coordination Interventions on the Continuity of Care for Patients With Chronic Conditions: Participatory Action Research in Five Latin American Countries

Although fragmentation in the provision of services is considered an obstacle to effective health care, there is scant evidence on the impact of interventions to improve care coordination between primary care and secondary care in terms of continuity of care -i.e. from the patient perspective- particularly in Latin America (LA). Within the framework of the Equity-LA II project, interventions to improve coordination across care levels were implemented in five LA countries (Brazil, Chile, Colombia, Mexico and Uruguay) through a participatory action research (PAR) process. This paper analyses the impact of these PAR interventions on the cross-level continuity of care of chronic patients in public healthcare networks. A quasi-experimental study was performed with measurements based on two surveys of a sample of patients with chronic conditions (392 per network; 800 per country). Both the baseline (2015) and evaluation (2017) surveys were conducted using the CCAENA questionnaire. In each country, two comparable public healthcare networks were selected, one intervention and one control. Outcomes were cross-level continuity of information and of clinical management. Descriptive analyses were conducted and Poisson regression models with robust variance fitted to estimate changes. With differences between countries, the results showed improvements in cross-level continuity of clinical information (transfer of clinical information) and of clinical management (care coherence). These results are consistent with those of previous studies on the effectiveness of the interventions implemented in each country in improving care coordination in Brazil, Chile, and Colombia. Differences between countries are probably related to particular contextual factors and events that occurred during the implementation process. This supports the notion that certain context and process factors are needed to improve continuity of care. The results provide evidence that, although the interventions were designed to enhance care coordination and aimed at health professionals, patients report improvements in continuity of care.

Interventions to Improve Clinical Coordination between Levels: Participatory Experience in a Public Healthcare Network in Xalapa, Mexico

INTRODUCTION

Coordination of care can be improved through an intervention or a combination of several ones. In addition, it is recommended to encourage the active involvement of professionals in the design, implementation and assessment of coordination mechanisms.

OBJECTIVE

To analyse the factors that influence the implementation of participatively designed interventions and their effects on clinical coordination between levels of care in a public healthcare network of health services in Xalapa, Veracruz, Mexico.

METHODS

A qualitative, descriptive-interpretative study, for which individual interviews and discussion groups with a criterion sample of participants: Local Steering Committee and the Professional Platform. A content analysis, with mixed category generation and segmentation by intervention and topics, was carried out. According to the problem analysis, participants designed two sequential interventions: offline virtual consultation, and joint training meetings on maternal health and chronic diseases.

RESULTS

Respondents perceived a differentiated impact on clinical coordination according to intervention: greater in the case of joint maternal health trainings and limited for the chronic diseases meetings, as they were the offline virtual consultation was rarely used.

CONCLUSION

The involvement of professionals in designing the interventions, as well as institutional support and reflexive methods for training, all decisively improved clinical coordination between levels.

Challenges of diagnostic genomics in Latin America

Cancer genome sequencing methods have now become essential for diagnostic purposes, for devising treatment strategies, and for monitoring disease regression and progression. However, access to these benefits has not permeated homogeneously throughout the world; certain regions, such as Latin America, have been slower at adopting these technologies in terms of their routine use, development and patient access. There are also differences among Latin American subregions with respect to their prioritized types of neoplasia and the drugs that are available and approved in them. An overview of the current situation, including the status of genomics for cancer diagnostics and efforts by type of cancer is presented. In addition, we discuss the perspective of initiatives, alliances, and educational/research programs that pledge to make cancer genomics diagnosis a reality for Latin American individuals' health.

Can care coordination across levels be improved through the implementation of participatory action research interventions? Outcomes and conditions for sustaining changes in five Latin American countries

BACKGROUND

Finding new strategies for care integration has become a policy priority for many fragmented health systems in Latin America. Although the implementation of interventions through a participatory action research (PAR) approach is considered to be more effective in achieving organizational change, its application is scarce. This study, part of the research project Equity-LA II, aims to analyze the impact of PAR interventions on care coordination across levels, and key aspects for their sustainability and transferability, from the stakeholder viewpoint in healthcare networks of Brazil, Chile, Colombia, Mexico and Uruguay. Different interventions were designed and implemented through a PAR process to improve communication and clinical agreement between primary care and secondary care doctors: joint meetings to discuss clinical cases and/or training; shared care guidelines; offline virtual consultations; a referral and reply letter; and an induction program.

METHODS

A qualitative, descriptive-interpretative study was conducted in the healthcare network of each country. Focus groups and semi-structured individual interviews were conducted with a criterion sample of participants: local steering committee (29) and professional platform members (28), other health professionals (49) and managers (28). Thematic content analysis was conducted, segmented by country and type of intervention.

RESULTS

Informants highlighted that joint meetings based on reflexive methods contributed substantially to improving contextually relevant elements of clinical management coordination - communication in patient follow-up, clinical agreement, appropriateness of referrals - and also administrative coordination. The meetings, alongside the PAR process, also helped to improve interaction between professionals - knowing each other personally and mutual trust - thus fostering willingness to collaborate. The PAR approach, moreover, served to spread awareness of the coordination problems and need for intervention, encouraging greater commitment and interest in participating. No noteworthy contributions were identified in remaining interventions due to low uptake. A necessary condition for the sustainability and replicability was that PAR process had to be used appropriately in a favourable context.

CONCLUSIONS

Evidence is provided on the substantial contribution of interventions to improving locally relevant clinical coordination elements and professional interaction when implemented through an adequate PAR process (in terms of time, method and participation levels), a necessary condition for their sustainability and replicability.