The challenge of implementing peer-led interventions in a professionalized health service: a case study of the national health trainers service in England

What can healthcare systems learn from looking at tensions in innovation processes? A systematic literature review

Background

Until now, scholarship on innovation processes in healthcare systems lack an in-depth appreciation of tensions. Tensions often revolve around barriers and result from individual assessments and prioritizations that guide actions to eventually overcome these barriers. In order to develop a more differentiated understanding of tensions’ role in healthcare innovation processes, this paper aims to shed light on the multifaceted ways in which tensions emerge, are being dealt with, and how they hinder or, at times, facilitate innovation processes.

Methods

A systematic review of published and grey literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline. The review involved searching three databases for original research articles and manually searching citations. Twenty-nine original full texts were identified, evaluated, and coded. These include papers on innovation in healthcare systems that investigated innovation-related organizational tensions. The findings were synthesized into different types of tensions in healthcare system innovation and the descriptions of the conflicting elements. We also analyzed the investigated innovations by type, process stages, and across different countries and healthcare systems.

Results

A total of forty-two tensions were identified and grouped into nine categories. Organizing tensions were predominant, followed by learning/belonging, performing, and performing/organizing tensions. Tensions most frequently occurred in the implementation phase and in the form of a dilemma. Included studies were conducted mainly in government-funded healthcare systems.

Conclusion

Our data suggest that innovation processes in healthcare systems are impaired by conflicts between contradictory elements, working cultures, and convictions and the organizational and regulatory context. Since the majority of the tensions we collected in our study can be addressed, future policy-making and research should take advantage of this fact and develop strategies that significantly influence the successful management of tensions and thus improve the implementation of innovations.

Developing an implementation research logic model: using a multiple case study design to establish a worked exemplar

Background

Implementation science frameworks explore, interpret, and evaluate different components of the implementation process. By using a program logic approach, implementation frameworks with different purposes can be combined to detail complex interactions. The Implementation Research Logic Model (IRLM) facilitates the development of causal pathways and mechanisms that enable implementation. Critical elements of the IRLM vary across different study designs, and its applicability to synthesizing findings across settings is also under-explored. The dual purpose of this study is to develop an IRLM from an implementation research study that used case study methodology and to demonstrate the utility of the IRLM to synthesize findings across case sites.

Method

The method used in the exemplar project and the alignment of the IRLM to case study methodology are described. Cases were purposely selected using replication logic and represent organizations that have embedded exercise in routine care for people with cancer or mental illness. Four data sources were selected: semi-structured interviews with purposely selected staff, organizational document review, observations, and a survey using the Program Sustainability Assessment Tool (PSAT). Framework analysis was used, and an IRLM was produced at each case site. Similar elements within the individual IRLM were identified, extracted, and re-produced to synthesize findings across sites and represent the generalized, cross-case findings.

Results

The IRLM was embedded within multiple stages of the study, including data collection, analysis, and reporting transparency. Between 33-44 determinants and 36-44 implementation strategies were identified at sites that informed individual IRLMs. An example of generalized findings describing “intervention adaptability” demonstrated similarities in determinant detail and mechanisms of implementation strategies across sites. However, different strategies were applied to address similar determinants. Dependent and bi-directional relationships operated along the causal pathway that influenced implementation outcomes.

Conclusions

Case study methods help address implementation research priorities, including developing causal pathways and mechanisms. Embedding the IRLM within the case study approach provided structure and added to the transparency and replicability of the study. Identifying the similar elements across sites helped synthesize findings and give a general explanation of the implementation process. Detailing the methods provides an example for replication that can build generalizable knowledge in implementation research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00337-8.

Wellness project implementation within Houston's Faith and Diabetes initiative: a mixed methods study

Background

Faith-based health promotion has shown promise for supporting healthy lifestyles, but has limited evidence of reaching scale or sustainability. In one recent such effort, volunteers from a diverse range of faith organizations were trained as peer educators to implement diabetes self-management education (DSME) classes within their communities. The purpose of this study was to identify factors associated with provision of these classes within six months of peer-educator training.

Methods

This study used the Consolidated Framework for Implementation Research (CFIR) to identify patterns from interviews, observations, attendance records, and organizational background information. Two research team members thematically coded interview transcripts and observation memos to identify patterns distinguishing faith organizations that did, versus did not, conduct DSME classes within six months of peer-educator training. Bivariate statistics were also used to identify faith organizational characteristics associated with DSME class completion within this time frame.

Results

Volunteers from 24 faith organizations received peer-educator training. Of these, 15 led a DSME class within six months, graduating a total of 132 participants. Thematic analyses yielded two challenges experienced disproportionately by organizations unable to complete DSME within six months: [1] Their peer educators experienced DSME as complex, despite substantial planning efforts at simplification, and [2] the process of engaging peer educators and leadership within their organizations was often more difficult than anticipated, despite initial communication by Faith and Diabetes organizers intended to secure informed commitments by both groups. Many peer educators were overwhelmed by training content, the responsibility required to start and sustain DSME classes, and other time commitments. Other priorities competed for time in participants’ lives and on organizational calendars, and scheduling processes could be slow. In an apparent dynamic of “crowding out,” coordination was particularly difficult in larger organizations, which were less likely than smaller organizations to complete DSME classes despite their more substantial resources.

Conclusions

Initial commitment from faith organizations’ leadership and volunteers may not suffice to implement even relatively short and low cost health promotion programs. Faith organizations might benefit from realistic previews about just how challenging it is to make these programs a sufficiently high organizational and individual priority.

Our Peers-Empowerment and Navigational Support (OP-ENS): Development of a Peer Health Navigator Intervention to Support Medicaid Beneficiaries With Physical Disabilities

People with disabilities (PWD) are a health disparities population who experience well-documented physical, structural, attitudinal, and financial barriers to health care. The disability rights community is deeply engaged in advocacy to promote health care justice for all PWD. As the community continues to work toward systems change, there is a critical need for community-directed interventions that ensure individuals with disabilities are able to access the health care services they need and are entitled to. Peer health navigator (PHN) programs have been shown to help people from diverse underserved communities break down barriers to health care. The PHN model has not been systematically adapted to meet the needs of PWD. In this article, we describe the collaborative process of developing Our Peers—Empowerment and Navigational Supports (OP-ENS), an evidence-informed PHN intervention for Medicaid beneficiaries with physical disabilities in Chicago, IL, USA. Our Peers—Empowerment and Navigational Supports is a 12-month community-based PHN intervention that pairs Medicaid beneficiaries with physical disabilities (peers) with disability PHNs who use a structured recursive process of barrier identification and asset mapping, goal setting, and action planning to help peers meet their health care needs. Our Peers—Empowerment and Navigational Supports was developed by a collaborative team that included disability rights leaders, representatives from a Medicaid managed care organization, and academic disability health care justice researchers. We highlight both the conceptual and empirical evidence that informed OP-ENS as well as the lessons learned that can assist future developers.

Factors associated with the implementation of community-based peer-led health promotion programs: A scoping review

Peer education is growing in popularity as a useful health promotion strategy. However, optimal conditions for implementing peer-led health promotion programs (HPPs) remain unclear. This scoping review aimed to describe factors that can influence implementation of peer-led HPPs targeting adult populations. Five databases were searched using the keywords "health promotion/prevention", "implementation", "peers", and related terms. Studies were included if they reported at least one factor associated with the implementation of community-based peer-led HPPs. Fifty-five studies were selected for the analysis. The method known as "best fit framework synthesis" was used to analyze the factors identified in the selected papers. Many factors included in existing implementation conceptual frameworks were deemed applicable to peer-led HPPs. However, other factors related to individuals, programs, and implementation context also emerged from the analysis. Based on this synthesis, an adapted theoretical framework was elaborated, grounded in a complex adaptive system perspective and specifying potential mechanisms through which factors may influence implementation of community-based peer-led HPPs. Further research is needed to test the theoretical framework against empirical data. Findings from this scoping review increase our knowledge of the optimal conditions for implementing peer-led HPPs and thereby maximizing the benefits of such programs.

"It was the whole picture" a mixed methods study of successful components in an integrated wellness service in North East England

Background

A growing number of Local Authorities (LAs) have introduced integrated wellness services as part of efforts to deliver cost effective, preventive services that address the social determinants of health. This study examined which elements of an integrated wellness service in the north east of England were effective in improving health and wellbeing (HWB).

Methods

The study used a mixed-methods approach. In-depth semi-structured interviews (IVs) were conducted with integrated wellness service users (n = 25) and focus groups (FGs) with group based service users (n = 14) and non-service users (n = 23) to gather the views of stakeholders. Findings are presented here alongside analysis of routine monitoring data. The different data were compared to examine what each data source revealed about the effectiveness of the service.

Results

Findings suggest that integrated wellness services work by addressing the social determinants of health and respond to multiple complex health and social concerns rather than single issues. The paper identifies examples of ‘active ingredients’ at the heart of the programme, such as sustained relationships, peer support and confidence building, as well as the activities through which changes take place, such as sports and leisure opportunities which in turn encourage social interaction. Wider wellbeing outcomes, including reduced social isolation and increased self-efficacy are also reported.

Practical and motivational support helped build community capacity by encouraging community groups to access funding, helped navigate bureaucratic systems, and promoted understanding of marginalised communities. Fully integrated wellness services could support progression opportunities through volunteering and mentoring.

Conclusions

An integrated wellness service that offers a holistic approach was valued by service users and allowed them to address complex issues simultaneously. Few of the reported health gains were captured in routine data. Quantitative and qualitative data each offered a partial view of how effectively services were working.

Measuring the impact of Health Trainers Services on health and health inequalities: does the service's data collection and reporting system provide reliable information?

Background

The Health Trainers Service is one of the few public health policies where a bespoke database-the Data Collection and Reporting System (DCRS)-was developed to monitor performance. We seek to understand the context within which local services and staff have used the DCRS and to consider how this might influence interpretation of collected data.

Methods

In-depth case studies of six local services purposively sampled to represent the range of service provider arrangements, including detailed interviews with key stakeholders (n = 118).

Results

Capturing detailed information on activity with clients was alien to many health trainers' work practices. This related to technical challenges, but it also ran counter to beliefs as to how a 'lay' service would operate. Interviewees noted the inadequacy of the dataset to capture all client impacts; that is, it did not enable them to input information about issues a client living in a deprived neighbourhood might experience and seek help to address.

Conclusions

The utility of the DCRS may be compromised both by incomplete ascertainment of activity and by incorrect data inputted by some Health Trainers. The DCRS is also underestimate the effectiveness of work health trainers have undertaken to address 'upstream' factors affecting client health.

Insiders and incomers: how lay public health workers' knowledge might improve public health practice

Since 2005, health trainers and other lay public health workers (LPHWs) have been increasingly active in the UK. Although elsewhere in the world LPHWs are expected to come from the communities within which they work and know that their knowledge is valued, neither is the case for LPHWs in the UK. This study sought to discover the lay knowledge of health trainers and other LPHWs, aiming to ascertain how this knowledge might more effectively be utilised within UK public health services. This paper describes a participatory and ethnographic case study research project undertaken on an anonymised urban estate in North East England. Findings were generated by a range of means including by participant observation and semi-structured interviews. Seven LPHWs took part, as did 32 other community members. This study found that the lay health knowledge of an individual UK LPHW is determined primarily by his or her position within, or in relation to, the community within which he or she works. Insider LPHWs possess an embodied knowledge and incomer LPHWs possess an experiential knowledge which, although different from one another, are essentially interpersonal in nature. Lay health knowledge can take different forms, and different LPHWs can provide different forms of lay health knowledge. Public health structures and services in the UK should make better use of all forms of LPHW knowledge, and should seek from LPHWs training on how to engage the most 'hard-to-reach' or 'difficult-to-engage' groups. Services recruiting LPHWs should decide whether they are seeking embodied insider LPHW knowledge, experiential incomer LPHW knowledge or a mixture of both.

'It is not a quick fix' structural and contextual issues that affect implementation of integrated health and well-being services: a qualitative study from North East England

OBJECTIVE

The objective of this article is to examine the factors affecting the design, commissioning and delivery of integrated health and well-being services (IHWSs), which seek to address multiple health-related behaviours, improve well-being and tackle health inequalities using holistic approaches.

STUDY DESIGN

Qualitative studies embedded within iterative process evaluations.

METHODS

Semi-structured interviews conducted with 16 key informants as part of two separate evaluations of IHWSs in North East England, supplemented by informal observations of service delivery. Transcripts and fieldnotes were analysed thematically.

RESULTS

The study findings identify a challenging organisational context in which to implement innovative service redesign, as a result of budget cuts and changes in NHS and local authority capacity. Pressures to demonstrate outcomes affected the ability to negotiate the practicalities of joint working. Progress is at risk of being undermined by pressures to disinvest before the long-term benefits to population health and well-being are realised. The findings raise important questions about contract management and relationships between commissioners and providers involved in implementing these new ways of working.

CONCLUSIONS

These findings provide useful learning in terms of the delivery and commissioning of similar IHWSs, contributing to understanding of the benefits and challenges of this model of working.

Do complexity-informed health interventions work? A scoping review

BACKGROUND

The lens of complexity theory is widely advocated to improve health care delivery. However, empirical evidence that this lens has been useful in designing health care remains elusive. This review assesses whether it is possible to reliably capture evidence for efficacy in results or process within interventions that were informed by complexity science and closely related conceptual frameworks.

METHODS

Systematic searches of scientific and grey literature were undertaken in late 2015/early 2016. Titles and abstracts were screened for interventions (A) delivered by the health services, (B) that explicitly stated that complexity science provided theoretical underpinning, and (C) also reported specific outcomes. Outcomes had to relate to changes in actual practice, service delivery or patient clinical indicators. Data extraction and detailed analysis was undertaken for studies in three developed countries: Canada, UK and USA. Data were extracted for intervention format, barriers encountered and quality aspects (thoroughness or possible biases) of evaluation and reporting.

RESULTS

From 5067 initial finds in scientific literature and 171 items in grey literature, 22 interventions described in 29 articles were selected. Most interventions relied on facilitating collaboration to find solutions to specific or general problems. Many outcomes were very positive. However, some outcomes were measured only subjectively, one intervention was designed with complexity theory in mind but did not reiterate this in subsequent evaluation and other interventions were credited as compatible with complexity science but reported no relevant theoretical underpinning. Articles often omitted discussion on implementation barriers or unintended consequences, which suggests that complexity theory was not widely used in evaluation.

CONCLUSIONS

It is hard to establish cause and effect when attempting to leverage complex adaptive systems and perhaps even harder to reliably find evidence that confirms whether complexity-informed interventions are usually effective. While it is possible to show that interventions that are compatible with complexity science seem efficacious, it remains difficult to show that explicit planning with complexity in mind was particularly valuable. Recommendations are made to improve future evaluation reports, to establish a better evidence base about whether this conceptual framework is useful in intervention design and implementation.

Feasibility of Parent-to-Parent Support in Recently Diagnosed Childhood Diabetes: The PLUS Study

Purpose

The purpose of this study was to develop and test the feasibility of a parent-to-parent support intervention for parents whose child has recently been diagnosed with type 1 diabetes in the United Kingdom.

Methods

The research team conducted a formative evaluation, working with parents to design an individual-level parent-to-parent support intervention. Issues of recruitment, uptake, attrition, pattern of contact, and intervention acceptability were assessed.

Results

A US program was adapted in collaboration with a parents’ advisory group. Of 19 parents nominated as potential mentors by their pediatric diabetes specialist nurses, 12 (63%) volunteered and 11 continued for the 12-month intervention period. Thirty-three children were diagnosed with diabetes in the study period, with 25 families eligible to participate as recipients of the intervention; 9 parents from 7 of those families participated, representing 28% of those eligible. Feedback from parents and clinic staff identified peer support as a welcome service. Lessons were learned about the nature of the supporting relationship (eg, proximity, connectedness, and managing endings) that will enhance the design of future peer support programs.

Conclusions

Parent-to-parent support in the context of newly diagnosed childhood diabetes in the United Kingdom is feasible to deliver, with good engagement of mentors and clinic staff. The program was acceptable to parents who chose to participate, although uptake by parents whose child had been recently diagnosed was lower than expected. The results merit further investigation, including exploration of parent preference in relation to peer support.