Knowledge translation in Uganda: a qualitative study of Ugandan midwives' and managers' perceived relevance of the sub-elements of the context cornerstone in the PARIHS framework

Challenges and Opportunities for Paving the Road to Global Health Equity Through Implementation Science

Implementation science focuses on enhancing the widespread uptake of evidence-based interventions into routine practice to improve population health. However, optimizing implementation science to promote health equity in domestic and global resource-limited settings requires considering historical and sociopolitical processes (e.g., colonization, structural racism) and centering in local sociocultural and indigenous cultures and values. This review weaves together principles of decolonization and antiracism to inform critical and reflexive perspectives on partnerships that incorporate a focus on implementation science, with the goal of making progress toward global health equity. From an implementation science perspective, wesynthesize examples of public health evidence-based interventions, strategies, and outcomes applied in global settings that are promising for health equity, alongside a critical examination of partnerships, context, and frameworks operationalized in these studies. We conclude with key future directions to optimize the application of implementation science with a justice orientation to promote global health equity.

Co-created community contracts support biosecurity changes in a region where African swine fever is endemic – Part II: Implementation of biosecurity measures

Smallholder subsistence pig production is common in Uganda and African swine fever (ASF) is endemic in the country, with its spread driven by human activities along the smallholder value chain. Previous research in the study area has revealed that many stakeholders are aware of how ASF is spread, its prevention and control, and have a generally positive attitude towards biosecurity. Despite this, even basic biosecurity is largely lacking. Costs, as well as a lack of adaptation to the local context, culture and traditions have been identified as factors hindering biosecurity implementation. Community engagement and local ownership of disease problems are increasingly recognised as important for improving disease prevention and control. The objective of this study was to investigate the capacity of participatory action at community level with broad inclusion of stakeholders to improve biosecurity in the smallholder pig value chain. Specific attention was paid to participants' perceptions and experiences of implementing the biosecurity measures included in their co-created community contracts. The study was conducted in Northern Uganda in villages purposively selected on the basis of previous occurrences of ASF. In each village, farmers and traders were also purposively selected. At a first meeting, basic information about ASF was shared and participants presented with a list of biosecurity measures adapted for farmers and traders respectively. Participants discussed each measure in farmer and trader subgroups, decided on the measures to implement for one year, and signed a community contract to this effect. The following year, interviews were again undertaken and implementation support given. Interview data were coded and thematically analysed. Each subgroup chose a minimum of three and a maximum of nine measures, with wide variations between villages in their selection of measures. At the follow-ups, none of the subgroups had fully implemented what had been agreed in their contract, but all had changed some of their biosecurity routines. Some frequently recommended biosecurity measures, such as not borrowing breeding boars, were not considered feasible. Relatively simple and cheap biosecurity measures were rejected for reasons of cost, highlighting the participants' general level of poverty and the relevance of poverty as a specific factor governing disease control results. The participatory methodology allowing for discussions, co-creation and the option to refuse measures seemed to facilitate the implementation of measures that had initially been thought to be controversial. The broad community approach was deemed to be positive for strengthening community identity, cooperation and implementation.

Co-created community contracts support biosecurity changes in a region where African swine fever is endemic - Part I: The methodology

In Northern Uganda more people live in poverty than elsewhere in the country. Small-scale pig-keeping is common and African swine fever (ASF) is endemic, spreading along the smallholder value chain. Biosecurity measures remain the only way to prevent and control the spread of ASF in this context. Previous research in the study area has shown that many stakeholders are aware of ASF, how it is spread and methods for prevention and control, but biosecurity implementation remains limited. Participatory approaches have been suggested in order to increase community engagement in relation to animal disease control, ensuring that disease prevention or control actions are guided by local people's priorities and the promotion of local ownership of disease control. The objective of this study was to investigate the capacity of participatory action at community level with a broad inclusion of stakeholders to initiate change and greater stakeholder ownership to improve biosecurity in the smallholder pig value chain. Specific attention was paid to the feasibility of co-created community contracts for this purpose. The study was carried out in Northern Uganda in six purposively selected villages and included both farmers and traders. Centred on co-created community contracts on biosecurity, the study comprised repeated group discussions, semi-structured and structured group and individual interviews, as well as field observations. At the first meeting, participants were presented with suggested biosecurity measures adapted for farmers and traders respectively. Participants discussed each measure, agreed which ones to implement for one year, and co-created a community contract to this effect. During the study period, repeated interviews were undertaken and implementation support was provided. Interview data was coded and thematically analysed. Great diversity was observed between communities with regard to which and how many measures were selected, illustrating heterogeneity in the possibilities of biosecurity implementation and the complexity of livelihood challenges. The methodology appeared to be effective at instigating change, with all the communities changing some of their biosecurity behaviour during the study period. The intensified communication and cooperation around pigs in the communities reinforced the sense of group identity and the capacity-building offered at the first meeting supported implementation and appeared to be more important than the physical contract. Participants reported feeling empowered and described how they shared their knowledge, educated their peers and acted as catalysts for wider biosecurity change in their communities. These are promising results and indicate a positive attitude to both the agreed measures and the methodology.

Conceptual and relational advances of the PARIHS and i-PARIHS frameworks over the last decade: a critical interpretive synthesis

BACKGROUND

The number of research publications reporting the use of the Promoting Action on Research Implementation in Health Services (PARIHS) framework and the integrated PARIHS (i-PARIHS) framework has grown steadily. We asked how the last decade of implementation research, predicated on the (i-)PARIHS framework (referring to the PARIHS or i-PARIHS framework), has contributed to our understanding of the conceptualizations of, relationships between, and dynamics among the core framework elements/sub-elements. Building on the Helfrich et al. (2010) review of research on the PARIHS framework, we undertook a critical interpretive synthesis to: (1) identify conceptual and relational advances in the (i-)PARIHS framework and (2) identify conceptual and relational aspects of the (i-)PARIHS framework that warrant further work.

METHODS

We performed a systematic search in PubMed/PubMed Central, Ovid MEDLINE, CINAHL, JSTOR, SCOPUS, Web of Science, and PsycInfo. Articles were eligible for synthesis if they (a) were peer-reviewed articles, written in English, and published between January 2009 and December 2021, (b) applied the (i-)PARIHS framework explicitly to guide implementation research, and (c) made conceptual (expanding the conceptualization of core elements) and/or relational contributions (elaborating relationships among elements/sub-elements, or theorizing the relationships using empirical data). We used a critical interpretive synthesis approach to synthesize conceptual-relational advances of the (i-)PARIHS framework.

RESULTS

Thirty-seven articles were eligible for synthesis. Twenty-four offered conceptual contributions, and 18 offered relational contributions (5 articles contributed in both ways). We found conceptual expansion of all core (i-)PARIHS elements, with most emphasis on context (particularly outer context and leadership), facilitation, and implementation success. Articles also gave insights into the complex relationships and relational dynamism among these elements, characterized as contingent, interactive, multilevel, and temporal effects.

CONCLUSIONS

We observed developmental advances of the (i-)PARIHS framework and proposed several directions to further advance the framework. Conceptualization of (i-)PARIHS elements (particularly evidence/innovation and recipients) need to be further developed by specifying conceptual and operational definitions of underlying sub-elements. Relationships among (i-)PARIHS elements/sub-elements need to be further elaborated through empirical studies that consider situational contingencies and causal complexities. This will require examining necessity and sufficiency of (i-)PARIHS elements/sub-elements in relation to implementation outcomes, interactions among elements, and mechanism-based explanations.

Context Matters in Evidence Implementation Globally Comment on "Stakeholder Perspectives of Attributes and Features of Context Relevant to Knowledge Translation in Health Settings: A Multi-Country Analysis"

Context influences the effectiveness of healthcare interventions and should be considered to inform their implementation. However, context remains poorly defined in the knowledge translation (KT) literature. The paper by Squires and colleagues constitutes a valuable contribution to the field of KT as it provides the basis for a comprehensive framework to assess the influence of context on implementation success. In their study, Squires et al identified 66 context features, grouped into 16 attributes. Their findings highlight a great convergence in the context features mentioned by stakeholders across countries, experience levels and roles in KT. Thus, the proposed framework could eventually transfer to several implementation settings. However, all study participants were from high-income countries. It would therefore be important to replicate this research in low- and middle-income countries (LMICs). A common understanding of what context means is essential to assessing its influence on the implementation of healthcare interventions globally.

Evaluating factors that influenced the successful implementation of an evidence-based neonatal care intervention in Chinese hospitals using the PARIHS framework

Background

Evidence based interventions (EBIs) can improve patient care and outcomes. Understanding the process for successfully introducing and implementing EBIs can inform effective roll-out and scale up. The Promoting Action on Research Implementation in Health Services (PARIHS) framework can be used to evaluate and guide the introduction and implementation of EBIs. In this study, we used kangaroo mother care (KMC) as an example of an evidence-based neonatal intervention recently introduced in selected Chinese hospitals, to identify the factors that influenced its successful implementation. We also explored the utility of the PARIHS framework in China and investigated how important each of its constructs (evidence, context and facilitation) and sub-elements were perceived to be to successful implementation of EBIs in a Chinese setting.

Method

We conducted clinical observations and semi-structured interviews with 10 physicians and 18 nurses in five tertiary hospitals implementing KMC. Interview questions were organized around issues including knowledge and beliefs, resources, culture, implementation readiness and climate. We used directed content analysis to analyze the interview transcript, amending the PARIHS framework to incorporate emerging sub-themes. We also rated the constructs and sub-elements on a continuum from “low (weak)”, “moderate” or “high (strong)” highlighting the ones considered most influential for hospital level implementation by study participants.

Results

Using KMC as an example, our finding suggest that clinical experience, culture, leadership, evaluation, and facilitation are highly influential elements for EBI implementation in China. External evidence had a moderate impact, especially in the initial awareness raising stages of implementation and resources were also considered to be of moderate importance, although this may change as implementation progresses. Patient experience was not seen as a driver for implementation at hospital level.

Conclusion

Based on our findings examining KMC implementation as a case example, the PARIHS framework can be a useful tool for planning and evaluating EBI implementation in China. However, it’s sub-elements should be assessed and adapted to the implementation setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07493-6.

The impact of health worker absenteeism on patient health care seeking behavior, testing and treatment: A longitudinal analysis in Uganda

INTRODUCTION

Absenteeism of frontline health workers in public sector facilities is widespread in low-income countries. There is little quantitative evidence on how health worker absenteeism influences patient treatment seeking behavior, though low public sector utilization and heavy reliance on the informal sector are well documented in low-income settings.

METHODS

Using a unique panel dataset covering health facilities and households over a 10-month period in Uganda, we investigate the extent to which health worker absenteeism (defined as zero health workers present at a health facility) impacts patient care seeking behavior, testing, and treatment.

RESULTS

We find high rates of health worker absenteeism at public sector health facilities, with most of the absenteeism occurring at lower level public health clinics. On average, no health worker was present in 42% of all days monitored in lowest level public health clinics, whereas this number was less than 5% in high level public hospitals and private facilities. In our preferred empirical model with household fixed effects, we find that health worker absenteeism reduces the odds that a patient seeks care in the public sector (OR = 0.65, 95% CI = 0.44-0.95) and receives malaria testing (OR = 0.73, 95% CI = 0.53-0.99) and increases the odds of paying out-of-pocket for treatment (OR = 1.41, 95% CI = 1.10-1.80). The estimated differences in care-seeking are larger for children under-five than for the overall study population.

CONCLUSIONS

The impact of health worker absenteeism on the quality of care received as well as the financial burden faced by households in sub-Saharan Africa is substantial.

Identifying actionable strategies: using Consolidated Framework for Implementation Research (CFIR)-informed interviews to evaluate the implementation of a multilevel intervention to improve colorectal cancer screening

BACKGROUND

Many evidence-based interventions (EBIs) found to be effective in research studies often fail to translate into meaningful patient outcomes in practice. The purpose of this study was to identify facilitators and barriers that affect the implementation of three EBIs to improve colorectal cancer (CRC) screening in an urban federally qualified health center (FQHC) and offer actionable recommendations to improve future implementation efforts.

METHODS

We conducted 16 semi-structured interviews guided by the Consolidation Framework for Implementation Research (CFIR) to describe diverse stakeholders' implementation experience. The interviews were conducted in the participant's clinic, audio-taped, and professionally transcribed for analysis.

RESULTS

We used the five CFIR domains and 39 constructs and subconstructs as a coding template to conduct a template analysis. Based on experiences with the implementation of three EBIs, stakeholders described barriers and facilitators related to the intervention characteristics, outer setting, and inner setting. Implementation barriers included (1) perceived burden and provider fatigue with EHR (Electronic Health Record) provider reminders, (2) unreliable and ineffectual EHR provider reminders, (3) challenges to providing health care services to diverse patient populations, (4) lack of awareness about CRC screening among patients, (5) absence of CRC screening goals, (6) poor communication on goals and performance, and (7) absence of printed materials for frontline implementers to educate patients. Implementation facilitators included (1) quarterly provider assessment and feedback reports provided real-time data to motivate change, (2) integration with workflow processes, (3) pressure from funding requirement to report quality measures, (4) peer pressure to achieve high performance, and (5) a culture of teamwork and patient-centered mentality.

CONCLUSIONS

The CFIR can be used to conduct a post-implementation formative evaluation to identify barriers and facilitators that influenced the implementation. Furthermore, the CFIR can provide a template to organize research data and synthesize findings. With its clear terminology and meta-theoretical framework, the CFIR has the potential to promote knowledge-building for implementation. By identifying the contextual determinants, we can then determine implementation strategies to facilitate adoption and move EBIs to daily practice.

Comprehensive Needs Assessment to Ensure Appropriate Rehabilitation Training for Community-Based Workers and Caregivers in India

IMPORTANCE

Rehabilitation researchers and occupational therapy practitioners frequently conduct projects that involve the provision of services or the dissemination of knowledge in low- and middle-income countries (LMICs); however, the needs assessment process underlying these transcultural projects is often underreported.

OBJECTIVE

To identify a comprehensive set of feeding-related training needs that reflect the culture, resources, and service delivery practices in the West Bengal region of India and that will be used to develop video-based training modules that are contextually relevant and support decentralized training of community-based rehabilitation workers and caregivers of children with cerebral palsy (CP).

DESIGN

Mixed methods design using focus groups and observations.

SETTING

Community setting in rural, suburban, and urban locations in West Bengal, India.

PARTICIPANTS

Caregivers of children with CP and community-based rehabilitation workers with experience working with children with CP.

OUTCOMES AND MEASURES

Focus groups and in-home mealtime observations.

RESULTS

Several findings suggest training priorities that were not anticipated. Caregivers commonly fed children by means of hand feeding while sitting on the floor. Children were fed a limited variation of food consistencies, often in positions of neck hyperextension. Water was frequently used to stimulate swallowing. Caregivers struggled to help children with oral hygiene practices after meals.

CONCLUSIONS AND RELEVANCE

A thorough needs assessment yielded insights that can favorably alter the trajectory of transcultural service and research projects. For occupational therapists who provide advice on practice, continuing education, or research in a transcultural project, the findings underscore the value of engaging local stakeholders and using firsthand observation.

WHAT THIS ARTICLE ADDS

The rigorous, multistakeholder needs assessment process described herein can serve as a road map for researchers and occupational therapy practitioners conducting transcultural projects in LMICs.

Examination of tools associated with the evaluation of knowledge uptake and utilization: A scoping review

Knowledge transfer and exchange (KTE) has become an integral part of organizational practice. Evaluation of KTE, as well as knowledge products generated through this process, is important for understanding the effectiveness of KTE strategies. This scoping review aimed to identify tools and frameworks used to evaluate knowledge uptake and utilization (KUU). The search strategy included review of PubMed and Scopus databases, hand searching of relevant journals, and citation tracing. Over 6500 abstracts were screened; 292 full-text articles were shortlisted by two reviewers. Seventy-two articles described tools for evaluating KUU. A total of 23 tools could be generally applied to knowledge products/processes used in different sectors; 36 evaluation tools were designed for specific knowledge products (i.e., websites); 9 tools were discipline-specific (i.e., medical field), and four articles described evaluations of knowledge products/processes using alternative methods such as Google Analytics or qualitative methods. The majority of tools (n = 40, 56 %) focused on usability of a knowledge product or process. This scoping review identified various tools being used to assess the effectiveness and impact of KTE processes/products, however, the measures were as varied as the projects, and were often not designed to evaluate KTE in particular.

Evaluating the implementation of the Reproductive Life Plan in disadvantaged communities: A mixed-methods study using the i-PARIHS framework

INTRODUCTION

The Reproductive Life Plan (RLP) is a clinical tool to help clients find strategies to achieve their reproductive goals. Despite much research on the RLP from high-income countries, it has never been studied in low- or middle income countries. Together with health workers called Mentor Mothers (MMs), we used a context-adapted RLP in disadvantaged areas in Eswatini. Our aim was to evaluate the implementation of the RLP in this setting.

METHODOLOGY

MMs participated in focus group discussions (FGDs, n = 3 MMs n = 29) in January 2018 and at follow-up in May 2018 (n = 4, MMs n = 24). FGDs covered challenges in using the RLP, how to adapt it, and later experiences from using it. We used a deductive qualitative thematic analysis with the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, creating themes guided by its four constructs: facilitation, innovation, recipients and context. The MMs also answered a questionnaire to assess the implementation process inspired by normalization process theory.

RESULTS

The RLP intervention was feasible and acceptable among MMs and fit well with existing practices. The RLP questions were perceived as advantageous since they opened up discussions with clients and enabled reflection. All except one MM (n = 23) agreed or strongly agreed that they valued the effect the RLP has had on their work. Using the RLP, the MMs observed progress in pregnancy planning among their clients and thought it improved the quality of contraceptive counselling. The clients' ability to form and achieve their reproductive goals was hampered by contextual factors such as intimate partner violence and women's limited reproductive health and rights.

DISCUSSION

The RLP was easily implemented in these disadvantaged communities and the MMs were key persons in this intervention. The RLP should be further evaluated among clients and suitable approaches to include partners are required.

The use of the PARIHS framework in implementation research and practice-a citation analysis of the literature

BACKGROUND

The Promoting Action on Research Implementation in Health Services (PARIHS) framework was developed two decades ago and conceptualizes successful implementation (SI) as a function (f) of the evidence (E) nature and type, context (C) quality, and the facilitation (F), [SI = f (E,C,F)]. Despite a growing number of citations of theoretical frameworks including PARIHS, details of how theoretical frameworks are used remains largely unknown. This review aimed to enhance the understanding of the breadth and depth of the use of the PARIHS framework.

METHODS

This citation analysis commenced from four core articles representing the key stages of the framework's development. The citation search was performed in Web of Science and Scopus. After exclusion, we undertook an initial assessment aimed to identify articles using PARIHS and not only referencing any of the core articles. To assess this, all articles were read in full. Further data extraction included capturing information about where (country/countries and setting/s) PARIHS had been used, as well as categorizing how the framework was applied. Also, strengths and weaknesses, as well as efforts to validate the framework, were explored in detail.

RESULTS

The citation search yielded 1613 articles. After applying exclusion criteria, 1475 articles were read in full, and the initial assessment yielded a total of 367 articles reported to have used the PARIHS framework. These articles were included for data extraction. The framework had been used in a variety of settings and in both high-, middle-, and low-income countries. With regard to types of use, 32% used PARIHS in planning and delivering an intervention, 50% in data analysis, 55% in the evaluation of study findings, and/or 37% in any other way. Further analysis showed that its actual application was frequently partial and generally not well elaborated.

CONCLUSIONS

In line with previous citation analysis of the use of theoretical frameworks in implementation science, we also found a rather superficial description of the use of PARIHS. Thus, we propose the development and adoption of reporting guidelines on how framework(s) are used in implementation studies, with the expectation that this will enhance the maturity of implementation science.

Defining and assessing context in healthcare implementation studies: a systematic review

BACKGROUND

The implementation of evidence-based healthcare interventions is challenging, with a 17-year gap identified between the generation of evidence and its implementation in routine practice. Although contextual factors such as culture and leadership are strong influences for successful implementation, context remains poorly understood, with a lack of consensus regarding how it should be defined and captured within research. This study addresses this issue by providing insight into how context is defined and assessed within healthcare implementation science literature and develops a definition to enable effective measurement of context.

METHODS

Medline, PsychInfo, CINAHL and EMBASE were searched. Articles were included if studies were empirical and evaluated context during the implementation of a healthcare initiative. These English language articles were published in the previous 10 years and included a definition and assessment of context. Results were synthesised using a narrative approach.

RESULTS

Three thousand and twenty-one search records were obtained of which 64 met the eligibility criteria and were included in the review. Studies used a variety of definitions in terms of the level of detail and explanation provided. Some listed contextual factors (n = 19) while others documented sub-elements of a framework that included context (n = 19). The remaining studies provide a rich definition of general context (n = 11) or aspects of context (n = 15). The Alberta Context Tool was the most frequently used quantitative measure (n = 4), while qualitative papers used a range of frameworks to evaluate context. Mixed methods studies used diverse approaches; some used frameworks to inform the methods chosen while others used quantitative measures to inform qualitative data collection. Most studies (n = 50) applied the chosen measure to all aspects of study design with a majority analysing context at an individual level (n = 29).

CONCLUSIONS

This review highlighted inconsistencies in defining and measuring context which emphasised the need to develop an operational definition. By providing this consensus, improvements in implementation processes may result, as a common understanding will help researchers to appropriately account for context in research.

Empowering Health Workers to Protect Their Own Health: A Study of Enabling Factors and Barriers to Implementing HealthWISE in Mozambique, South Africa, and Zimbabwe

Ways to address the increasing global health workforce shortage include improving the occupational health and safety of health workers, particularly those in high-risk, low-resource settings. The World Health Organization and International Labour Organization designed HealthWISE, a quality improvement tool to help health workers identify workplace hazards to find and apply low-cost solutions. However, its implementation had never been systematically evaluated. We, therefore, studied the implementation of HealthWISE in seven hospitals in three countries: Mozambique, South Africa, and Zimbabwe. Through a multiple-case study and thematic analysis of data collected primarily from focus group discussions and questionnaires, we examined the enabling factors and barriers to the implementation of HealthWISE by applying the integrated Promoting Action on Research Implementation in Health Services (i-PARiHS) framework. Enabling factors included the willingness of workers to engage in the implementation, diverse teams that championed the process, and supportive senior leadership. Barriers included lack of clarity about how to use HealthWISE, insufficient funds, stretched human resources, older buildings, and lack of incident reporting infrastructure. Overall, successful implementation of HealthWISE required dedicated local team members who helped facilitate the process by adapting HealthWISE to the workers' occupational health and safety (OHS) knowledge and skill levels and the cultures and needs of their hospitals, cutting across all constructs of the i-PARiHS framework.

Scaling Up Safer Birth Bundle Through Quality Improvement in Nepal (SUSTAIN)-a stepped wedge cluster randomized controlled trial in public hospitals

Background

Each year, 2.2 million intrapartum-related deaths (intrapartum stillbirths and first day neonatal deaths) occur worldwide with 99% of them taking place in low- and middle-income countries. Despite the accelerated increase in the proportion of deliveries taking place in health facilities in these settings, the stillborn and neonatal mortality rates have not reduced proportionately. Poor quality of care in health facilities is attributed to two-thirds of these deaths. Improving quality of care during the intrapartum period needs investments in evidence-based interventions. We aim to evaluate the quality improvement package—Scaling Up Safer Bundle Through Quality Improvement in Nepal (SUSTAIN)—on intrapartum care and intrapartum-related mortality in public hospitals of Nepal.

Methods

We will conduct a stepped wedge cluster randomized controlled trial in eight public hospitals with each having least 3000 deliveries a year. Each hospital will represent a cluster with an intervention transition period of 2 months in each. With a level of significance of 95%, the statistical power of 90% and an intra-cluster correlation of 0.00015, a study period of 19 months should detect at least a 15% change in intrapartum-related mortality. Quality improvement training, mentoring, systematic feedback, and a continuous improvement cycle will be instituted based on bottleneck analyses in each hospital. All concerned health workers will be trained on standard basic neonatal resuscitation and essential newborn care. Portable fetal heart monitors (Moyo®) and neonatal heart rate monitors (Neobeat®) will be introduced in the hospitals to identify fetal distress during labor and to improve neonatal resuscitation. Independent research teams will collect data in each hospital on intervention inputs, processes, and outcomes by reviewing records and carrying out observations and interviews. The dose-response effect will be evaluated through process evaluations.

Discussion

With the global momentum to improve quality of intrapartum care, better understanding of QI package within a health facility context is important. The proposed package is based on experiences from a similar previous scale-up trial carried out in Nepal. The proposed evaluation will provide evidence on QI package and technology for implementation and scale up in similar settings.

Trial registration number

ISRCTN16741720. Registered on 2 March 2019.

Ready to deliver maternal and newborn care? Health providers' perceptions of their work context in rural Mozambique

Background: Deficiencies in the provision of evidence-based obstetric care are common in low-income countries, including Mozambique. Constraints relate to lack of human and financial resources and weak health systems, however limited resources alone do not explain the variance. Understanding the healthcare context ahead of implementing new interventions can inform the choice of strategies to achieve a successful implementation. The Context Assessment for Community Health (COACH) tool was developed to assess modifiable aspects of the healthcare context that theoretically influence the implementation of evidence.

Objectives: To investigate the comprehensibility and the internal reliability of COACH and its use to describe the healthcare context as perceived by health providers involved in maternal care in Mozambique.

Methods: A response process evaluation was completed with six purposively selected health providers to uncover difficulties in understanding the tool. Internal reliability was tested using Cronbach’s α. Subsequently, a cross-sectional survey using COACH, which contains 49 items assessing eight dimensions, was administered to 175 health providers in 38 health facilities within six districts in Mozambique.

Results: The content of COACH was clear and most items were understood. All dimensions were near to or exceeded the commonly accepted standard for satisfactory internal reliability (0.70). Analysis of the survey data indicated that items on all dimensions were rated highly, revealing positive perception of context. Significant differences between districts were found for the Work culture, Leadership, and Informal payment dimensions. Responses to many items had low variance and were left-skewed.

Conclusions: COACH was comprehensible and demonstrated good reliability, although biases may have influenced participants’ responses. The study suggests that COACH has the potential to evaluate the healthcare context to identify shortcomings and enable the tailoring of strategies ahead of implementation. Supplementing the tool with qualitative approaches will provide an in-depth understanding of the healthcare context.

Evaluation frameworks in health services: An integrative review of use, attributes and elements

AIMS AND OBJECTIVE

To synthesise the evidence on the use of evaluation frameworks by nurses and midwives in research designed to improve healthcare services and practice. A secondary aim was to identify the attributes and elements of evaluation frameworks.

BACKGROUND

Evaluation is an integral component of any initiative to improve outcomes or change clinical practice. Yet often an evaluation may not yield the information required to sustain or integrate an initiative into practice. Evaluation frameworks can support effective evaluations, but there is a lack of consensus regarding elements and attributes of frameworks that support use.

METHODS

We undertook an integrative review to synthesise the use of evaluation frameworks in practice guided by the Preferred Reporting Items for Systematic review and Meta-Analysis flow diagram and checklist 2009 (Supporting Information File 4). The protocol was registered with PROSPERO (CRD42018087033). A broad range of electronic databases were systematically searched using keywords.

FINDINGS

Twenty-five papers were included from a diverse range of clinical areas and across high-, middle- and low-income nations. Twenty of the research projects had used nine existing frameworks, and five had developed an evaluation specific to an initiative. Frameworks supported the processes of evaluation and made them more meaningful by simplifying a complex process (providing structure and guidance for the evaluation processes); identifying and including stakeholders; explaining reasons for outcomes; generating transferable lessons; and identifying the mechanisms driving or inhibiting change.

CONCLUSION

Nurses and midwives reported that frameworks were useful in undertaking evaluations. Each framework had positive attributes and missing or confusing elements. When undertaking an evaluation, it is pertinent to review the elements and attributes of a framework to ensure it includes evaluation measures that are relevant to specific projects.

RELEVANCE TO CLINICAL PRACTICE

Nurses are actively involved in evaluation of clinical practice. This review identifies important elements to consider when choosing a framework for evaluation.

Improved postpartum care after a participatory facilitation intervention in Dar es Salaam, Tanzania: a mixed method evaluation

Background: In order to improve the health and survival of mothers/newborns, the quality and attendance rates of postpartum care (PPC) must be increased, particularly in low-resource settings.

Objective: To describe outcomes of a collegial facilitation intervention to improve PPC in government-owned health institutions in a low-resource suburb in Dar es Salaam, Tanzania.

Methods: A before-and-after evaluation of an intervention and comparison group was conducted using mixed methods (focus group discussions, questionnaires, observations, interviews, and field-notes) at health institutions. Maternal and child health aiders, enrolled nurse midwives, registered nurse midwives, and medical and clinical officers participated. A collegial facilitation intervention was conducted and healthcare providers were organized in teams to improve PPC at their workplaces. Facilitators defined areas of improvement with colleagues and met regularly with a supervisor for support.

Results: The number of mothers visiting the institution for PPC increased in the intervention group. Some care actions were noted in more than 80% of the observations and mothers reported high satisfaction with care. In the comparison group, PPC continued to be next to non-existent. The healthcare providers’ knowledge increased in both groups but was higher in the intervention group. The t-test showed a significant difference in knowledge between the intervention and comparison groups and between before and after the intervention in both groups. The difference of differences for knowledge was 1.3. The providers perceived the intervention outcomes to include growing professional confidence/knowledge, improved PPC quality, and mothers’ positive response. The quality grading was based on the national guidelines and involved nine experts and showed that none of the providers reached the level of good quality of care.

Conclusions: The participatory facilitation intervention contributed to improved quality of PPC, healthcare providers’ knowledge and professional confidence, awareness of PPC among mothers, and increased PPC attendance.

Implementation of a facilitation intervention to improve postpartum care in a low-resource suburb of Dar es Salaam, Tanzania

Background

Implementation of evidence into practice is inadequate in many low-income countries, contributing to the low-quality care of mothers and newborns. This study explored strategies used in a facilitation intervention to improve postpartum care (IPPC) in a low-resource suburb in Dar es Salaam, Tanzania. The intervention was conducted during 1 year in government-owned health institutions providing reproductive and child health services. The institutions were divided into six clusters based on geographic proximity, and the healthcare providers of postpartum care (PPC) (n = 100) in these institutions formed IPPC teams. Each team was supported by a locally recruited facilitator who was trained in PPC, group dynamics, and quality improvement. The IPPC teams reflected on their practices, identified problems and solutions for improving PPC, enacted change, and monitored the adopted actions.

Methods

A qualitative design was employed using data from focus group discussions with healthcare providers (n = 8) and facilitators (n = 2), and intervention documentation. The discussions were conducted in Kiswahili, lasted for 45–90 min, were audio-recorded, transcribed verbatim, and translated into English. Thematic analysis guided the analysis.

Results

Four main strategies were identified in the data: (1) Increasing awareness and knowledge of PPC by HCPs and mothers was an overarching strategy applied in training, meetings, and clinical practice; (2) The mobilization of professional and material resources was achieved through unleashing of the IPPC teams’ own potential to conduct PPC and act as change agents; (3) Improving documentation and communication; and (4) Promoting an empowering and collaborative working style were other strategies applied to improve daily care routines. The facilitators encouraged teamwork and networking among IPPC teams within and between institutions.

Conclusion

This facilitation intervention is a promising approach for implementing evidence and improving quality of PPC in a low-resource setting. Context-specific actions taken by the facilitators and healthcare providers are likely integral to the successfulness of implementing evidence into practice. The results contribute to increasing the understanding of facilitation as an intervention and can be useful for researchers, HCPs, and policymakers when improving quality of postpartum care, particularly in low-income settings.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0794-x) contains supplementary material, which is available to authorized users.

Organizational contextual features that influence the implementation of evidence-based practices across healthcare settings: a systematic integrative review

BACKGROUND

Organizational contextual features have been recognized as important determinants for implementing evidence-based practices across healthcare settings for over a decade. However, implementation scientists have not reached consensus on which features are most important for implementing evidence-based practices. The aims of this review were to identify the most commonly reported organizational contextual features that influence the implementation of evidence-based practices across healthcare settings, and to describe how these features affect implementation.

METHODS

An integrative review was undertaken following literature searches in CINAHL, MEDLINE, PsycINFO, EMBASE, Web of Science, and Cochrane databases from January 2005 to June 2017. English language, peer-reviewed empirical studies exploring organizational context in at least one implementation initiative within a healthcare setting were included. Quality appraisal of the included studies was performed using the Mixed Methods Appraisal Tool. Inductive content analysis informed data extraction and reduction.

RESULTS

The search generated 5152 citations. After removing duplicates and applying eligibility criteria, 36 journal articles were included. The majority (n = 20) of the study designs were qualitative, 11 were quantitative, and 5 used a mixed methods approach. Six main organizational contextual features (organizational culture; leadership; networks and communication; resources; evaluation, monitoring and feedback; and champions) were most commonly reported to influence implementation outcomes in the selected studies across a wide range of healthcare settings.

CONCLUSIONS

We identified six organizational contextual features that appear to be interrelated and work synergistically to influence the implementation of evidence-based practices within an organization. Organizational contextual features did not influence implementation efforts independently from other features. Rather, features were interrelated and often influenced each other in complex, dynamic ways to effect change. These features corresponded to the constructs in the Consolidated Framework for Implementation Research (CFIR), which supports the use of CFIR as a guiding framework for studies that explore the relationship between organizational context and implementation. Organizational culture was most commonly reported to affect implementation. Leadership exerted influence on the five other features, indicating it may be a moderator or mediator that enhances or impedes the implementation of evidence-based practices. Future research should focus on how organizational features interact to influence implementation effectiveness.

Making sense of complexity in context and implementation: the Context and Implementation of Complex Interventions (CICI) framework

BACKGROUND

The effectiveness of complex interventions, as well as their success in reaching relevant populations, is critically influenced by their implementation in a given context. Current conceptual frameworks often fail to address context and implementation in an integrated way and, where addressed, they tend to focus on organisational context and are mostly concerned with specific health fields. Our objective was to develop a framework to facilitate the structured and comprehensive conceptualisation and assessment of context and implementation of complex interventions.

METHODS

The Context and Implementation of Complex Interventions (CICI) framework was developed in an iterative manner and underwent extensive application. An initial framework based on a scoping review was tested in rapid assessments, revealing inconsistencies with respect to the underlying concepts. Thus, pragmatic utility concept analysis was undertaken to advance the concepts of context and implementation. Based on these findings, the framework was revised and applied in several systematic reviews, one health technology assessment (HTA) and one applicability assessment of very different complex interventions. Lessons learnt from these applications and from peer review were incorporated, resulting in the CICI framework.

RESULTS

The CICI framework comprises three dimensions-context, implementation and setting-which interact with one another and with the intervention dimension. Context comprises seven domains (i.e., geographical, epidemiological, socio-cultural, socio-economic, ethical, legal, political); implementation consists of five domains (i.e., implementation theory, process, strategies, agents and outcomes); setting refers to the specific physical location, in which the intervention is put into practise. The intervention and the way it is implemented in a given setting and context can occur on a micro, meso and macro level. Tools to operationalise the framework comprise a checklist, data extraction tools for qualitative and quantitative reviews and a consultation guide for applicability assessments.

CONCLUSIONS

The CICI framework addresses and graphically presents context, implementation and setting in an integrated way. It aims at simplifying and structuring complexity in order to advance our understanding of whether and how interventions work. The framework can be applied in systematic reviews and HTA as well as primary research and facilitate communication among teams of researchers and with various stakeholders.

Paying for Performance to Improve the Delivery and Uptake of Family Planning in Low and Middle Income Countries: A Systematic Review

Paying for performance is a strategy to meet the unmet need for family planning in low and middle income countries; however, rigorous evidence on effectiveness is lacking. Scientific databases and grey literature were searched from 1994 to May 2016. Thirteen studies were included. Payments were linked to units of targeted services, usually modified by quality indicators. Ancillary components and payment indicators differed between studies. Results were mixed for family planning outcome measures. Paying for performance was associated with improved modern family planning use in one study, and increased user and coverage rates in two more. Paying for performance with conditional cash transfers increased family planning use in another. One study found increased use in the upper wealth group only. However, eight studies reported no impact on modern family planning use or prevalence. Secondary outcomes of equity, financial risk protection, satisfaction, quality, and service organization were mixed. Available evidence is inconclusive and limited by the scarcity of studies and by variation in intervention, study design, and outcome measures. Further studies are warranted.

Environmental Factors Influencing Adoption of Canadian Guidelines on Smoking Cessation in Dental Healthcare Settings in Quebec: A Qualitative Study of Dentists' Perspectives

Background: This study aimed to understand dentists’ perspective of the environmental determinants which positively or negatively influence the implementation of Canadian smoking cessation clinical practice guidelines (5As: Ask-Advise-Assess-Assist-Arrange) in private dental clinics in Quebec. Methods: This study used a qualitative design and an integrative conceptual framework composed of three theoretical perspectives. Data collection was conducted in individual semi-directed interviews with 20 private dentists lasting between 35 and 45 min. The audio-recorded data were transcribed verbatim, followed by a directed content analysis. Results: Some of the barriers identified to counselling in smoking cessation were lack of time, patient attitude, lack of prescription of nicotine replacement therapies, lack of reimbursement, and the lack of training of the dental team. Enablers cited by participants were the style of dentist’s leadership, the availability of community, human and material resources, the perception of counselling as a professional duty, and the culture of dental medicine. In addition to these variables, dentists’ attitude and behaviour were affected by different organisations giving initial or continual training to dentists, governmental policies, and the compatibility of Canadian smoking cessation guidelines with the practice of dentistry. Conclusion: Our findings will inform the development of smoking cessation interventions in dental healthcare settings.

Implementation of integrated stepped care for unhealthy alcohol use in HIV clinics

Background

Effective counseling and pharmacotherapy for unhealthy alcohol use are rarely provided in HIV treatment settings to patients. Our goal was to describe factors influencing implementation of a stepped care model to address unhealthy alcohol use in HIV clinics from the perspectives of social workers, psychologists and addiction psychiatrists.

Methods

We conducted two focus groups with Social Workers (n = 4), Psychologists (n = 2), and Addiction Psychiatrists (n = 4) involved in an ongoing randomized controlled trial evaluating the effectiveness of integrated stepped care for unhealthy alcohol use in HIV-infected patients at five Veterans Health Administration (VA) HIV clinics. Data collection and analyses were guided by the Consolidated Framework for Implementation Research (CFIR) domains, with a focus on the three domains which we considered to be most relevant: intervention characteristics (i.e. motivational interviewing, pharmacotherapy), the inner setting (i.e. HIV clinics), and characteristics of individuals (i.e. the providers). A multidisciplinary team used directed content analysis to identify major themes.

Results

From the providers’ perspective, the major implementation themes that emerged by CFIR domain included: (1) Intervention characteristics: providers valued tools and processes for facilitating patient motivation for treatment of unhealthy alcohol use given their perceived lack of motivation, but expressed a desire for greater flexibility; (2) Inner setting: treating unhealthy alcohol use in HIV clinics was perceived by providers to be consistent with VA priorities; and (3) Characteristics of individuals: there was high self-efficacy to conduct the intervention, an expressed need for more consistent utilization to maintain skills, and consideration of alternative models for delivering the components of the intervention.

Conclusions

Use of the CFIR framework reveals that implementation of integrated stepped care for unhealthy alcohol use in HIV clinics is facilitated by tools to help providers enhance patient motivation or address unhealthy alcohol use among patients perceived to be unmotivated. Implementation may be facilitated by its consistency with organizational values and existing models of care and attention to optimizing provider self-efficacy and roles (i.e. approaches to treatment integration).

Impact of Contextual Factors on the Effect of Interventions to Improve Health Worker Performance in Sub-Saharan Africa: Review of Randomised Clinical Trials

BACKGROUND

Africa bears 24% of the global burden of disease but has only 3% of the world's health workers. Substantial variation in health worker performance adds to the negative impact of this significant shortfall. We therefore sought to identify interventions implemented in sub-Saharan African aiming to improve health worker performance and the contextual factors likely to influence local effectiveness.

METHODS AND FINDINGS

A systematic search for randomised controlled trials of interventions to improve health worker performance undertaken in sub-Saharan Africa identified 41 eligible trials. Data were extracted to define the interventions' components, calculate the absolute improvement in performance achieved, and document the likelihood of bias. Within-study variability in effect was extracted where reported. Statements about contextual factors likely to have modified effect were subjected to thematic analysis. Interventions to improve health worker performance can be very effective. Two of the three trials assessing mortality impact showed significant reductions in death rates (age<5 case fatality 5% versus 10%, p<0.01; maternal in-hospital mortality 6.8/1000 versus 10.3/1000; p<0.05). Eight of twelve trials focusing on prescribing had a statistically significant positive effect, achieving an absolute improvement varying from 9% to 48%. However, reported range of improvement between centres within trials varied substantially, in many cases exceeding the mean effect. Nine contextual themes were identified as modifiers of intervention effect across studies; most frequently cited were supply-line failures, inadequate supervision or management, and failure to follow-up training interventions with ongoing support, in addition to staff turnover.

CONCLUSIONS

Interventions to improve performance of existing staff and service quality have the potential to improve patient care in underserved settings. But in order to implement interventions effectively, policy makers need to understand and address the contextual factors which can contribute to differences in local effect. Researchers therefore must recognise the importance of reporting how context may modify effect size.

Leadership in evidence-based practice: a systematic review

Purpose

– This study aims to systematically review published empirical research on leadership as a determinant for the implementation of evidence-based practice (EBP) and to investigate leadership conceptualization and operationalization in this field.

Design/methodology/approach

– A systematic review with narrative synthesis was conducted. Relevant electronic bibliographic databases and reference lists of pertinent review articles were searched. To be included, a study had to involve empirical research and refer to both leadership and EBP in health care. Study quality was assessed with a structured instrument based on study design.

Findings

– A total of 17 studies were included. Leadership was mostly viewed as a modifier for implementation success, acting through leadership support. Yet, there was definitional imprecision as well as conceptual inconsistency, and studies seemed to inadequately address situational and contextual factors. Although referring to an organizational factor, the concept was mostly analysed at the individual or group level.

Research limitations/implications

– The concept of leadership in implementation science seems to be not fully developed. It is unclear whether attempts to tap the concept of leadership in available instruments truly capture and measure the full range of the diverse leadership elements at various levels. Research in implementation science would benefit from a better integration of research findings from other disciplinary fields. Once a more mature concept has been established, researchers in implementation science could proceed to further elaborate operationalization and measurement.

Originality/value

– Although the relevance of leadership in implementation science has been acknowledged, the conceptual base of leadership in this field has received only limited attention.

Exploring the influence of context in a community-based facilitation intervention focusing on neonatal health and survival in Vietnam: a qualitative study

BACKGROUND

In the Neonatal health - Knowledge into Practice (NeoKIP) trial in Vietnam, local stakeholder groups, supported by trained laywomen acting as facilitators, promoted knowledge translation (KT) resulting in decreased neonatal mortality. In general, as well as in the community-based NeoKIP trial, there is a need to further understand how context influences KT interventions in low- and middle-income countries (LMICs). Thus, the objective of this study was to explore the influence of context on the facilitation process in the NeoKIP intervention.

METHODS

A secondary content analysis was performed on 16 Focus Group Discussions with facilitators and participants of the stakeholder groups, applying an inductive approach to the content on context through naïve understanding and structured analysis.

RESULTS

The three main-categories of context found to influence the facilitation process in the NeoKIP intervention were: (1) Support and collaboration of local authorities and other communal stakeholders; (2) Incentives to, and motivation of, participants; and (3) Low health care coverage and utilization. In particular, the role of local authorities in a KT intervention was recognized as important. Also, while project participants expected financial incentives, non-financial benefits such as individual learning were considered to balance the lack of reimbursement in the NeoKIP intervention. Further, project participants recognized the need to acknowledge the needs of disadvantaged groups.

CONCLUSIONS

This study provides insight for further understanding of the influence of contextual aspects to improve effects of a KT intervention in Vietnam. We suggest that future KT interventions should apply strategies to improve local authorities' engagement, to identify and communicate non-financial incentives, and to make disadvantaged groups a priority. Further studies to evaluate the contextual aspects in KT interventions in LMICs are also needed.

Health system context and implementation of evidence-based practices-development and validation of the Context Assessment for Community Health (COACH) tool for low- and middle-income settings

BACKGROUND

The gap between what is known and what is practiced results in health service users not benefitting from advances in healthcare, and in unnecessary costs. A supportive context is considered a key element for successful implementation of evidence-based practices (EBP). There were no tools available for the systematic mapping of aspects of organizational context influencing the implementation of EBPs in low- and middle-income countries (LMICs). Thus, this project aimed to develop and psychometrically validate a tool for this purpose.

METHODS

The development of the Context Assessment for Community Health (COACH) tool was premised on the context dimension in the Promoting Action on Research Implementation in Health Services framework, and is a derivative product of the Alberta Context Tool. Its development was undertaken in Bangladesh, Vietnam, Uganda, South Africa and Nicaragua in six phases: (1) defining dimensions and draft tool development, (2) content validity amongst in-country expert panels, (3) content validity amongst international experts, (4) response process validity, (5) translation and (6) evaluation of psychometric properties amongst 690 health workers in the five countries.

RESULTS

The tool was validated for use amongst physicians, nurse/midwives and community health workers. The six phases of development resulted in a good fit between the theoretical dimensions of the COACH tool and its psychometric properties. The tool has 49 items measuring eight aspects of context: Resources, Community engagement, Commitment to work, Informal payment, Leadership, Work culture, Monitoring services for action and Sources of knowledge.

CONCLUSIONS

Aspects of organizational context that were identified as influencing the implementation of EBPs in high-income settings were also found to be relevant in LMICs. However, there were additional aspects of context of relevance in LMICs specifically Resources, Community engagement, Commitment to work and Informal payment. Use of the COACH tool will allow for systematic description of the local healthcare context prior implementing healthcare interventions to allow for tailoring implementation strategies or as part of the evaluation of implementing healthcare interventions and thus allow for deeper insights into the process of implementing EBPs in LMICs.

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.

Malaria treatment policy change in Uganda: what role did evidence play?

Background

Although increasing attention is being paid to knowledge translation (KT), research findings are not being utilized to the desired extent. The present study explores the role of evidence, barriers, and factors facilitating the uptake of evidence in the change in malaria treatment policy in Uganda, building on previous work in Uganda that led to the development of a middle range theory (MRT) outlining the main facilitatory factors for KT. Application of the MRT to a health policy case will contribute to refining it.

Methods

Using a case study approach and mixed methods, perceptions of respondents on whether evidence was available, had been considered and barriers and facilitatory factors to the uptake of evidence were explored. In addition, the respondents’ rating of the degree of consistency between the policy decision and available evidence was assessed. Data collection methods included key informant interviews and document review. Qualitative data were analysed using content thematic analysis, whereas quantitative data were analysed using Excel spreadsheets. The two data sets were eventually triangulated.

Results

Evidence was used to change the malaria treatment policy, though the consistency between evidence and policy decisions varied along the policy development cycle. The availability of high-quality and contextualized evidence, including effective dissemination, Ministry of Health institutional capacity to lead the KT process, intervention of the WHO and a regional professional network, the existence of partnerships for KT with mutual trust and availability of funding, tools, and inputs to implement evidence, were the most important facilitatory factors that enhanced the uptake of evidence. Among the barriers that had to be overcome were resistance from implementers, the health system capacity to implement evidence, and financial sustainability.

Conclusion

The results agree with facilitatory factors identified in the earlier developed MRT, though additional factors emerged. These results refine the earlier MRT stating that high-quality and contextualized evidence will be taken up in policies, leading to evidence-informed policies when the MoH leads the KT process, partnerships are in place for KT, the WHO and regional professional bodies play a role, and funding, tools, and required inputs for implementing evidence are available.

Electronic supplementary material

The online version of this article (doi:10.1186/1475-2875-13-345) contains supplementary material, which is available to authorized users.

Facilitators and barriers to applying a national quality registry for quality improvement in stroke care

BACKGROUND

National quality registries (NQRs) purportedly facilitate quality improvement, while neither the extent nor the mechanisms of such a relationship are fully known. The aim of this case study is to describe the experiences of local stakeholders to determine those elements that facilitate and hinder clinical quality improvement in relation to participation in a well-known and established NQR on stroke in Sweden.

METHODS

A strategic sample was drawn of 8 hospitals in 4 county councils, representing a variety of settings and outcomes according to the NQR's criteria. Semi-structured telephone interviews were conducted with 25 managers, physicians in charge of the Riks-Stroke, and registered nurses registering local data at the hospitals. Interviews, including aspects of barriers and facilitators within the NQR and the local context, were analysed with content analysis.

RESULTS

An NQR can provide vital aspects for facilitating evidence-based practice, for example, local data drawn from national guidelines which can be used for comparisons over time within the organisation or with other hospitals. Major effort is required to ensure that data entries are accurate and valid, and thus the trustworthiness of local data output competes with resources needed for everyday clinical stroke care and quality improvement initiatives. Local stakeholders with knowledge of and interest in both the medical area (in this case stroke) and quality improvement can apply the NQR data to effectively initiate, carry out, and evaluate quality improvement, if supported by managers and co-workers, a common stroke care process and an operational management system that embraces and engages with the NQR data.

CONCLUSION

While quality registries are assumed to support adherence to evidence-based guidelines around the world, this study proposes that a NQR can facilitate improvement of care but neither the registry itself nor the reporting of data initiates quality improvement. Rather, the local and general evidence provided by the NQR must be considered relevant and must be applied in the local context. Further, the quality improvement process needs to be facilitated by stakeholders collaborating within and outside the context, who know how to initiate, perform, and evaluate quality improvement, and who have the resources to do so.

Urban settings do not ensure access to services: findings from the immunisation programme in Kampala Uganda

Background

Previous studies on vaccination coverage in developing countries focus on individual- and community-level barriers to routine vaccination mostly in rural settings. This paper examines health system barriers to childhood immunisation in urban Kampala Uganda.

Methods

Mixed methods were employed with a survey among child caretakers, 9 focus group discussions (FGDs), and 9 key informant interviews (KIIs). Survey data underwent descriptive statistical analysis. Latent content analysis was used for qualitative data.

Results

Of the 821 respondents in the survey, 96% (785/821) were mothers with a mean age of 26 years (95% CI 24–27). Poor geographical access to immunisation facilities was reported in this urban setting by FGDs, KIIs and survey respondents (24%, 95% CI 21–27). This coupled with reports of few health workers providing immunisation services led to long queues and long waiting times at facilities. Consumers reported waiting for 3–6 hours before receipt of services although this was more common at public facilities. Only 33% (95% CI 30–37) of survey respondents were willing to wait for three or more hours before receipt of services. Although private-for-profit facilities were engaged in immunisation service provision their participation was low as only 30% (95% CI 27–34) of the survey respondents utilised these facilities. The low participation could be due to lack of financial support for immunisation activities at these facilities. This in turn could explain the rampant informal charges for services in this setting. Charges ranged from US$ 0.2 to US$4 and these were more commonly reported at private (70%, 95% CI 65–76) than at public (58%, 95% CI 54–63) facilities. There were intermittent availability of vaccines and transport for immunisation services at both private and public facilities.

Conclusions

Complex health system barriers to childhood immunisation still exist in this urban setting; emphasizing that even in urban areas with great physical access, there are hard to reach people. As the rate of urbanization increases especially in sub-Saharan Africa, governments should strengthen health systems to cater for increasing urban populations.

Improving knowledge translation in Uganda: more needs to be done

Introduction

Meeting the health-related Millennium Development Goals in Africa calls for better access to and higher utilisation of quality evidence. The mechanisms through which research evidence can effectively guide public health policy and implementation of health programmes are not fully understood. Challenges to the use of evidence to inform policy and practice include the lack of a common understanding of what constitutes evidence and limited insight on the effectiveness of different research uptake activities. Available Knowledge Translation (KT) models have mainly been developed in high income countries and may not be directly applicable in resource-limited settings. In this study we examine the uptake of evidence in public health policy making in Uganda.

Methods

We conducted a cross-sectional qualitative study consisting of in-depth interviews with 17 purposively-selected health policy makers and researchers. The study explored respondents’ perceptions of the role of evidence in public health policy development, their understanding of KT and their views on the appropriateness of different KT activities that are currently implemented in Uganda.

Results

Although all respondents stated that evidence should inform health policies and programmes, they noted that this occurred infrequently. We noted a lack of conceptual clarity about KT and what precisely constitutes evidence. Respondents reported having been involved in different KT activities, including partnerships and platforms created for knowledge sharing between researchers and end users, but with very mixed results.

Conclusion

There is need for conceptual clarity on the notion of KT and an understanding of the most appropriate KT strategies in low-income settings.