1
|
Bullock HL, Lavis JN, Mulvale G, Wilson MG. An examination of mental health policy implementation efforts and the intermediaries that support them in New Zealand, Canada and Sweden: a comparative case study. FRONTIERS IN HEALTH SERVICES 2024; 4:1371207. [PMID: 39234210 PMCID: PMC11371757 DOI: 10.3389/frhs.2024.1371207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 07/11/2024] [Indexed: 09/06/2024]
Abstract
Introduction The implementation of evidence-informed policies and practices across systems is a complex, multifaceted endeavor, often requiring the mobilization of multiple organizations from a range of contexts. In order to facilitate this process, policy makers, innovation developers and service deliverers are increasingly calling upon intermediaries to support implementation, yet relatively little is known about precisely how they contribute to implementation. This study examines the role of intermediaries supporting the implementation of evidence-informed policies and practices in the mental health and addictions systems of New Zealand, Ontario, Canada and Sweden. Methods Using a comparative case study methodology and taking an integrated knowledge translation approach, we drew from established explanatory frameworks and implementation theory to address three questions: (1) Why were the intermediaries established? (2) How are intermediaries structured and what strategies do they use in systems to support the implementation of policy directions? and (3) What explains the lack of use of particular strategies? Data collection included three site visits, 49 key informant interviews and document analysis. Results In each jurisdiction, a unique set of problems (e.g., negative events involving people with mental illness), policies (e.g., feedback on effectiveness of existing policies) and political events (e.g., changes in government) were coupled by a policy entrepreneur to bring intermediaries onto the decision agenda. While intermediaries varied greatly in their structure and characteristics, both the strategies they used and the strategies they didn't use were surprisingly similar. Specifically it was notable that none of the intermediaries used strategies that directly targeted the public, nor used audit and feedback. This emerged as the principle policy puzzle. Our analysis identified five reasons for these strategies not being employed: (1) their need to build/maintain healthy relationships with policy actors; (2) their need to build/maintain healthy relationships with service delivery system actors; (3) role differentiation with other system actors; (4) perceived lack of "fit" with the role of policy intermediaries; and (5) resource limitations that preclude intensive distributed (program-level) work. Conclusion Policy makers and implementers must consider capacity to support implementation, and our study identifies how intermediaries can be developed and harnessed to support the implementation process.
Collapse
Affiliation(s)
- Heather L Bullock
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada
- Waypoint Research Institute, Waypoint Centre for Mental Health Care, Penetanguishene, ON, Canada
| | - John N Lavis
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Gillian Mulvale
- DeGroote School of Business, McMaster University, Hamilton, ON, Canada
| | - Michael G Wilson
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada
| |
Collapse
|
2
|
Crane ME, Kendall PC, Chorpita BF, Sanders MR, Miller AR, Webster-Stratton C, McWilliam J, Beck JS, Ashen C, Embry DD, Pickering JA, Daleiden EL. The role of implementation organizations in scaling evidence-based psychosocial interventions. Implement Sci 2023; 18:24. [PMID: 37349845 PMCID: PMC10288683 DOI: 10.1186/s13012-023-01280-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 06/02/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND To bring evidence-based interventions (EBIs) to individuals with behavioral health needs, psychosocial interventions must be delivered at scale. Despite an increasing effort to implement effective treatments in communities, most individuals with mental health and behavioral problems do not receive EBIs. We posit that organizations that commercialize EBIs play an important role in disseminating EBIs, particularly in the USA. The behavioral health and implementation industry is growing, bringing the implementation field to an important inflection point: how to scale interventions to improve access while maintaining EBI effectiveness and minimizing inequities in access to psychosocial intervention. MAIN BODY We offer a first-hand examination of five illustrative organizations specializing in EBI implementation: Beck Institute for Cognitive Behavioral Therapy; Incredible Years, Inc.; the PAXIS Institute; PracticeWise, LLC; and Triple P International. We use the Five Stages of Small Business Growth framework to organize themes. We discuss practical structures (e.g., corporate structures, intellectual property agreements, and business models) and considerations that arise when trying to scale EBIs including balancing fidelity and reach of the intervention. Business models consider who will pay for EBI implementation and allow organizations to scale EBIs. CONCLUSION We propose research questions to guide scaling: understanding the level of fidelity needed to maintain efficacy, optimizing training outcomes, and researching business models to enable organizations to scale EBIs.
Collapse
Affiliation(s)
- Margaret E Crane
- Department of Psychology, Temple University, Weiss Hall, 1701 N 13th St, Philadelphia, PA, 19122, USA.
- Department of Psychiatry, New York Presbyterian-Weill Cornell Medicine, 425 E 61st St, New York, NY, 10065, USA.
| | - Philip C Kendall
- Department of Psychology, Temple University, Weiss Hall, 1701 N 13th St, Philadelphia, PA, 19122, USA.
| | - Bruce F Chorpita
- Department of Psychology, University of California Los Angeles, 502 Portola Plaza, Los Angeles, CA, 90095, USA
- PracticeWise, LLC, 410 Coach Rd, Satellite Beach, FL, 32937, USA
| | - Matthew R Sanders
- Parenting and Family Support Centre, School of Psychology, The University of Queensland, St Lucia, QLD, 4067, Australia
| | - Allen R Miller
- Beck Institute for Cognitive Behavior Therapy, 1 Belmont Ave #700, Bala Cynwyd, PA, 19004, USA
| | | | - Jenna McWilliam
- Triple P International, 11 Market St N, Indooroopilly, QLD, 4068, Australia
| | - Judith S Beck
- Beck Institute for Cognitive Behavior Therapy, 1 Belmont Ave #700, Bala Cynwyd, PA, 19004, USA
| | - Ceth Ashen
- C. Ashen Consulting, 222 North Canon Dr. Ste 205, Beverly Hills, CA, 90210, USA
| | | | | | - Eric L Daleiden
- PracticeWise, LLC, 410 Coach Rd, Satellite Beach, FL, 32937, USA
| |
Collapse
|
3
|
Chen SP, Chang WP, Fleet B, Rai S, Panteluk S, Choy A, Hunter D. Is a Forensic Cohabitation Program Recovery-Oriented? A Logic Model Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 19:9. [PMID: 35010267 PMCID: PMC8751001 DOI: 10.3390/ijerph19010009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Recovery orientation is a movement in mental health practice. Although general mental health services have taken the lead in promoting recovery, forensic psychiatric systems have lagged behind because of the need to reconcile recovery principles with the complexities of legal mandates. Advocating recovery and making systemic changes can be challenging because they require seeking a balance between the competing duties to the patient and the public. This paper used a logic model framework to demonstrate a cohabitation program that placed a woman and her newborn infant in a secure forensic rehabilitation unit, and analyzed the key assumptions of recovery upon which it was based. METHODS This was a qualitative program evaluation. Data collection involved individual interviews with the woman, the infant's father, five primary healthcare providers, and five system administrators, and 11 focus groups with unit staff and other patients. Content analysis was used to guide the data analysis and develop the critical components of the program logic model. RESULTS A logic model that consists of input (team building, program planning, staff and patient preparation, resource management), output (logistic activities, risk management, mental healthcare, staff/other patient support, discharge preparation), and outcome (individual, provider, system, and society) components was developed. CONCLUSIONS This study demonstrates a recovery-oriented program for a woman cohabitating with her baby in a secure forensic psychiatric rehabilitation unit. The logic model provided a comprehensive understanding of the way the recovery principles, such as shared decision-making, positive risk-taking, informed choices, and relational security, were implemented.
Collapse
Affiliation(s)
- Shu-Ping Chen
- Department of Occupational Therapy, Faculty of Rehabilitation Medicine, College of Health Sciences, University of Alberta, Edmonton, AB T6G 2G4, Canada
| | - Wen-Pin Chang
- Stepping Stones Behavioral Solutions, LLC, Indianapolis, IN 46205, USA;
| | - Bryan Fleet
- Alberta Hospital Edmonton, Edmonton, AB T5Y 6A8, Canada; (B.F.); (S.R.); (S.P.); (A.C.); (D.H.)
| | - Santoch Rai
- Alberta Hospital Edmonton, Edmonton, AB T5Y 6A8, Canada; (B.F.); (S.R.); (S.P.); (A.C.); (D.H.)
| | - Steve Panteluk
- Alberta Hospital Edmonton, Edmonton, AB T5Y 6A8, Canada; (B.F.); (S.R.); (S.P.); (A.C.); (D.H.)
| | - Alberto Choy
- Alberta Hospital Edmonton, Edmonton, AB T5Y 6A8, Canada; (B.F.); (S.R.); (S.P.); (A.C.); (D.H.)
| | - DeAnn Hunter
- Alberta Hospital Edmonton, Edmonton, AB T5Y 6A8, Canada; (B.F.); (S.R.); (S.P.); (A.C.); (D.H.)
| |
Collapse
|
4
|
Lindholm LH, Laitila M, Lassila A, Kampman O. Importance of congruence between communicating and executing implementation programmes: a qualitative study of focus group interviews. Implement Sci Commun 2020; 1:94. [PMID: 33292835 PMCID: PMC7594330 DOI: 10.1186/s43058-020-00090-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 10/19/2020] [Indexed: 11/29/2022] Open
Abstract
Background The Ostrobothnia Depression Programme (ODP) in Finland was intended to implement two evidence-based brief psychotherapy interventions, namely motivational interview and behavioural activation, in several regional psychiatric teams. A simultaneous effectiveness study was conducted. Considerable tension was encountered between these two arms, causing resistance to change. We conducted a qualitative case study to better understand this tension and to discuss how managerial and executive practices may ensure the successful running of a hybrid design programme. Methods We conducted focus group interviews to evaluate the phases of preparation and practical execution of the ODP from the perspectives of management and the programme executives. To gather the data, we applied the revised Socratic approach for health technology assessment and focus group interviews. We analysed the data deductively according to the Normalization Process Theory. Results We identified two main critical issues: (1) The ODP programme plan ignored the team leaders’ crucial role in influencing the implementation climate and mobilizing organizational strategies. The ODP had a simplistic top-down design with minimal and delayed collaboration with its target groups in the preparation phase. (2) Incongruence occurred between what the project group had explicitly communicated about being the spearhead of the ODP and what they then actually enacted. These two issues caused tension between the implementation efforts and the effectiveness study as well as resistance to change among the staff. Conclusion Early, open collaboration with all prospective stakeholders towards a shared understanding about the programme is the first action the programme administrators should take. Agreement on goals and the means to achieve them would lower tension between the two arms of a hybrid design programme, thereby reducing resistance to change. Congruence between the goals communicated and the actual managerial and executive actions is of paramount importance in getting the programme recipients on board. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-020-00090-w.
Collapse
Affiliation(s)
- Lars H Lindholm
- Department of Psychiatry, South Ostrobothnia Hospital District, Hanneksenrinne 7, FI-60220, Seinäjoki, Finland. .,Faculty of Medicine and Health Technology, Tampere University, PO Box 100, FI-33014, Tampere, Finland.
| | - Minna Laitila
- Department of Psychiatry, South Ostrobothnia Hospital District, Hanneksenrinne 7, FI-60220, Seinäjoki, Finland
| | - Antero Lassila
- Department of Psychiatry, South Ostrobothnia Hospital District, Hanneksenrinne 7, FI-60220, Seinäjoki, Finland
| | - Olli Kampman
- Department of Psychiatry, South Ostrobothnia Hospital District, Hanneksenrinne 7, FI-60220, Seinäjoki, Finland.,Faculty of Medicine and Health Technology, Tampere University, PO Box 100, FI-33014, Tampere, Finland.,Department of Psychiatry, Pirkanmaa Hospital District, PO Box 2000, FI-33521, Tampere, Finland
| |
Collapse
|
5
|
Hamza DM, Ross S, Oandasan I. Process and outcome evaluation of a CBME intervention guided by program theory. J Eval Clin Pract 2020; 26:1096-1104. [PMID: 31927788 PMCID: PMC7496603 DOI: 10.1111/jep.13344] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 12/13/2019] [Accepted: 12/16/2019] [Indexed: 11/27/2022]
Abstract
RATIONALE Competency-based medical education (CBME) has gained momentum as an improved training model, but literature on outcomes of CBME, including evaluation of implementation processes, is minimal. We present a case for the following: (a) the development of a program theory is essential prior to or in the initial stages of implementation of CBME; (b) the program theory should guide the strategies and methods for evaluation that will answer questions about anticipated and unintended outcomes; and (c) the iterative process of testing assumptions and hypotheses will lead to modifications to the program theory to inform best practices of implementing CBME. METHODS We use the Triple C Competency-based Curriculum as a worked example to illustrate how process and outcome evaluation, guided by a program theory, can lead to meaningful enhancement of CBME curriculum, assessment, and implementation strategies. Using a mixed methods design, the processes and outcomes of Triple C were explored through surveys, interviews, and historical document review, which captured the experiences of various stakeholders. FINDINGS The theory-led program evaluation process was able to identify areas that supported CBME implementation: the value of a strong nondirective national vertical core supporting the transformation in education, program autonomy, and adaptability to pre-existing local context. Areas in need of improvement included the need for ongoing support from College of Family Physicians of Canada (CFPC) and better planning for shifts in program leadership over time. CONCLUSIONS Deliberately pairing evaluation alongside change is an important activity and, when accomplished, yields valuable information from the experiences of those implementing and experiencing a program. Evaluation and the development of an updated program theory facilitate the introduction of new changes and theories that build on these findings, which also supports the desired goal of contributing toward cumulative science rather than "reinventing the wheel."
Collapse
Affiliation(s)
- Deena M. Hamza
- Postgraduate Medical EducationUniversity of AlbertaEdmontonAlbertaCanada
| | - Shelley Ross
- Department of Family MedicineUniversity of Alberta, EdmontonAlbertaCanada
| | - Ivy Oandasan
- Department of EducationCollege of Family Physicians of CanadaTorontoOntarioCanada
- Department of Family and Community MedicineUniversity of TorontoTorontoOntarioCanada
| |
Collapse
|
6
|
Mills T, Lawton R, Sheard L. Advancing complexity science in healthcare research: the logic of logic models. BMC Med Res Methodol 2019; 19:55. [PMID: 30871474 PMCID: PMC6419426 DOI: 10.1186/s12874-019-0701-4] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 03/03/2019] [Indexed: 12/31/2022] Open
Abstract
Background Logic models are commonly used in evaluations to represent the causal processes through which interventions produce outcomes, yet significant debate is currently taking place over whether they can describe complex interventions which adapt to context. This paper assesses the logic models used in healthcare research from a complexity perspective. A typology of existing logic models is proposed, as well as a formal methodology for deriving more flexible and dynamic logic models. Analysis Various logic model types were tested as part of an evaluation of a complex Patient Experience Toolkit (PET) intervention, developed and implemented through action research across six hospital wards/departments in the English NHS. Three dominant types of logic model were identified, each with certain strengths but ultimately unable to accurately capture the dynamics of PET. Hence, a fourth logic model type was developed to express how success hinges on the adaption of PET to its delivery settings. Aspects of the Promoting Action on Research Implementation in Health Services (PARIHS) model were incorporated into a traditional logic model structure to create a dynamic “type 4” logic model that can accommodate complex interventions taking on a different form in different settings. Conclusion Logic models can be used to model complex interventions that adapt to context but more flexible and dynamic models are required. An implication of this is that how logic models are used in healthcare research may have to change. Using logic models to forge consensus among stakeholders and/or provide precise guidance across different settings will be inappropriate in the case of complex interventions that adapt to context. Instead, logic models for complex interventions may be targeted at facilitators to enable them to prospectively assess the settings they will be working in and to develop context-sensitive facilitation strategies. Researchers should be clear as to why they are using a logic model and experiment with different models to ensure they have the correct type. Electronic supplementary material The online version of this article (10.1186/s12874-019-0701-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Thomas Mills
- Bradford Institute for Health Research, Temple Bank House, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, UK.
| | - Rebecca Lawton
- Bradford Institute for Health Research, Temple Bank House, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, UK
| | - Laura Sheard
- Bradford Institute for Health Research, Temple Bank House, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, UK
| |
Collapse
|
7
|
Harris C, Green S, Elshaug AG. Sustainability in Health care by Allocating Resources Effectively (SHARE) 10: operationalising disinvestment in a conceptual framework for resource allocation. BMC Health Serv Res 2017; 17:632. [PMID: 28886740 PMCID: PMC5590199 DOI: 10.1186/s12913-017-2506-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 08/03/2017] [Indexed: 11/15/2022] Open
Abstract
Background This is the tenth in a series of papers reporting a program of Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. After more than a decade of research, there is little published evidence of active and successful disinvestment. The paucity of frameworks, methods and tools is reported to be a factor in the lack of success. However there are clear and consistent messages in the literature that can be used to inform development of a framework for operationalising disinvestment. This paper, along with the conceptual review of disinvestment in Paper 9 of this series, aims to integrate the findings of the SHARE Program with the existing disinvestment literature to address the lack of information regarding systematic organisation-wide approaches to disinvestment at the local health service level. Discussion A framework for disinvestment in a local healthcare setting is proposed. Definitions for essential terms and key concepts underpinning the framework have been made explicit to address the lack of consistent terminology. Given the negative connotations of the word ‘disinvestment’ and the problems inherent in considering disinvestment in isolation, the basis for the proposed framework is ‘resource allocation’ to address the spectrum of decision-making from investment to disinvestment. The focus is positive: optimising healthcare, improving health outcomes, using resources effectively. The framework is based on three components: a program for decision-making, projects to implement decisions and evaluate outcomes, and research to understand and improve the program and project activities. The program consists of principles for decision-making and settings that provide opportunities to introduce systematic prompts and triggers to initiate disinvestment. The projects follow the steps in the disinvestment process. Potential methods and tools are presented, however the framework does not stipulate project design or conduct; allowing application of any theories, methods or tools at each step. Barriers are discussed and examples illustrating constituent elements are provided. Conclusions The framework can be employed at network, institutional, departmental, ward or committee level. It is proposed as an organisation-wide application, embedded within existing systems and processes, which can be responsive to needs and priorities at the level of implementation. It can be used in policy, management or clinical contexts. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2506-7) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Claire Harris
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia. .,Centre for Clinical Effectiveness, Monash Health, Melbourne, Victoria, Australia.
| | - Sally Green
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Adam G Elshaug
- Menzies Centre for Health Policy, Sydney School of Public Health, University of Sydney, Sydney, Australia.,Lown Institute, Brookline, Massachusetts, USA
| |
Collapse
|
8
|
The Triple P Implementation Framework: the Role of Purveyors in the Implementation and Sustainability of Evidence-Based Programs. PREVENTION SCIENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR PREVENTION RESEARCH 2016; 17:636-45. [DOI: 10.1007/s11121-016-0661-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|