A realist evaluation to identify contexts and mechanisms that enabled and hindered implementation and had an effect on sustainability of a lean intervention in pediatric healthcare

Strengthening public health systems during an emerging respiratory disease pandemic: A realist review

The recent outbreak of respiratory diseases such as COVID-19 has highlighted the need to strengthen public health systems to respond effectively to such crises. While previous research has identified various public health interventions for pandemics, there remains a significant gap in understanding which interventions can strengthen public health systems during emerging respiratory pandemics and under what conditions. To address this gap, we conducted a realist review to examine public health interventions during emerging respiratory disease pandemics, focusing on context, mechanisms, and outcomes. We conducted a literature search across PubMed, Scopus, ProQuest, and Web of Science for studies published since 2003. Finally, we analyzed and assessed the quality of 601 articles and analyzed 32 of them. This study emphasizes the importance of understanding the situational, structural, cultural, and environmental contexts that influence public health interventions within the six building blocks of public health systems. We have also identified the mechanisms of these interventions at the individual, organizational, and national levels for successful outcomes, such as improved access to health services, health equity, and effectiveness. This information is important for policymakers and practitioners who can use it to develop evidence-based strategies to strengthen public health systems during emerging respiratory disease pandemics. Our review introduced a new conceptual model to explore the interaction between context, interventions, mechanisms, and outcomes to strengthen public health systems. However, further research is needed to determine the effect of specific contextual factors on public health system interventions during respiratory disease pandemics.

Developing an initial explanatory theory for Partnering for Change using realist evaluation

INTRODUCTION

Partnering for Change (P4C) is an innovative practice model for school-based occupational therapy developed in Canada and informed by a program of research spanning nearly two decades. National and international interest in P4C necessitated development of an explanatory theory to guide implementation in varied contexts. The purpose of this study is to document the process of theory development and to provide an overview of the initial P4C explanatory theory.

METHODS

Realist evaluation was used to construct an initial explanatory theory of P4C drawing on P4C developers' conceptualisations of the model, document analysis, and analysis of transcripts from interviews and focus groups.

CONSUMER AND COMMUNITY INVOLVEMENT

No consumers were involved in the study design or analysis.

FINDINGS

Four sets of premises expressed as context-mechanism-outcome configurations (CMOCs) comprise the initial explanatory theory of P4C. An abstracted summary of these four sets along with contexts, mechanisms, and outcomes central to the P4C initial explanatory theory is presented. An exemplar CMOC is shared to illustrate how theoretical premises are developed and expressed using realist evaluation.

CONCLUSION

This study advances knowledge regarding the hypothesised core elements of P4C and provides an example of using realist evaluation to advance knowledge in occupational therapy. Preliminary implications for clinical practice are discussed.

PLAIN LANGUAGE SUMMARY

Partnering for Change (P4C) is a way of providing occupational therapy services in schools that helps all children to learn and participate successfully. P4C was created in Ontario, Canada, and has been researched for almost 20 years. People in different parts of Canada and other countries are interested in trying P4C. As the researchers who created P4C, we think there is a need to explain how it works so it can be used in different places. This study explains how we created a theory to describe P4C. To develop this theory, we used a method called realist evaluation that would help us explain how, why, and in what situations P4C works best. To do this, we analysed documents and transcripts of interviews and focus groups. Our findings are organised into four main ideas, each explained in terms of contexts (the situations), mechanisms (how and why P4C works), and outcomes (the impacts of P4C). One detailed example is given to show how these ideas were formed and work together. In conclusion, our study helps us understand the key parts of P4C and shows how realist evaluation can be used to improve knowledge in occupational therapy. The study also suggests some early ideas on how P4C can be used in practice.

Protocol for an interview-based method for mapping mental models using causal-loop diagramming and realist interviewing

Causal-loop diagramming, a method from system dynamics, is increasingly used in evaluation to describe individuals' understanding of how policies or programs do or could work ("mental models"). The use of qualitative interviews to inform model development is common, but guidance for how to design and conduct these interviews to elicit causal information in participant mental models is scant. A key strength of semi-structured qualitative interviews is that they let participants speak freely; they are not, however, designed to elicit causal information. Moreover, much of human communication about mental models-particularly larger causal structures such as feedback loops-is implicit. In qualitative research, part of the skill and art of effective interviewing and analysis involves listening for information that is expressed implicitly. Similarly, a skilled facilitator can recognize and inquire about implied causal structures, as is commonly done in group model building. To standardize and make accessible these approaches, we have formalized a protocol for designing and conducting semi-structured interviews tailored to eliciting mental models using causal-loop diagramming. We build on qualitative research methods, system dynamics, and realist interviewing. This novel, integrative method is designed to increase transparency and rigor in the use of interviews for system dynamics and has a variety of potential applications.

Planning Individual and Population-Based Interventions in Global Health: Applying the DEA-A Framework to Promote Behavioral, Emotional, and/or Cognitive Change among Stakeholders

Addressing health challenges that impact human well-being requires a comprehensive, interdisciplinary approach that would be at the crossroad of population-based prevention and individual-level clinical care, which is in line with a Global Health perspective. In the absence of a unifying theoretical framework to guide such interventions, a Dynamic Ecosystem Adaptation through the Allostasis (DEA-A) framework has been proposed, emphasizing the functional adaptation of individuals and organizations in symbiosis with their living ecosystem. While a conceptual model has been presented, this methodological contribution aims at illustrating the practical application of the DEA-A framework for planning Global Health interventions. The methodology combines Intervention Mapping and Cognitive and Behavioral Theory, extended to the ecosystem. Practical guidelines and supporting tools are provided to help public health providers and clinicians in establishing a functional ecosystem diagnosis of the issue; defining not only behavioral, but also emotional and cognitive change objectives (allostasis targets) expected for each stakeholder; and designing intervention plans targeting determinants of these allostasis. The discussion addresses implementation and evaluation perspectives of interventions based on the DEA-A framework, emphasizing the importance of considering change in its processual and ecosystem complexity. Lastly, encouragements for a deeper understanding of individual and ecosystem homeostasis/allostasis processes are made in order to promote more functional interventions.

Implementing Clinical Guidelines for the Treatment of Psychosis: The Frontline Leaders' Point of View. A Qualitative Study

Background

Despite the large amount of leadership and implementation theories and recommendations, healthcare services continue to struggle with efficiently incorporating new knowledge. The questioning of conventional leadership approaches in healthcare organizations prompted us to investigate how frontline leaders comprehend their own implementation intentions and actions, and how these intentions and actions may impact the implementation of clinical guidelines in mental healthcare in Norway.

Methods

Employing a theory-driven qualitative design, we conducted nine semi-structured interviews with frontline leaders who had recently led implementation of clinical guidelines for the treatment of psychosis in mental health. We employed Systematic Text Condensation, informed by Normalization Process Theory, to structure and analyze the data and used fidelity scales to measure the degree of implementation and distinguish between leaders' levels of success in implementation.

Results

Frontline leaders in units that achieved high success in implementation described their intentions and actions differently, from those with less success. The former group's actions aligned more closely with the constructs of the Normalization Process Theory compared to the latter group when describing their actions. Frontline leaders leading units with a high degree of implementation success describe relation-orientation, trust, and providing adaptive space for staff members to take initiative. In contrast, those leading units with less implementation success describe more control and guidance of co-operators and place more emphasize on information and knowledge.

Conclusion

Differences in how frontline leaders describe their actions and intentions to achieve clinical guideline implementation suggest that the leadership approach of these frontline leaders is an important factor to consider when planning and conducting implementation. To better understand the implementation process, it is important to pay attention to how frontline leaders customize their leadership approaches to the dynamics of complex organizations, and how they interact with their team and superiors.

The usage of data in NHS primary care commissioning: a realist evaluation

BACKGROUND

To improve health outcomes and address mounting costs pressures, policy-makers have encouraged primary care commissioners in the British National Health Service (NHS) to increase the usage of data in decision-making. However, there exists limited research on this topic. In this study, we aimed to understand how and why primary care commissioners use data (i.e. quantitative, statistical information) to inform commissioning, and what outcomes this leads to.

METHODS

A realist evaluation was completed to create context-mechanism-outcome configurations (CMOs) relating to the contexts influencing the usage of data in primary care commissioning. Using a realist logic of analysis and drawing on substantive theories, we analysed qualitative content from 30 interviews and 51 meetings (51 recordings and 19 accompanying meeting minutes) to develop CMOs. Purposive sampling was used to recruit interviewees from diverse backgrounds.

RESULTS

Thirty-five CMOs were formed, resulting in an overarching realist programme theory. Thirteen CMOs were identical and 3 were truncated versions of those formed in an existing realist synthesis on the same topic. Seven entirely new CMOs, and 12 refined and enhanced CMOs vis-à-vis the synthesis were created. The findings included CMOs containing contexts which facilitated the usage of data, including the presence of a data champion and commissioners' perceptions that external providers offered new skillsets and types of data. Other CMOs included contexts presenting barriers to using data, such as data not being presented in an interoperable way with consistent definitions, or financial pressures inhibiting commissioners' abilities to make evidence-based decisions.

CONCLUSIONS

Commissioners are enthusiastic about using data as a source of information, a tool to stimulate improvements, and a warrant for decision-making. However, they also face considerable challenges when using them. There are replicable contexts available to facilitate commissioners' usage of data, which we used to inform policy recommendations. The findings of this study and our recommendations are pertinent in light of governments' increasing commitment to data-driven commissioning and health policy-making.

Connecting the science and practice of implementation - applying the lens of context to inform study design in implementation research

The saying "horses for courses" refers to the idea that different people and things possess different skills or qualities that are appropriate in different situations. In this paper, we apply the analogy of "horses for courses" to stimulate a debate about how and why we need to get better at selecting appropriate implementation research methods that take account of the context in which implementation occurs. To ensure that implementation research achieves its intended purpose of enhancing the uptake of research-informed evidence in policy and practice, we start from a position that implementation research should be explicitly connected to implementation practice. Building on our collective experience as implementation researchers, implementation practitioners (users of implementation research), implementation facilitators and implementation educators and subsequent deliberations with an international, inter-disciplinary group involved in practising and studying implementation, we present a discussion paper with practical suggestions that aim to inform more practice-relevant implementation research.

Understanding the implementation of health checks in the prevention and early detection of chronic diseases among Aboriginal and Torres Strait Islander people in Australia: a realist review protocol

INTRODUCTION

Chronic disease remains the leading cause of morbidity and mortality among Aboriginal and Torres Strait Islander peoples in Australia. Regular structured, comprehensive health assessments are available to Aboriginal and Torres Strait Islander people as annual health checks funded through the Medicare Benefits Schedule. This realist review aims to identify context-specific enablers and tensions and contribute to developing an evidence framework to guide the implementation of health checks in the prevention and early detection of chronic diseases for Aboriginal and Torres Strait Islander people.

METHODS AND ANALYSIS

The review will involve the following steps: (1) Aboriginal and Torres Strait Islander engagement and research governance; (2) defining the scope of the review; (3) search strategy; (4) screening, study selection and appraisal; (5) data extraction and organisation of evidence; (6) data synthesis and drawing conclusions. This realist review will follow the Realist and MEta-narrative Evidence Syntheses: Evolving Standards guidance and will be reported as set up by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols statement. The realist programme theory will be developed through a literature review using multiple database searches from 1 November 1999 to 31 June 2022, limited to the English language, and stakeholder consultation, which will be refined throughout the review process. The study findings will be reported by applying the context-mechanism-outcome configuration to gain a deeper understanding of context and underlying mechanisms that influence the implementation of health checks in the prevention and early detection of chronic diseases among Aboriginal and Torres Strait Islander people in Australia.

ETHICS AND DISSEMINATION

Ethical approval is not required as this review will be using secondary data. Findings will be published in a peer-reviewed journal and presented at scientific conferences.

SYSTEMATIC REVIEW REGISTRATION

The review protocol has been registered on the international prospective register of systematic reviews: CRD42022326697.

Meta-evaluation of a whole systems programme, ActEarly: A study protocol

INTRODUCTION

Living in an area with high levels of child poverty predisposes children to poorer mental and physical health. ActEarly is a 5-year research programme that comprises a large number of interventions (>20) with citizen science and co-production embedded. It aims to improve the health and well-being of children and families living in two areas of the UK with high levels of deprivation; Bradford in West Yorkshire, and the London Borough of Tower Hamlets. This protocol outlines the meta-evaluation (an evaluation of evaluations) of the ActEarly programme from a systems perspective, where individual interventions are viewed as events in the wider policy system across the two geographical areas. It includes investigating the programme's impact on early life health and well-being outcomes, interdisciplinary prevention research collaboration and capacity building, and local and national decision making.

METHODS

The ActEarly meta-evaluation will follow and adapt the five iterative stages of the 'Evaluation of Programmes in Complex Adaptive Systems' (ENCOMPASS) framework for evaluation of public health programmes in complex adaptive systems. Theory-based and mixed-methods approaches will be used to investigate the fidelity of the ActEarly research programme, and whether, why and how ActEarly contributes to changes in the policy system, and whether alternative explanations can be ruled out. Ripple effects and systems mapping will be used to explore the relationships between interventions and their outcomes, and the degree to which the ActEarly programme encouraged interdisciplinary and prevention research collaboration as intended. A computer simulation model ("LifeSim") will also be used to evaluate the scale of the potential long-term benefits of cross-sectoral action to tackle the financial, educational and health disadvantages faced by children in Bradford and Tower Hamlets. Together, these approaches will be used to evaluate ActEarly's dynamic programme outputs at different system levels and measure the programme's system changes on early life health and well-being.

DISCUSSION

This meta-evaluation protocol presents our plans for using and adapting the ENCOMPASS framework to evaluate the system-wide impact of the early life health and well-being programme, ActEarly. Due to the collaborative and non-linear nature of the work, we reserve the option to change and query some of our evaluation choices based on the feedback we receive from stakeholders to ensure that our evaluation remains relevant and fit for purpose.

Enhanced Peer-Group strategies to support prevention of Mother-to-Child HIV transmission leads to increased retention in care in Uganda: A Randomized controlled trial

Introduction

Despite scale up of Option B+, long-term retention of women in HIV care during pregnancy and the postpartum period remains an important challenge. We compared adherence to clinic appointments and antiretroviral therapy (ART) at different follow-up time points between enrolment and 24 months postpartum among pregnant women living with HIV and initiating Option B+ randomized to a peer group support, community-based drug distribution and income-generating intervention called "Friends for Life Circles" (FLCs) versus the standard of care (SOC).

Methods

Between 16 May 2016 and 12 September 2017, 540 ART-naïve pregnant women living with HIV at urban and rural health facilities in Uganda were enrolled in the study. Participants were randomized 1:1 to the FLC intervention or SOC and assessed for adherence to prevention of mother to child HIV transmission (PMTCT) clinic appointments at 6 weeks, 12 and 24 months postpartum, self-reported adherence to ART at 6 weeks, 6 and 24 months postpartum validated by plasma HIV-1 RNA viral load (VL) measured at the same time points, and HIV status and HIV-free survival of infants at 18 months postpartum. We used Log-rank and Chi-Square p-values to test the equality of Kaplan-Meier survival probabilities and hazard rates (HR) for failure to retain in care for any reason by study arm.

Results

There was no significant difference in adherence to PMTCT clinic visits or to ART or in median viral loads between FLC and SOC arms at any follow-up time points. Retention in care through the end of study was high in both arms but significantly higher among participants randomized to FLC (86.7%) compared to SOC (79.3%), p=0.022. The adjusted HR of visit dropout was 2.5 times greater among participants randomized to SOC compared to FLC (aHR=2.498, 95% CI: 1.417 - 4.406, p=0.002). Median VL remained < 400 copies/ml in both arms at 6 weeks, 6 and 24 months postpartum.

Conclusions

Our findings suggest that programmatic interventions that provide group support, community based ART distribution and income-generation activities may contribute to retention in PMTCT care, HIV-free survival of children born to women living with HIV, and to the elimination of mother to child HIV transmission (MTCT).

Sustaining improvement of hospital-wide initiative for patient safety and quality: a systematic scoping review

BACKGROUND

Long-term sustained improvement following implementation of hospital-wide quality and safety initiatives is not easily achieved. Comprehensive theoretical and practical understanding of how gained improvements can be sustained to benefit safe and high-quality care is needed. This review aimed to identify enabling and hindering factors and their contributions to improvement sustainability from hospital-wide change to enhance patient safety and quality.

METHODS

A systematic scoping review method was used. Searched were peer-reviewed published records on PubMed, Scopus, World of Science, CINAHL, Health Business Elite, Health Policy Reference Centre and Cochrane Library and grey literature. Review inclusion criteria included contemporary (2010 and onwards), empirical factors to improvement sustainability evaluated after the active implementation, hospital(s) based in the western Organisation for Economic Co-operation and Development countries. Numerical and thematic analyses were undertaken.

RESULTS

17 peer-reviewed papers were reviewed. Improvement and implementation approaches were predominantly adopted to guide change. Less than 6 in 10 (53%) of reviewed papers included a guiding framework/model, none with a demonstrated focus on improvement sustainability. With an evaluation time point of 4.3 years on average, 62 factors to improvement sustainability were identified and emerged into three overarching themes: People, Process and Organisational Environment. These entailed, as subthemes, actors and their roles; planning, execution and maintenance of change; and internal contexts that enabled sustainability. Well-coordinated change delivery, customised local integration and continued change effort were three most critical elements. Mechanisms between identified factors emerged in the forms of Influence and Action towards sustained improvement.

CONCLUSIONS

The findings map contemporary empirical factors and their mechanisms towards change sustainability from a hospital-wide initiative to improve patient safety and quality. The identified factors and mechanisms extend current theoretical and empirical knowledgebases of sustaining improvement particularly with those beyond the active implementation. The provided conceptual framework offers an empirically evidenced and actionable guide to assist sustainable organisational change in hospital settings.

HIV advocacy: knowledge translation and implementation at three diverse sites in sub-Saharan Africa

PURPOSE

To explore how the gap in knowledge translation around HIV and rehabilitation could be addressed using advocacy. This article describes and reflects on lessons learned from incorporating content on HIV and advocacy into the curricula at three diverse physiotherapy (PT) programs in sub-Saharan Africa.

METHODS

A realistic evaluation approach was followed. Three study sites were purposively chosen to reflect diverse settings with respect to pedagogical approach, university or college, degree or diploma programs, use of technology, and regional prevalence of HIV. A multi-faceted intervention was implemented that included three activities: (i) to develop three core components of a novel knowledge translation intervention designed to improve knowledge, attitudes, and self-efficacy in HIV and rehabilitation advocacy among PT students; (ii) to tailor and implement the knowledge translation intervention by local faculty according to the context and needs of their program and to implement this with a cohort of PT students at each of the three study sites; and (iii) to evaluate the adaptation and implementation of the intervention at each site.

RESULTS

Differences exist between the three-country programmes, specifically in the length of time the degree takes, the extent of HIV inclusion in the curriculum and years of the study included in the project.

CONCLUSIONS

This research adds to the call to shift the focus of HIV care from just test-and-treat, or on just keeping people alive, towards a broader approach that centres the whole person, that focuses not only on surviving but on thriving, and which commits to the goal of optimising functioning and living full, whole lives with HIV. Advocacy across the continuum of care plays a pivotal role in translating research findings into practice.Implications for rehabilitationResults are relevant for policymakers in government and at senior levels within universities whose mandates include informing, reviewing, and driving educational programs and curricula.The result from this project illuminates the role for rehabilitation and allows for incorporating HIV into curriculum and practice for physiotherapists and other related stakeholders so that they can advocate for and with patients.

A Dog with an Office: The Process of Embedding a Wellness Dog Intervention in a University Setting

Universities are places to promote the wellbeing of people who learn, work, and live within them. This article reports on an innovative, holistic, and embedded wellness dog program that was developed by the Faculty of Nursing to support the wellbeing of students, faculty, and staff. The innovation included a collaborative partnership between two faculties (the faculties of Veterinary Medicine and Nursing), and the targeted purchase, training, and socialization of a wellness dog. Pet wellness programs have the potential to be an important mental health intervention on university campuses. While the program was postponed due to COVID-19, the purpose of this article is to share processes used to create the wellness dog program, with suggestions regarding implementation and evaluation.

Realist evaluation of the impact of the research translation process on health system sustainability: a study protocol

INTRODUCTION

Sustainability at a system level relates to the capacity of the system to be able to service the ongoing health needs of the population. It is a multifaceted concept encompassing both the affordability and efficiency of a system and the system's ability to adapt and change.To address issues that currently threaten health system sustainability, healthcare leaders, policy makers, clinicians and researchers are searching for solutions to ensure the delivery of safe, value-based care into the future. The timely translation of research evidence into sustainable interventions that can be adopted into the health system is one way of bolstering the sustainability of the system as a whole. We present a protocol for the realist evaluation of a research translation funding programme to understand how the research translation process contributes to health system sustainability and value-based healthcare.

METHODS AND ANALYSIS

Underpinned by the realist evaluation framework, we will: (1) Develop the Initial Program Theory (IPT) of the research translation process; (2) Test the program theory through case study analysis; and (3) Refine and consolidate the theory through stakeholder consultation. The evaluation uses a case example of a research translation programme, chosen for its representation of a microcosm of the broader health system and the heterogeneity of service improvement activities taking place within it. Across the three phases, analysis of data from documents about the research translation program and interviews and focus groups with stakeholders and program users will draw on the context (C), mechanism (M), outcome (O) formula that is core to realist evaluation. In addition, system dynamic methods will capture the feedback loops and complex relationships among the IPT and context-mechanism-outcome configurations. This approach to evaluation of a research translation funding programme may be adapted to similar programmes operating in other settings.

ETHICS AND DISSEMINATION

Curtin University Human Research Ethics Committee, Western Australia, approved this study (approval number: HRE2020-0464). Results will be published in scientific journals, and communicated to respondents and relevant partners.

Conceptualising contexts, mechanisms and outcomes for implementing large-scale, multisite hospital improvement initiatives: a realist synthesis

DESIGN

Realist synthesis.

STUDY BACKGROUND

Large-scale hospital improvement initiatives can standardise healthcare across multiple sites but results are contingent on the implementation strategies that complement them. The benefits of these implemented interventions are rarely able to be replicated in different contexts. Realist studies explore this phenomenon in depth by identifying underlying context-mechanism-outcome interactions.

OBJECTIVES

To review implementation strategies used in large-scale hospital initiatives and hypothesise initial programme theories for how they worked across different contexts.

METHODS

An iterative, four-step process was applied. Step 1 explored the concepts inherent in large-scale interventions using database searches and snowballing. Step 2 identified strategies used in their implementation. Step 3 identified potential initial programme theories that may explain strategies' mechanisms. Step 4 focused on one strategy-theory pairing to develop and test context-mechanism-outcome hypotheses. Data was drawn from searches (March-May 2020) of MEDLINE, Embase, PubMed and CINAHL, snowballed from key papers, implementation support websites and the expertise of the research team and experts.

INCLUSION CRITERIA

reported implementation of a large-scale, multisite hospital intervention. RAMESES reporting standards were followed.

RESULTS

Concepts were identified from 51 of 381 articles. Large-scale hospital interventions were characterised by a top-down approach, external and internal support and use of evidence-based interventions. We found 302 reports of 28 different implementation strategies from 31 reviews (from a total of 585). Formal theories proposed for the implementation strategies included Diffusion of Innovation, and Organisational Readiness Theory. Twenty-three context-mechanism-outcome statements for implementation strategies associated with planning and assessment activities were proposed. Evidence from the published literature supported the hypothesised programme theories and were consistent with Organisational Readiness Theory's tenets.

CONCLUSION

This paper adds to the literature exploring why large-scale hospital interventions are not always successfully implemented and suggests 24 causative mechanisms and contextual factors that may drive outcomes in the planning and assessment stage.

Influences of post-implementation factors on the sustainability, sustainment, and intra-organizational spread of complex interventions

Background

Complex interventions are increasingly applied to healthcare problems. Understanding of post-implementation sustainment, sustainability, and spread of interventions is limited. We examine these phenomena for a complex quality improvement initiative led by care aides in 7 care homes (long-term care homes) in Manitoba, Canada. We report on factors influencing these phenomena two years after implementation.

Methods

Data were collected in 2019 via small group interviews with unit- and care home-level managers (n = 11) from 6 of the 7 homes using the intervention. Interview participants discussed post-implementation factors that influenced continuing or abandoning core intervention elements (processes, behaviors) and key intervention benefits (outcomes, impact). Interviews were audio-recorded, transcribed verbatim, and analyzed with thematic analysis.

Results

Sustainment of core elements and sustainability of key benefits were observed in 5 of the 6 participating care homes. Intra-unit intervention spread occurred in 3 of 6 homes. Factors influencing sustainment, sustainability, and spread related to intervention teams, unit and care home, and the long-term care system.

Conclusions

Our findings contribute understanding on the importance of micro-, meso-, and macro-level factors to sustainability of key benefits and sustainment of some core processes. Inter-unit spread relates exclusively to meso-level factors of observability and practice change institutionalization. Interventions should be developed with post-implementation sustainability in mind and measures taken to protect against influences such as workforce instability and competing internal and external demands. Design should anticipate need to adapt interventions to strengthen post-implementation traction.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08026-x.

Sustainment of a Complex Culturally Competent Care Intervention for Hispanic Living Donor Kidney Transplantation: A Longitudinal Analysis of Adaptations

Introduction:

Sustainment refers to continued intervention delivery over time, while continuing to produce intended outcomes, often with ongoing adaptations, which are purposeful changes to the design or delivery of an intervention to improve its fit or effectiveness. The Hispanic Kidney Transplant Program (HKTP), a complex, culturally competent intervention, was implemented in two transplant programs to reduce disparities in Hispanic/Latinx living donor kidney transplant rates. This study longitudinally examined the influence of adaptations on HKTP sustainment.

Methods:

Qualitative interviews, learning collaborative calls, and telephone meetings with physicians, administrators, and staff (n = 55) were conducted over three years of implementation to identify HKTP adaptations. The Framework for Reporting Adaptations and Modifications-Expanded was used to classify adaptation types and frequency, which were compared across sites over time.

Results:

Across sites, more adaptations were made in the first year (n = 47), then fell and plateaued in the two remaining years (n = 35). Adaptations at Site-A were consistent across years (2017: n = 18, 2018: n = 17, 2019: n = 14), while Site-B made considerably fewer adaptations after the first year (2017: n = 29, 2018: n = 18, 2019: n = 21). Both sites proportionally made mostly skipping (32%), adding (20%), tweaking (20%), and substituting (16%) adaptation types. Skipping- and substituting-type adaptations were made due to institutional structural characteristics and lack of available resources, respectively. However, Site-A’s greater proportion of skipping-type adaptations was attributed to greater system complexity, and Site-B’s greater proportion of adding-type adaptation was attributed to the egalitarian team-based culture.

Conclusion:

Our findings can help prepare implementers to expect certain context-specific adaptations and preemptively avoid those that hinder sustainment.

Resilience in advanced cancer caregiving. A systematic review and meta-synthesis

BACKGROUND

Close relatives provide much of the care to people with cancer. As resilience can shield family caregivers from mental health problems, there has been a burgeoning interest in resilience-promoting interventions. However, the evidence necessary for the development of these interventions is scant and unsynthesized.

AIM

To create an overall picture of evidence on resilience in cancer caregiving by a theory-driven meta-synthesis.

DESIGN

In this systematically constructed review a thematic synthesis approach has been applied. The original findings were coded and structured deductively according to the theoretical framework. Consequently, the codes were organized inductively into themes and subthemes.

DATA SOURCES

Through September 2019, five electronic databases were searched for qualitative studies on resilience in cancer caregiving. The search was extended by a supplementary hand search. Seventeen studies met the eligibility criteria.

RESULTS

The elements of resilience, as described in the pre-defined theoretical framework of Bonanno, are reflected in the lived experiences of family caregivers. The resilience process starts with the diagnosis of advanced cancer and may result in mental wellbeing, benefit finding, and personal growth. The process is influenced by context elements such as individual history, sociocultural background, caregiver characteristics, and the behavior of the supportive network. A repertoire of coping strategies that caregivers use throughout the caregiving process moderates the resilience process.

CONCLUSION

This review and theoretical synthesis reveal key elements of resilience in the process of cancer caregiving, including influencing factors and outcomes. Implications and avenues for further research are discussed.

Better safe than sorry: Evaluating the implementation process of a home-visitation intervention aimed at preventing unintentional childhood injuries in the hospital setting

Background

Child home injuries prevention interventions have rarely been implemented in hospitals. The SHABI program ("Keeping our Children Safe"; in Hebrew: "SHomrim Al BetIchut Yeladenu") recruits at-risk families arriving with child injury to the Emergency Department. Medical/nursing students conduct two home visits four months apart, providing safety equipment and guidance. One hundred thirty-five families had a first visit and 98 completed the second. Fifty percentage of families were ultra-Orthodox Jews, 11% Arab, and 28% had ≥3 preschool children. We investigated SHABI's implementation using the Consolidated Framework for Implementation Research (CFIR).

Methods

Between May 2018 and March 2021 SHABI was implemented in the Emergency Department of a hospital in Israel's northern periphery, an area with high child injury rates. The Implementation process was examined through Emergency Department medical records and tracking registries, hospital management, nurses', and home visitors' meetings notes (n = 9), and a research diary. Hospital's inner setting and SHABI's characteristics were evaluated through interviews with hospital management, nurses, and home visitors 8 months after baseline (n = 18). Home visitors' characteristics were evaluated through interviews, post-visit questionnaire on challenges encountered (n = 233), families' perceptions of SHABI and home visitors' skills through telephone interviews (n = 212); and home visitors awareness of dangers at home (n = 8) baseline and 8 months later. Qualitative data were analyzed through explanatory content analysis according to CFIR constructs. Quantitative data were analyzed using X2 and Wilcoxon test for dependent subgroups.

Results

Despite alignment between SHABI and the hospital's mission, structural hospital-community disconnect prevented implementation as planned, requiring adaptation and collaboration with the medical school to overcome this barrier. Recruitment was included in the initial patient triage process but was only partially successful. Medical/nursing students were recruited as home visitors, and following training proved competent. Children were a distraction during the visits, but home visitors developed strategies to overcome this.

Conclusions

Injury prevention programs in hospitals have significant benefits. Identifying implementation barriers and facilitators allowed implementers to make adaptations and cope with the innovative implementation setting. Models of cooperation between hospital, community and other clinical settings should be further examined.

Contextual factors and mechanisms that influence sustainability: a realist evaluation of two scaled, multi-component interventions

Background

In 2012, Alberta Health Services created Strategic Clinical Networks^TM (SCNs) to develop and implement evidence-informed, clinician-led and team-delivered health system improvement in Alberta, Canada. SCNs have had several provincial successes in improving health outcomes. Little research has been done on the sustainability of these evidence-based implementation efforts.

Methods

We conducted a qualitative realist evaluation using a case study approach to identify and explain the contextual factors and mechanisms perceived to influence the sustainability of two provincial SCN evidence-based interventions, a delirium intervention for Critical Care and an Appropriate Use of Antipsychotics (AUA) intervention for Senior’s Health. The context (C) + mechanism (M) = outcome (O) configurations (CMOcs) heuristic guided our research.

Results

We conducted thirty realist interviews in two cases and found four important strategies that facilitated sustainability: Learning collaboratives, audit & feedback, the informal leadership role, and patient stories. These strategies triggered certain mechanisms such as sense-making, understanding value and impact of the intervention, empowerment, and motivation that increased the likelihood of sustainability. For example, informal leaders were often hands-on and influential to front-line staff. Learning collaboratives broke down professional and organizational silos and encouraged collective sharing and learning, motivating participants to continue with the intervention. Continual audit-feedback interventions motivated participants to want to perform and improve on a long-term basis, increasing the likelihood of sustainability of the two multi-component interventions. Patient stories demonstrated the interventions’ impact on patient outcomes, motivating staff to want to continue doing the intervention, and increasing the likelihood of its sustainability.

Conclusions

This research contributes to the field of implementation science, providing evidence on key strategies for sustainability and the underlying causal mechanisms of these strategies that increases the likelihood of sustainability. Identifying causal mechanisms provides evidence on the processes by which implementation strategies operate and lead to sustainability. Future work is needed to evaluate the impact of informal leadership, learning collaboratives, audit-feedback, and patient stories as strategies for sustainability, to generate better guidance on planning sustainable improvements with long term impact.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07214-5.

Effects of a workplace exercise intervention on cardiometabolic health: study protocol for a randomised controlled trial

INTRODUCTION

The worldwide rising levels of physical inactivity especially in the United Arab Emirates (UAE) and the Eastern Mediterranean region are alarming. The UAE reports one of the highest rates of non-communicable disease mortality and insufficient physical activity (PA) is a major underlying cause. Therefore, action is required to reduce physical inactivity using evidence-based strategies. This study aimed to evaluate the efficacy of a worksite exercise intervention on cardiometabolic health in the UAE.

METHODS AND ANALYSIS

This is a protocol for a pragmatic parallel randomised controlled trial with a 1:1 allocation ratio to the intervention group and delayed intervention group. A total of 150 participants will be recruited from a semigovernment telecommunications company in Dubai (UAE) after meeting the eligibility criteria. The intervention group will receive 2 hours of exercise per week during working hours for 12 weeks (maximum 1 hour/day). The intervention group will be assigned to attend personal trainer sessions in the workplace gym throughout the intervention period. After the intervention is completed, the delayed intervention group will also receive 2 hours of exercise time per week from working hours for 4 weeks. The main outcome measure is the change in the cardiometabolic risk components, that is, systolic or diastolic blood pressure, waist circumference, glycated haemoglobin, fasting plasma glucose, low-density lipoprotein cholesterol from baseline to the end of the intervention. The secondary outcome is to examine whether the workplace exercise intervention improves PA levels 4 weeks postintervention.

ETHICS AND DISSEMINATION

The study has been approved by the Dubai Scientific Research Ethics Committee (DSREC-SR-08/2019_02). The results will be disseminated as follows: at various national and international scientific conferences; as part of a PhD thesis in Public Health at the College of Medicine and Health Sciences, UAE University; and in a manuscript submitted to a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT04403789.

A qualitative study of evidence-based therapeutic process in mental health services in Ghana- context-mechanisms-outcomes

Background

Evidence-based clinical practice is an inherent component of mental health professional practice in developed countries. However, little is known about professional perspectives of evidence-based practice in mental in developing countries such as Ghana. This paper describes the processes involved in the delivery of best practice in Ghana. The paper reports on a realistic evaluation of mental health nurses and allied health professionals’ views on the evidence-based therapeutic process in Ghana.

Methods

A purposive sample of 30 mental health professionals (MHPs) was recruited to participate in semi-structured, in-depth interviews. Thematic analysis was used to analyse the data. A program theory of Context + Mechanism = Outcome (CMO) configuration was developed from the analysis.

Results

The thematic analysis identified two contexts, mechanism and outcome configurations (themes): 1) technical competency stimulates evidence-based mental health services, and 2) therapeutic relationship building ensures effective interaction. The study demonstrates that contextual factors (technical competencies and therapeutic relationship building) together with mechanisms (intentional and unintentional) help to promote quality in mental health service provision. However, contextual factors such as a lack of sign language interpreters yielded unintended outcomes including barriers to communication with providers for consumers with hearing impairment and those from linguistic minority backgrounds.

Conclusion

Government stakeholders and policymakers should prioritise policies, periodic monitoring and adequate financial incentives to support the mechanisms that promote technical competence in MHPs and the building of therapeutic relationship.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06993-1.

Determining the skills needed by frontline NHS staff to deliver quality improvement: findings from six case studies

Background

Previous studies have detailed the technical, learning and soft skills healthcare staff deploy to deliver quality improvement (QI). However, research has mainly focused on management and leadership skills, overlooking the skills frontline staff use to improve care. Our research explored which skills mattered to frontline health practitioners delivering QI projects.

Study design

We used a theory-driven approach, informed by communities of practice, knowledge-in-practice-in-context and positive deviance theory. We used case studies to examine skill use in three pseudonymised English hospital Trusts, selected on the basis of Care Quality Commission rating. Seventy-three senior staff orientation interviews led to the selection of two QI projects at each site. Snowball sampling obtained a maximally varied range of 87 staff with whom we held 122 semistructured interviews at different stages of QI delivery, analysed thematically.

Results

Six overarching ‘Socio-Organisational Functional and Facilitative Tasks’ (SOFFTs) were deployed by frontline staff. Several of these had to be enacted to address challenges faced. The SOFFTs included: (1) adopting and promulgating the appropriate organisational environment; (2) managing the QI rollercoaster; (3) getting the problem right; (4) getting the right message to the right people; (5) enabling learning to occur; and (6) contextualising experience. Each task had its own inherent skills.

Conclusion

Our case studies provide a nuanced understanding of the skills used by healthcare staff. While technical skills are important, the ability to judge when and how to use wider skills was paramount. The provision of QI training and fidelity to the improvement programme may be less of a priority than the deployment of SOFFT skills used to overcome barriers. QI projects will fail if such skills and resources are not accessed.

Combining Realist approaches and Normalization Process Theory to understand implementation: a systematic review

BACKGROUND

Realist approaches and Normalization Process Theory (NPT) have both gained significant traction in implementation research over the past 10 years. The aim of this study was therefore to explore how the approaches are combined to understand problems of implementation, to determine the degree of complementarity of the two approaches and to provide practical approaches for using them together.

METHODS

Systematic review of research studies combining Realist and NPT approaches. Realist methodology is concerned with understanding and explaining causation, that is, how and why policies, programmes and interventions achieve their effects. NPT is a theory of implementation that explains how practices become normalised. Databases searched (January 2020) were ASSIA, CINAHL, Health Research Premium Collection via Proquest (Family Health Database, Health & Medical Collection, Health Management Database, MEDLINE, Nursing & Allied Health Database, Psychology Database, Public Health Database) and PsycARTICLES. Studies were included if the author(s) stated they used both approaches: a scientific Realist perspective applying the principles of Pawson and Tilley's Realist Evaluation or Pawson's Realist Synthesis and Normalization Process Theory either solely or in addition to other theories. Two authors screened records; discrepancies were reviewed by a third screener. Data was extracted by three members of the team and a narrative synthesis was undertaken.

RESULTS

Of 245 total records identified, 223 unique records were screened and 39 full-text papers were reviewed, identifying twelve papers for inclusion in the review. These papers represented eight different studies. Extent and methods of integration of the approaches varied. In most studies (6/8), Realist approaches were the main driver. NPT was mostly used to enhance the explanatory power of Realist analyses, informing development of elements of Contexts, Mechanisms and Outcomes (a common heuristic in realist work). Authors' reflections on the integration of NPT and Realist approaches were limited.

CONCLUSIONS

Using Realist and NPT approaches in combination can add explanatory power for understanding the implementation of interventions and programmes. Attention to detailed reporting on methods and analytical process when combining approaches, and appraisal of theoretical and practical utility is advised for advancing knowledge of applying these approaches in research.

SYSTEMATIC REVIEW REGISTRATION

Not registered.

Implementing pharmaceutical track-and-trace systems: a realist review

INTRODUCTION

One way to prevent falsified medical products from entering the regulated pharmaceutical supply chain is to implement a pharmaceutical track-and-trace system (PTTS). Such systems in the most extensive versions generally mandate a scan at every point of contact with the medical product: from the point of entry to dispensation. There have been several attempts to implement such systems; for example, a 'full' PTTS in Turkey and the more pared-down version offered by the European Union's Falsified Medicines Directive and Delegated Act. This study aims to identify facilitators and barriers to implementing (elements of) a PTTS, with the Turkish system used as a benchmark.

METHODS

We conducted a 'realist' review, which synthesises literature and aims to establish how a specific technology works, for whom, under which circumstances. We searched Embase, Medline Ovid, Web of Science, Cochrane Central and Google Scholar databases, yielding 2,790 scholarly articles. We selected 21 for review.

RESULTS

Implementation of PTTS elements has been attempted in different compositions in several primarily high-income and middle-income countries. Factors that affected implementation included stakeholders like the government and supply chain actors, the coordination between them, and their awareness, knowledge, and skills, as well as regulation and legislation, monetary investments, and technical and digital requirements.

CONCLUSION

The interplay between contextual factors is crucial for successful PTTS implementation. Specifically, the findings indicate that aligning the incentives for all actors and allowing for adjustments in a continuous implementation process will likely facilitate implementation.

Protocol for an implementation and realist evaluation of a new organisational model for primary care practices in the canton of Vaud, Switzerland

INTRODUCTION

Continuity of care, especially for patients with complex needs, is a major challenge for healthcare systems in many high-income countries, including Switzerland. Since 2015, a collaborative project between Unisanté-Department of Family Medicine (DMF), some general practitioners (GPs) and canton of Vaud's public health authorities has sought to develop a new organisational model for the provision of primary care to ensure better care coordination and to provide adapted care deliveries to patients' healthcare needs. The model's main component is the addition of a primary care nurse to GPs practices. Three additional tools are individualised patient care plans, electronic medical records and patient empanelment. To assess this model, a 2-year pilot study has begun in nine GPs' practices in the canton. This paper presents the protocol for an evaluation of the implementation and effectiveness of the new organisational model.

METHOD AND ANALYSIS

We will conduct a before-and-after study using a mixed-methods and a realist approach. First, we will use quantitative and qualitative data to assess the new organisational model's implementation (feasibility, fidelity, acceptability and costs) and effectiveness (healthcare services use, patient experience, staff experience and patient-level costs). Combining this data with focus group data will enable a realist evaluation of the pilot project, which will help understand the elements of context and mechanism that affect implementation.

ETHICS AND DISSEMINATION

The evaluation will inform the canton of Vaud's health authorities about the limits of and perspectives for this organisational model. All results will also be made available to the practices and the patients involved. At the end of the project, we will propose organisational adaptations and a sustainable financial model for extending the model to other practices in the canton and potentially to the national level.The canton of Vaud's Human Research Ethics Committee approved the study, and Data Protection and Information Law Authority gave a favourable opinion concerning data processing procedures.

Combining the theory of change and realist evaluation approaches to elicit an initial program theory of the MomConnect program in South Africa

Background

One of the Sustainable Development Goals is to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030. In South Africa, the flagship National Department of Health MomConnect program was launched in 2014 to strengthen the quality of maternal and child health (MCH) services and improve mortality outcomes. MomConnect was rapidly rolled out with a limited understanding of how and why the program was expected to work even though studies had shown the effectiveness of the MomConnect program in improving the uptake of MCH services. This study aimed to unearth the initial program theory of the MomConnect program based on explicit and implicit assumptions of how the program was organized and expected to work.

Methods

We conducted a document analysis using design- and implementation-related documents of the MomConnect program guided by the principles of Theory of Change (ToC) and Realist Evaluation (RE). Content and thematic analysis approaches were deductively applied to analyze the documents toward constructing ToC and RE-informed models. Abductive thinking and retroduction were further applied to the realist-informed approach to link program context, mechanisms, and outcomes to construct the initial program theory.

Results

ToC and RE-informed models illustrated how the MomConnect program was organized and expected to work. The process of constructing the ToC provided the platform for the development of the initial program theory, which identified three critical elements: (1) the central modalities of the MomConnect program; (2) the intended outcomes; and (3) the tentative causal links indicating, in a stepwise manner of, how the outcomes were intended to be achieved. The RE approach ‘enhanced’ the causal links by identifying relevant programmatic contexts and linking the postulated mechanisms of action (empowerment, encouragement, motivation, and knowledge acquisition) to program outcomes.

Conclusion

The application of ToC and RE provided an explicitly cumulative approach to knowledge generation in unveiling the initial program theory of MomConnect rather than delivering answers to questions of program effectiveness.

Organizational Support in Healthcare Redesign Education: A Mixed-Methods Exploratory Study of Expert Coach and Executive Sponsor Experiences

Healthcare organizations must continue to improve services to meet the rising demand and patient expectations. For this to occur, the health workforce needs to have knowledge and skills to design, implement, and evaluate service improvement interventions. Studies have shown that effective training in health service improvement and redesign combines didactic education with experiential project-based learning and on-the-ground coaching. Project-based learning requires organizational support and oversight, generally through executive sponsorship. A mixed-methods approach, comprising online surveys and semi-structured interviews, was used to explore the experiences of expert coaches and executive sponsors as key facilitators of workplace-based projects undertaken during an Australian postgraduate healthcare redesign course. Fifteen (54%) expert coaches and 37 (20%) executive sponsors completed the online survey. Ten expert coaches and six executive sponsors participated in interviews. The survey data revealed overall positive experiences for coaches and mixed experiences for sponsors. Interview participants expressed a sense of fulfillment that came from working with project teams to deliver a successful project and educational outcomes. However, concerns were raised about adequate resourcing, organizational recognition, competing priorities, and the skills required to effectively coach and sponsor. Expert coaches and executive sponsors sometimes felt under-valued and may benefit from cohort-tailored and evidence-based professional development.