A qualitative study of the dissemination and diffusion of innovations: bottom up experiences of senior managers in three health districts in South Africa

Initiating systemic capacity development for leadership from the bottom-up: a realist evaluation of a leadership innovation in a South African health district

The need for leadership within district health systems is critical for the effective delivery of services and for inter-sectoral collaboration for health. Leadership capacity development (LCD) has not, however, been prioritized within health systems, and the systemic capacity (i.e. roles, structures and processes) that is needed to develop managers who can lead is not always in place. This paper aims to contribute to understanding how to build such capacity, considering a relevant bottom-up innovation. We observed, in the period 2013-15, the emergent implementation of this innovation (a 'Leadership Commission') in a South African health district. What started out as an effort to train individual leaders evolved into the development of systemic capacity for LCD. We adopted realist evaluation as the main methodological approach, as well as case study design, and we first developed a programme theory of the internally driven LCD initiative, through a round of interviews with senior managers. We then tested the programme theory drawing on 14 in-depth interviews and field notes of meetings and processes. Our analysis suggests that building systemic capacity for LCD requires leadership to be expressed as a strategic priority by those with positional authority and that bottom-up LCD requires institutional commitment through strengthening routine structures or creating new ones. The ability to leverage existing resources is another key element of systemic capacity. The mechanisms that enable bottom-up capacity development include tacit and experiential knowledge, sensemaking, systems thinking and trust between, and motivation of, those tasked with leading LCD. Leadership development is constrained by increased workloads for those involved as the prioritization of leadership becomes simply an additional task, and sustainability challenges are likely in the absence of additional resources for bottom-up innovation.

Exploring the Role of Complexity in Health Care Technology Bottom-Up Innovations: Multiple-Case Study Using the Nonadoption, Abandonment, Scale-Up, Spread, and Sustainability Complexity Assessment Tool

BACKGROUND

New digital technology presents new challenges to health care on multiple levels. There are calls for further research that considers the complex factors related to digital innovations in complex health care settings to bridge the gap when moving from linear, logistic research to embracing and testing the concept of complexity. The nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework was developed to help study complexity in digital innovations.

OBJECTIVE

This study aims to investigate the role of complexity in the development and deployment of innovations by retrospectively assessing challenges to 4 digital health care innovations initiated from the bottom up.

METHODS

A multicase retrospective, deductive, and explorative analysis using the NASSS complexity assessment tool LONG was conducted. In total, 4 bottom-up innovations developed in Region Västra Götaland in Sweden were explored and compared to identify unique and shared complexity-related challenges.

RESULTS

The analysis resulted in joint insights and individual learning. Overall, the complexity was mostly found outside the actual innovation; more specifically, it related to the organization's readiness to integrate new innovations, how to manage and maintain innovations, and how to finance them. The NASSS framework sheds light on various perspectives that can either facilitate or hinder the adoption, scale-up, and spread of technological innovations. In the domain of condition or diagnosis, a well-informed understanding of the complexity related to the condition or illness (diabetes, cancer, bipolar disorders, and schizophrenia disorders) is of great importance for the innovation. The value proposition needs to be clearly described early to enable an understanding of costs and outcomes. The questions in the NASSS complexity assessment tool LONG were sometimes difficult to comprehend, not only from a language perspective but also due to a lack of understanding of the surrounding organization's system and its setting.

CONCLUSIONS

Even when bottom-up innovations arise within the same support organization, the complexity can vary based on the developmental phase and the unique characteristics of each project. Identifying, defining, and understanding complexity may not solve the issues but substantially improves the prospects for successful deployment. Successful innovation within complex organizations necessitates an adaptive leadership and structures to surmount cultural resistance and organizational impediments. A rigid, linear, and stepwise approach risks disregarding interconnected variables and dependencies, leading to suboptimal outcomes. Success lies in embracing the complexity with its uncertainty, nurturing creativity, and adopting a nonlinear methodology that accommodates the iterative nature of innovation processes within complex organizations.

Implementation considerations for non-communicable disease-related integration in primary health care: a rapid review of qualitative evidence

BACKGROUND

Integrated delivery of primary health care (PHC) services is a health reform recommended for achieving ambitious targets of the Sustainable Development Goals and Universal Health Coverage, responding to growing challenges of managing non-communicable and multimorbidity. However, more evidence is needed on effective implementation of PHC integration in different country settings.

OBJECTIVE

This rapid review synthesized qualitative evidence on implementation factors affecting integration of non-communicable disease (NCD) into PHC, from the perspective of implementers. The review contributes evidence to inform the World Health Organizations' guidance on integration of NCD control and prevention to strengthen health systems.

METHOD

The review was guided by standard methods for conducting rapid systematic reviews. Data analysis was guided by the SURE and WHO health system building blocks frameworks. We used Confidence in the Evidence of Reviews of Qualitative Research (GRADE-CERQual) to assess the confidence of the main findings.

RESULTS

The review identified 81 records eligible for inclusion, from 595 records screened. We sampled 20 studies for analysis (including 3 from expert recommendations). Studies covered a wide range of countries (27 countries from 6 continents), the majority from low-and middle-income countries (LMICs), with a diverse set of NCD-related PHC integration combinations and implementation strategies. The main findings were categorised into three overarching themes and several sub-themes. These are, A: Policy alignment and governance, B: Health systems readiness, intervention compatibility and leadership, and C: Human resource management, development, and support. The three overarching findings were assessed as each having a moderate level of confidence.

CONCLUSION

The review findings present insights on how health workers responses may be shaped by the complex interaction of individual, social, and organizational factors that may be specific to the context of the intervention, the importance of cross-cutting influences such as policy alignment, supportive leadership and health systems constraints, knowledge that can inform the development of future implementation strategies and implementation research.

Bottom-up innovation for health management capacity development: a qualitative case study in a South African health district

BACKGROUND

As part of health system strengthening in South Africa (2012-2017) a new district health manager, taking a bottom-up approach, developed a suite of innovations to improve the processes of monthly district management team meetings, and the practices of managers and NGO partners attending them. Understanding capacity as a property of the health system rather than only of individuals, the research explored the mechanisms triggered in context to produce outputs, including the initial sensemaking by the district manager, the subsequent sensegiving and sensemaking in the team and how these homegrown innovations interacted with existing social processes and norms within the system.

METHODS

We conducted a realist evaluation, adopting the case study design, over a two-year period (2013-2015) in the district of focus. The initial programme theory was developed from 10 senior manager interviews and a literature review. To understand the processes and mechanisms triggered in the local context and identify outputs, we conducted 15 interviews with managers in the management team and seven with non-state actors. These were supplemented by researcher notes based on time spent in the district. Thematic analysis was conducted using the Context-Mechanism-Outcome configuration alongside theoretical constructs.

RESULTS

The new district manager drew on systems thinking, tacit and experiential knowledge to design bottom-up innovations. Capacity was triggered through micro-practices of sensemaking and sensegiving which included using sticks (positional authority, enforcement of policies, over-coding), intentionally providing justifications for change and setting the scene (a new agenda, distributed leadership). These micro-practices in themselves, and by managers engaging with them, triggered a generative process of buy-in and motivation which influenced managers and partners to participate in new practices within a routine meeting.

CONCLUSION

District managers are well placed to design local capacity development innovations and must draw on systems thinking, tacit and experiential knowledge to enable relevant 'bottom-up' capacity development in district health systems. By drawing on soft skills and the policy resources (hardware) of the system they can influence motivation and buy-in to improve management practices. From a systems perspective, we argue that capacity development can be conceived of as part of the daily activity of managing within routine spaces.

Evaluating the dissemination and scale-up of two evidence-based parenting interventions to reduce violence against children: study protocol

Background

Eliminating violence against children is a prominent policy goal, codified in the Sustainable Development Goals, and parenting programs are one approach to preventing and reducing violence. However, we know relatively little about dissemination and scale-up of parenting programs, particularly in low- and middle-income countries (LMICs). The scale-up of two parenting programs, Parenting for Lifelong Health (PLH) for Young Children and PLH for Parents and Teens, developed under Creative Commons licensing and tested in randomized trials, provides a unique opportunity to study their dissemination in 25 LMICs.

Methods

The Scale-Up of Parenting Evaluation Research (SUPER) study uses a range of methods to study the dissemination of these two programs. The study will examine (1) process and extent of dissemination and scale-up, (2) how the programs are implemented and factors associated with variation in implementation, (3) violence against children and family outcomes before and after program implementation, (4) barriers and facilitators to sustained program delivery, and (5) costs and resources needed for implementation.Primary data collection, focused on three case study projects, will include interviews and focus groups with program facilitators, coordinators, funders, and other stakeholders, and a summary of key organizational characteristics. Program reports and budgets will be reviewed as part of relevant contextual information. Secondary data analysis of routine data collected within ongoing implementation and existing research studies will explore family enrolment and attendance, as well as family reports of parenting practices, violence against children, child behavior, and child and caregiver wellbeing before and after program participation. We will also examine data on staff sociodemographic and professional background, and their competent adherence to the program, collected as part of staff training and certification.

Discussion

This project will be the first study of its kind to draw on multiple data sources and methods to examine the dissemination and scale-up of a parenting program across multiple LMIC contexts. While this study reports on the implementation of two specific parenting programs, we anticipate that our findings will be of relevance across the field of parenting, as well as other violence prevention and social programs.

Implementation science outcomes of a gender-focused HIV and alcohol risk-reduction intervention in usual-care settings in South Africa

BACKGROUND

South Africa has the highest HIV prevalence globally, which disproportionately affects women. Hazardous alcohol use reduces antiretroviral adherence which can lead to adverse health. Few evidence-based interventions addressing hazardous alcohol use and HIV have been implemented in real-world settings. This study aimed to evaluate implementation outcomes from the Women's Health CoOp (WHC)-an evidence-based gender-focused HIV intervention-which was implemented in Cape Town.

METHODS

We conducted this implementation science trial using a modified stepped-wedge design. Four health clinics were paired with four substance use rehabilitation programs and randomized into four cycles. Women living with HIV and who use alcohol or other drugs were recruited into each cycle (n = 120 each cycle). We assessed adoption, acceptability, appropriateness, cost, and fidelity using a mixed methods approach.

RESULTS

Adoption: 100 % of staff trained in the WHC and designated as interventionists delivered one or more workshops. Acceptability: Interventionists found the WHC content beneficial to their patients and the WHC improved connections between clinical units in facilities. Appropriateness: The WHC aligned with facility goals to improve antiretroviral adherence and reduce alcohol use; however, there were implementation challenges, including staff shortages, stigma, and few places to refer women for supportive services. Cost: The cost of implementing the WHC was 20.59 ZAR (1.40 USD) per attendee. Fidelity: Interventionists implemented the WHC with high fidelity and quality.

CONCLUSIONS

The findings suggest it is feasible to integrate the WHC into usual-care settings. Future efforts to scale up the intervention will need to address social and structural implementation challenges.

TRIAL REGISTRATION

NCT02733003 approved 1/21/2016.

Optimization of Diabetic Macular Edema Management in the Real World: A Model of Excellence in Retina Units: The EMUREX Initiative

PURPOSE

To define and develop a model of excellence for the clinical management of diabetic macular edema (DME) patients in a real-world setting.

METHODS

A multidisciplinary joint commission (5 ophthalmologists, 1 nurse, and 1 pharmaceutic) established a series of preliminary recommendations based on clinical guidelines and DME activity results from 8 Pilot Hospitals (PH). These were validated by members of each PH and a group of DME patients in discussion workshops. Thus, the validated guideline (VG) took into consideration different aspects, namely, main core points (ranging 0-100), criteria, and indicators. Finally, each PH own setting was compared to the VG in order to settle down a starting point to clinical excellence.

RESULTS

Mean PH score was 51.5 (range 30-65). As compared to their maximum, main points that showed best scores were Clinical Guidelines and Protocols (78%) and Portfolio of Services (73%). Topics reaching close to 50% scoring included Resources (55%), Innovation (54%), Care Process (53%), Organization (52%), and Leadership (50%). Lowest scores were observed in the Strategic Alliances (46%) and Staff (37%) points.

CONCLUSIONS

Analysis of each PH by the VG delivered a global vision of the starting situation, especially focused in the identification of the different improvement areas. In order to further extend this model into the Public Health System, the effect of implementing it in different hospitals should be assessed to analyze its impact on daily clinical practice and health economics.