Process evaluation of a knowledge translation intervention using facilitation of local stakeholder groups to improve neonatal survival in the Quang Ninh province, Vietnam

A longitudinal mixed methods evaluation of a facilitation training intervention to build implementation capacity

Background

There is a demand for facilitators who can ease the collaboration within a team or an organization in the implementation of evidence-based interventions (EBIs) and who are positioned to build the implementation capacity in an organization. This study aimed to evaluate the results the Building implementation capacity for facilitation (BIC-F) intervention had on the participants' perceived knowledge, skills, and self-efficacy to facilitate implementation and the normalization of a systematic implementation model into their work routines, and its use into their respective organizations.

Methods

The BIC-F intervention was delivered to 37 facilitators in six workshops, which focused on teaching participants to apply a systematic implementation model and various facilitation tools and strategies. A longitudinal mixed methods design was used to evaluate the intervention. Data was collected pre- and post-intervention using questionnaires and semi-structured interviews grounded on the Normalization Process Theory (NPT). Quantitative data were analyzed using descriptive (mean, SD) and inferential (paired t-tests) methods. Qualitative data were analyzed using deductive content analysis according to NPT.

Results

An increase in the participants' perceived knowledge, skills, and self-efficacy was observed post-intervention. Normalization of the systematic implementation model in the participants' work routines was in an early phase, facilitated by high coherence, however, other NPT mechanisms were not sufficiently activated yet to contribute to full normalization. In the organizations where participants initiated the normalization process, they were still working towards achieving coherence and cognitive participation among relevant stakeholders.

Conclusion

The intervention had positive results on the participants' perceived knowledge, skills, and self-efficacy and these recognized the value of a systematic implementation model for their practice. However, further efforts are needed to apply it consistently as a part of their work routines and in the organization. Future interventions should provide long-term support for facilitators, and include methods to transfer training between organizational levels and to overcome contextual barriers.

Building a sharable literature collection to advance the science and practice of implementation facilitation

Background

Implementation science seeks to produce generalizable knowledge on strategies that promote the adoption and sustained use of evidence-based innovations. Literature reviews on specific implementation strategies can help us understand how they are conceptualized and applied, synthesize findings, and identify knowledge gaps. Although rigorous literature reviews can advance scientific knowledge and facilitate theory development, they are time-consuming and costly to produce. Improving the efficiency of literature review processes and reducing redundancy of effort is especially important for this rapidly developing field. We sought to amass relevant literature on one increasingly used evidence-based strategy, implementation facilitation (IF), as a publicly available resource.

Methods

We conducted a rigorous systematic search of PubMed, CINAHL, and Web of Science citation databases for peer-reviewed, English-language articles with "facilitation" and a combination of other terms published from January 1996 to December 2021. We searched bibliographies of articles published from 1996 to 2015 and identified articles during the full text review that reported on the same study. Two authors screened 3,168 abstracts. After establishing inter-rater reliability, they individually conducted full-text review of 786 relevant articles. A multidisciplinary team of investigators provided recommendations for preparing and disseminating the literature collection.

Findings

The literature collection is comprised of 510 articles. It includes 277 empirical studies of IF and 77 other articles, including conceptual/theoretical articles, literature reviews, debate papers and descriptions of large-scale clinical initiatives. Over half of the articles were published between 2017 and 2021. The collection is publicly available as an Excel file and as an xml file that can be imported into reference management software.

Conclusion

We created a publicly accessible collection of literature about the application of IF to implement evidence-based innovations in healthcare. The comprehensiveness of this collection has the potential to maximize efficiency and minimize redundancy in scientific inquiry about this strategy. Scientists and practitioners can use the collection to more rapidly identify developments in the application of IF and to investigate a wide range of compelling questions on its use within and across different healthcare disciplines/settings, countries, and payer systems. We offer several examples of how this collection has already been used.

Scoping review of interventions to improve continuity of postdischarge care for newborns in LMICs

INTRODUCTION

Neonatal mortality remains significant in low-income and middle-income countries (LMICs) with in-hospital mortality rates similar to those following discharge from healthcare facilities. Care continuity interventions have been suggested as a way of reducing postdischarge mortality by better linking care between facilities and communities. This scoping review aims to map and describe interventions used in LMICs to improve care continuity for newborns after discharge and examine assumptions underpinning the design and delivery of continuity.

METHODS

We searched seven databases (MEDLINE, CINAHL, Scopus, Web of Science, EMBASE, Cochrane library and (Ovid) Global health). Publications with primary data on interventions focused on continuity of care for newborns in LMICs were included. Extracted data included year of publication, study location, study design and type of intervention. Drawing on relevant theoretical frameworks and classifications, we assessed the extent to which interventions adopted participatory methods and how they attempted to establish continuity.

RESULTS

A total of 65 papers were included in this review; 28 core articles with rich descriptions were prioritised for more in-depth analysis. Most articles adopted quantitative designs. Interventions focused on improving continuity and flow of information via education sessions led by community health workers during home visits. Extending previous frameworks, our findings highlight the importance of interpersonal continuity in LMICs where communication and relationships between family members, healthcare workers and members of the wider community play a vital role in creating support systems for postdischarge care. Only a small proportion of studies focused on high-risk babies. Some studies used participatory methods, although often without meaningful engagement in problem definition and intervention implementation.

CONCLUSION

Efforts to reduce neonatal mortality and morbidity should draw across multiple continuity logics (informational, relational, interpersonal and managerial) to strengthen care after hospital discharge in LMIC settings and further focus on high-risk neonates, as they often have the worst outcomes.

Facilitating implementation of primary care mental health over time and across organizational contexts: a qualitative study of role and process

BACKGROUND

Healthcare organizations have increasingly utilized facilitation to improve implementation of evidence-based practices and programs (e.g., primary care mental health integration). Facilitation is both a role, related to the purpose of facilitation, and a process, i.e., how a facilitator operationalizes the role. Scholars continue to call for a better understanding of this implementation strategy. Although facilitation is described as dynamic, activities are often framed within the context of a staged process. We explored two understudied characteristics of implementation facilitation: 1) how facilitation activities change over time and in response to context, and 2) how facilitators operationalize their role when the purpose of facilitation is both task-focused (i.e., to support implementation) and holistic (i.e., to build capacity for future implementation efforts).

METHODS

We conducted individual monthly debriefings over thirty months with facilitators who were supporting PCMHI implementation in two VA networks. We developed a list of facilitation activities based on a literature review and debriefing notes and conducted a content analysis of debriefing notes by coding what activities occurred and their intensity by quarter. We also coded whether facilitators were "doing" these activities for sites or "enabling" sites to perform them.

RESULTS

Implementation facilitation activities did not occur according to a defined series of ordered steps but in response to specific organizational contexts through a non-linear and incremental process. Amount and types of activities varied between the networks. Concordant with facilitators' planned role, the focus of some facilitation activities was primarily on doing them for the sites and others on enabling sites to do for themselves; a number of activities did not fit into one category and varied across networks.

CONCLUSIONS

Findings indicate that facilitation is a dynamic and fluid process, with facilitation activities, as well as their timing and intensity, occurring in response to specific organizational contexts. Understanding this process can help those planning and applying implementation facilitation to make conscious choices about the facilitation role and the activities that facilitators can use to operationalize this role. Additionally, this work provides the foundation from which future studies can identify potential mechanisms of action through which facilitation activities enhance implementation uptake.

Consumers' and health providers' views and perceptions of partnering to improve health services design, delivery and evaluation: a co-produced qualitative evidence synthesis

BACKGROUND

Partnering with consumers in the planning, delivery and evaluation of health services is an essential component of person-centred care. There are many ways to partner with consumers to improve health services, including formal group partnerships (such as committees, boards or steering groups). However, consumers' and health providers' views and experiences of formal group partnerships remain unclear. In this qualitative evidence synthesis (QES), we focus specifically on formal group partnerships where health providers and consumers share decision-making about planning, delivering and/or evaluating health services. Formal group partnerships were selected because they are widely used throughout the world to improve person-centred care. For the purposes of this QES, the term 'consumer' refers to a person who is a patient, carer or community member who brings their perspective to health service partnerships. 'Health provider' refers to a person with a health policy, management, administrative or clinical role who participates in formal partnerships in an advisory or representative capacity. This QES was co-produced with a Stakeholder Panel of consumers and health providers. The QES was undertaken concurrently with a Cochrane intervention review entitled Effects of consumers and health providers working in partnership on health services planning, delivery and evaluation.

OBJECTIVES

1. To synthesise the views and experiences of consumers and health providers of formal partnership approaches that aimed to improve planning, delivery or evaluation of health services. 2. To identify best practice principles for formal partnership approaches in health services by understanding consumers' and health providers' views and experiences.

SEARCH METHODS

We searched MEDLINE, Embase, PsycINFO and CINAHL for studies published between January 2000 and October 2018. We also searched grey literature sources including websites of relevant research and policy organisations involved in promoting person-centred care.

SELECTION CRITERIA

We included qualitative studies that explored consumers' and health providers' perceptions and experiences of partnering in formal group formats to improve the planning, delivery or evaluation of health services.

DATA COLLECTION AND ANALYSIS

Following completion of abstract and full-text screening, we used purposive sampling to select a sample of eligible studies that covered a range of pre-defined criteria, including rich data, range of countries and country income level, settings, participants, and types of partnership activities. A Framework Synthesis approach was used to synthesise the findings of the sample. We appraised the quality of each study using the CASP (Critical Appraisal Skill Program) tool. We assessed our confidence in the findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. The Stakeholder Panel was involved in each stage of the review from development of the protocol to development of the best practice principles.

MAIN RESULTS

We found 182 studies that were eligible for inclusion. From this group, we selected 33 studies to include in the final synthesis. These studies came from a wide range of countries including 28 from high-income countries and five from low- or middle-income countries (LMICs). Each of the studies included the experiences and views of consumers and/or health providers of partnering in formal group formats. The results were divided into the following categories. Contextual factors influencing partnerships: government policy, policy implementation processes and funding, as well as the organisational context of the health service, could facilitate or impede partnering (moderate level of confidence). Consumer recruitment: consumer recruitment occurred in different ways and consumers managed the recruitment process in a minority of studies only (high level of confidence). Recruiting a range of consumers who were reflective of the clinic's demographic population was considered desirable, particularly by health providers (high level of confidence). Some health providers perceived that individual consumers' experiences were not generalisable to the broader population whereas consumers perceived it could be problematic to aim to represent a broad range of community views (high level of confidence). Partnership dynamics and processes: positive interpersonal dynamics between health providers and consumers facilitated partnerships (high level of confidence). However, formal meeting formats and lack of clarity about the consumer role could constrain consumers' involvement (high level of confidence). Health providers' professional status, technical knowledge and use of jargon were intimidating for some consumers (high level of confidence) and consumers could feel their experiential knowledge was not valued (moderate level of confidence). Consumers could also become frustrated when health providers dominated the meeting agenda (moderate level of confidence) and when they experienced token involvement, such as a lack of decision-making power (high level of confidence) Perceived impacts on partnership participants: partnering could affect health provider and consumer participants in both positive and negative ways (high level of confidence). Perceived impacts on health service planning, delivery and evaluation: partnering was perceived to improve the person-centredness of health service culture (high level of confidence), improve the built environment of the health service (high level of confidence), improve health service design and delivery e.g. facilitate 'out of hours' services or treatment closer to home (high level of confidence), enhance community ownership of health services, particularly in LMICs (moderate level of confidence), and improve consumer involvement in strategic decision-making, under certain conditions (moderate level of confidence). There was limited evidence suggesting partnering may improve health service evaluation (very low level of confidence). Best practice principles for formal partnering to promote person-centred care were developed from these findings. The principles were developed collaboratively with the Stakeholder Panel and included leadership and health service culture; diversity; equity; mutual respect; shared vision and regular communication; shared agendas and decision-making; influence and sustainability.

AUTHORS' CONCLUSIONS

Successful formal group partnerships with consumers require health providers to continually reflect and address power imbalances that may constrain consumers' participation. Such imbalances may be particularly acute in recruitment procedures, meeting structure and content and decision-making processes. Formal group partnerships were perceived to improve the physical environment of health services, the person-centredness of health service culture and health service design and delivery. Implementing the best practice principles may help to address power imbalances, strengthen formal partnering, improve the experiences of consumers and health providers and positively affect partnership outcomes.

A facilitated social innovation: stakeholder groups using Plan-Do-Study-Act cycles for perinatal health across levels of the health system in Cao Bang province, Vietnam

BACKGROUND

Universal coverage of evidence-based interventions for perinatal health, often part of evidence-based guidelines, could prevent most perinatal deaths, particularly if entire communities were engaged in the implementation. Social innovations may provide creative solutions to the implementation of evidence-based guidelines, but successful use of social innovations relies on the engagement of communities and health system actors. This proof-of-concept study aimed to assess whether an earlier successful social innovation for improved neonatal survival that employed regular facilitated Plan-Do-Study-Act meetings on the commune level was feasible and acceptable when implemented on multiple levels of the health system (52 health units) and resulted in actions with plausibly favourable effects on perinatal health and survival in Cao Bang province, northern Vietnam.

METHODS

The Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework guided the implementation and evaluation of the Perinatal Knowledge-Into-Practice (PeriKIP) project. Data collection included facilitators' diaries, health workers' knowledge on perinatal care, structured observations of antenatal care, focus group discussions with facilitators, their mentors and representatives of different actors of the initiated stakeholder groups and an individual interview with the Reproductive Health Centre director. Clinical experts assessed the relevance of the identified problems and actions taken based on facilitators' diaries. Descriptive statistics included proportions, means, and t-tests for the knowledge assessment and observations. Qualitative data were analysed by content analysis.

RESULTS

The social innovation resulted in the identification of about 500 relevant problems. Also, 75% of planned actions to overcome prioritised problems were undertaken, results presented and a plan for new actions to achieve the group's goals to enhance perinatal health. The facilitators had significant roles, ensuring that the stakeholder groups were established based on principles of mutual respect. Overall, the knowledge of perinatal health and performance of antenatal care improved over the intervention period.

CONCLUSIONS

The establishment of facilitated local stakeholder groups can remedy the need for tailored interventions and grassroots involvement in perinatal health and provide a scalable structure for focused efforts to reduce preventable deaths and promote health and well-being.

Training and support for the role of facilitator in implementation of innovations in health and community care: a scoping review protocol

BACKGROUND

Implementing and sustaining innovations in clinical practice, such as evidence-based practices, programmes, and policies, is frequently described as challenging. Facilitation as a strategy for supporting implementation requires a facilitator, i.e. an individual with a designated role to support the implementation process. A growing number of studies report that facilitation can help tackle the challenges in implementation efforts. To optimise the potential contribution of facilitation as a strategy to improve the implementation of new practices, there is a need to enhance understanding about what training and support is required for individuals in the facilitator role. The objective of this scoping review is to map how facilitators have been trained for, and supported in, the facilitator role in implementation studies in health and community care. Specifically, the review aims to examine what is reported on training and support of facilitators in terms of learning outcomes, content, dose, mode of delivery, learning activities, and qualifications of the trainers and how the facilitators perceive training and support.

METHODS

This scoping review will follow the guidance of the Joanna Briggs Institute and the PRISMA Extension for Scoping Review checklist. We will include articles in which (a) facilitation is deployed as an implementation strategy, with identified facilitator roles targeting staff and managers, to support the implementation of specified innovations in health or community care, and (b) training and/or support of facilitators is reported. We will exclude articles where facilitation is directed to education or training in specific clinical procedures or if facilitation supports the implementation of general quality improvement systems. All types of peer-reviewed studies and study protocols published in English will be included. A systematic search will be performed in MEDLINE (Ovid), Embase (embase.com), Web of Science Core Collection, and CINAHL (Ebsco).

DISCUSSION

The proposed scoping review will provide a systematic mapping of the literature on the training and support of implementation facilitators and contribute useful knowledge within the field of implementation science to inform future facilitation initiatives.

SYSTEMATIC REVIEW REGISTRATION

Registered at Open Science Framework (registration https://doi.org/10.17605/OSF.IO/M6NPQ ).

Effects of consumers and health providers working in partnership on health services planning, delivery and evaluation

BACKGROUND

Health services have traditionally been developed to focus on specific diseases or medical specialties. Involving consumers as partners in planning, delivering and evaluating health services may lead to services that are person-centred and so better able to meet the needs of and provide care for individuals. Globally, governments recommend consumer involvement in healthcare decision-making at the systems level, as a strategy for promoting person-centred health services. However, the effects of this 'working in partnership' approach to healthcare decision-making are unclear. Working in partnership is defined here as collaborative relationships between at least one consumer and health provider, meeting jointly and regularly in formal group formats, to equally contribute to and collaborate on health service-related decision-making in real time. In this review, the terms 'consumer' and 'health provider' refer to partnership participants, and 'health service user' and 'health service provider' refer to trial participants. This review of effects of partnership interventions was undertaken concurrently with a Cochrane Qualitative Evidence Synthesis (QES) entitled Consumers and health providers working in partnership for the promotion of person-centred health services: a co-produced qualitative evidence synthesis.

OBJECTIVES

To assess the effects of consumers and health providers working in partnership, as an intervention to promote person-centred health services.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL databases from 2000 to April 2019; PROQUEST Dissertations and Theses Global from 2016 to April 2019; and grey literature and online trial registries from 2000 until September 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs of 'working in partnership' interventions meeting these three criteria: both consumer and provider participants meet; they meet jointly and regularly in formal group formats; and they make actual decisions that relate to the person-centredness of health service(s).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened most titles and abstracts. One review author screened a subset of titles and abstracts (i.e. those identified through clinical trials registries searches, those classified by the Cochrane RCT Classifier as unlikely to be an RCT, and those identified through other sources). Two review authors independently screened all full texts of potentially eligible articles for inclusion. In case of disagreement, they consulted a third review author to reach consensus. One review author extracted data and assessed risk of bias for all included studies and a second review author independently cross-checked all data and assessments. Any discrepancies were resolved by discussion, or by consulting a third review author to reach consensus. Meta-analysis was not possible due to the small number of included trials and their heterogeneity; we synthesised results descriptively by comparison and outcome. We reported the following outcomes in GRADE 'Summary of findings' tables: health service alterations; the degree to which changed service reflects health service user priorities; health service users' ratings of health service performance; health service users' health service utilisation patterns; resources associated with the decision-making process; resources associated with implementing decisions; and adverse events.

MAIN RESULTS

We included five trials (one RCT and four cluster-RCTs), with 16,257 health service users and more than 469 health service providers as trial participants. For two trials, the aims of the partnerships were to directly improve the person-centredness of health services (via health service planning, and discharge co-ordination). In the remaining trials, the aims were indirect (training first-year medical doctors on patient safety) or broader in focus (which could include person-centredness of health services that targeted the public/community, households or health service delivery to improve maternal and neonatal mortality). Three trials were conducted in high income-countries, one was in a middle-income country and one was in a low-income country. Two studies evaluated working in partnership interventions, compared to usual practice without partnership (Comparison 1); and three studies evaluated working in partnership as part of a multi-component intervention, compared to the same intervention without partnership (Comparison 2). No studies evaluated one form of working in partnership compared to another (Comparison 3). The effects of consumers and health providers working in partnership compared to usual practice without partnership are uncertain: only one of the two studies that assessed this comparison measured health service alteration outcomes, and data were not usable, as only intervention group data were reported. Additionally, none of the included studies evaluating this comparison measured the other primary or secondary outcomes we sought for the 'Summary of findings' table. We are also unsure about the effects of consumers and health providers working in partnership as part of a multi-component intervention compared to the same intervention without partnership. Very low-certainty evidence indicated there may be little or no difference on health service alterations or health service user health service performance ratings (two studies); or on health service user health service utilisation patterns and adverse events (one study each). No studies evaluating this comparison reported the degree to which health service alterations reflect health service user priorities, or resource use. Overall, our confidence in the findings about the effects of working in partnership interventions was very low due to indirectness, imprecision and publication bias, and serious concerns about risk of selection bias; performance bias, detection bias and reporting bias in most studies.

AUTHORS' CONCLUSIONS

The effects of consumers and providers working in partnership as an intervention, or as part of a multi-component intervention, are uncertain, due to a lack of high-quality evidence and/or due to a lack of studies. Further well-designed RCTs with a clear focus on assessing outcomes directly related to partnerships for patient-centred health services are needed in this area, which may also benefit from mixed-methods and qualitative research to build the evidence base.

Performance of health workers on neonatal resuscitation care following scaled-up quality improvement interventions in public hospitals of Nepal - a prospective observational study

BACKGROUND

High-quality resuscitation among non-crying babies immediately after birth can reduce intrapartum-related deaths and morbidity. Helping Babies Breathe program aims to improve performance on neonatal resuscitation care in resource-limited settings. Quality improvement (QI) interventions can sustain simulated neonatal resuscitation knowledge and skills and clinical performance. This study aimed to evaluate the effect of a scaled-up QI intervention package on the performance of health workers on basic neonatal resuscitation care among non-crying infants in public hospitals in Nepal.

METHODS

A prospective observational cohort design was applied in four public hospitals of Nepal. Performances of health workers on basic neonatal care were analysed before and after the introduction of the QI interventions.

RESULTS

Out of the total 32,524 births observed during the study period, 3031 newborn infants were not crying at birth. A lower proportion of non-crying infants were given additional stimulation during the intervention compared to control (aOR 0.18; 95% CI 0.13-0.26). The proportion of clearing the airway increased among non-crying infants after the introduction of QI interventions (aOR 1.23; 95% CI 1.03-1.46). The proportion of non-crying infants who were initiated on BMV was higher during the intervention period (aOR 1.28, 95% CI 1.04-1.57) compared to control. The cumulative median time to initiate ventilation during the intervention was 39.46 s less compared to the baseline.

CONCLUSION

QI intervention package improved health workers' performance on the initiation of BMV, and clearing the airway. The average time to first ventilation decreased after the implementation of the package. The QI package can be scaled-up in other public hospitals in Nepal and other similar settings.

Knowledge mobilization in bridging patient-practitioner-researcher boundaries: A systematic integrative review

AIM

To review when, how, and in what context knowledge mobilization (KMb) has crossed patient-practitioner-researcher boundaries.

BACKGROUND

KMb is essential in contemporary health care, yet little is known about how patients are engaged.

DESIGN

Integrative review.

DATA SOURCES

Ten academic databases and grey literature.

REVIEW METHODS

We followed integrative review methodology to identify publications from 2006-2019 which contributed to understanding of cross-boundary KMb. We extracted data using a bespoke spreadsheet and the Template for Intervention Description and Replication (TIDieR) framework. We used meta-summary to organize key findings.

RESULTS

Thirty-three papers collectively provide new insights into 'when' and 'how' KMb has crossed patient-researcher-practitioner boundaries and the impact this has achieved. Knowledge is mobilized to improve care, promote health, or prevent ill health. Most studies focus on creating or re-shaping knowledge to make it more useful. Knowledge is mobilized in small community groups, in larger networks, and intervention studies. Finding the right people to engage in activities is crucial, as activities can be demanding and time-consuming. Devolving power to communities and using local people to move knowledge can be effective. Few studies report definitive outcomes of KMb.

CONCLUSION

Cross-boundary KMb can and does produce new and shared knowledge for health care. Positive outcomes can be achieved using diverse public engagement strategies. KMb process and theory is an emerging discipline, further research is needed on effective cross-boundary working and on measuring the impact of KMb.

IMPACT

This review provides new and nuanced understandings of how KMb theory has been used to bridge patient-researcher-practitioner boundaries. We have assessed 'how', 'when', and in what context patients, practitioners and researchers have attempted to mobilize knowledge and identified impact. We have developed a knowledge base about good practice and what can and potentially should be avoided in cross-boundary KMb.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Assessing the Implementation of a Behavior Change Intervention: Process Evaluation of a Stepped-Wedge Cluster Randomized Controlled Trial for Newborn Health

Maternal and under five-year-old mortality rates have reduced in the last two decades globally due to concerted effort, yet newborn deaths remain unacceptably prevalent. Behavior change is an important component of interventions to address newborn health problems in low-income countries. In Cambodia, maternal and newborn mortality has markedly decreased, and continued improvements will allow the country to achieve further reduction in newborn morbidity. The results of an implementation study of the Newborn Care and Infection Control Initiative using process evaluation are presented to provide insight into the trial implementation and context of the program that may have contributed to intervention results. The study utilized a mixed method process to explore the context, mechanisms, and implementation of intervention components: training of village health support group volunteers to provide home visits, training of midwives on infection prevention and control around the perinatal period, counseling on newborn care, and provision of training materials for counseling and intervention. Implementation was evaluated through quantitative and qualitative data collection including surveys, observation, semi-structured interviews, focus groups, and visual media. Descriptive statistics summarized the quantitative data and thematic analysis was used to explore the qualitative data. The evaluation identified several factors that might have influenced the outcomes of the trial: continuity of health center staff communication, timing and ability to complete home visits, and training quality. Additional support for parents in the perinatal period, preferably provided at the community level, will contribute to further improvement in health outcomes for newborns in this area. Researchers in this context should consider mechanisms to improve the coordination of health facility staff counseling while providing support and resources to ensure home visits to families with newborns are made on time. Attention to staffing, training, and quality of newborn health interventions is critical in planning for the scaling-up of newborn health programming.

From novice to expert: a qualitative study of implementation facilitation skills

BACKGROUND

It is widely reported that facilitation can aid implementation of evidence-based practices. Although scholars agree that facilitators need a diverse range of skills, only a few retrospective studies have identified some of these. During the test of a facilitation strategy within the context of a VA initiative to implement evidence-based care delivery models, we documented the skills an expert external facilitator transferred to two initially novice internal regional facilitators. Ours is the first study to explore facilitation skills as they are being applied and transferred.

METHODS

Facilitators applied the strategy at eight primary care clinics that lacked implementation capacity in two VA networks. We conducted monthly debriefing interviews over a 30-month period and documented these in detailed notes. External facilitator interviews focused specifically on training and mentoring internal facilitators and the skills that she transferred. We also conducted, recorded, and transcribed two qualitative interviews with each facilitator and queried them about training content and process. We conducted a content analysis of the data, using deductive and inductive methods, to identify skills the external facilitator helped internal facilitators learn. We also explored the complexity of facilitation skills and grouped them into overarching skillsets.

RESULTS

The external facilitator helped internal facilitators learn 22 complex skills; with few exceptions, these skills were not unique but overlapped with one another. We clustered 21 of these into 5 groups of overarching skillsets: (1) building relationships and creating a supportive environment, (2) changing the system of care and the structure and processes that support it, (3) transferring knowledge and skills and creating infrastructure support for ongoing learning, (4) planning and leading change efforts, and (5) assessing people, processes, and outcomes and creating infrastructure for program monitoring.

CONCLUSIONS

This study documented a broad range of implementation facilitation skills that are complex and overlapping. Findings suggest that studies and initiatives planning or applying facilitation as an implementation strategy should ensure that facilitators have or have the opportunity to learn the skills they need. Because facilitation skills are complex, the use of didactic methods alone may not be sufficient for transferring skills; future work should explore other methods and techniques.

Barriers and Enablers Affecting Successful Implementation of the Electronic Health Service Sisom: Multicenter Study of Child Participation in Pediatric Care

Background

Children’s participation in health care is one of the most important components in the management of their disease. Electronic health (eHealth) services that are adapted to the needs of children have the potential for restructuring how children and professionals work together. Therefore, a digital interactive assessment and communication tool, Sisom, was developed to give children aged between 6 and 12 years a voice in their own health care. However, the implementation of eHealth services such as Sisom in daily practice in pediatric health care is rarely investigated.

Objective

The aim of this study was to explore the process of implementing Sisom for children in pediatric care in Sweden. More specifically, the study aimed to (1) evaluate whether the implementation strategy was conducted as planned, (2) understand the barriers and facilitators of the implementation strategy in pediatric care settings, (3) gain insight into how professionals work with the specific intervention, and (4) gain insight into the usefulness and effects of the intervention from the professionals’ perspectives.

Methods

A process evaluation design was used to study the implementation of Sisom at 4 pediatric care centers in Sweden. An extensive amount of qualitative and quantitative data was collected before, during, and after the intervention through self-report checklists, memos, and interviews with professionals. In total, 46 children, aged between 6 and 13 years, participated. The children used Sisom on two occasions during 6 months. When they used Sisom, a printed report formed the basis for a forthcoming dialogue between professionals, children, and their parents.

Results

To our knowledge, this is the first implementation study of an eHealth communication tool aimed at strengthening children’s participation in pediatric health care. Key factors for successful implementation were alignment of the solution with the values and goals of the organization, health care professionals’ beliefs in the usefulness and usability of the solution, and health care professionals’ willingness to change their professional roles guided by the solution.

Conclusions

The results from the study show that it is possible to restructure health care delivery toward a child-centered approach, if there is a willingness and preparedness in the organization to implement an eHealth solution with the aim of restructuring the way of working with children’s participation.

Implementation of a behavioral medicine approach in physiotherapy: a process evaluation of facilitation methods

Background

In a quasi-experimental study, facilitation was used to support implementation of the behavioral medicine approach in physiotherapy. The facilitation consisted of an individually tailored multifaceted intervention including outreach visits, peer coaching, educational materials, individual goal-setting, video feedback, self-monitoring in a diary, manager support, and information leaflets to patients. A behavioral medicine approach implies a focus on health related behavior change. Clinical behavioral change was initiated but not maintained among the participating physiotherapists. To explain these findings, a deeper understanding of the implementation process is necessary. The aim was therefore to explore the impact mechanisms in the implementation of a behavioral medicine approach in physiotherapy by examining dose, reach, and participant experiences.

Methods

An explorative mixed-methods design was used as a part of a quasi-experimental trial. Twenty four physiotherapists working in primary health care were included in the quasi-experimental trial, and all physiotherapists in the experimental group (n = 15) were included in the current study. A facilitation intervention based mainly on social cognitive theory was tested during a 6-month period. Data were collected during and after the implementation period by self-reports of time allocation regarding participation in different implementation methods, documentation of individual goals, ranking of the most important implementation methods, and semi-structured interviews. Descriptive statistical methods and inductive content analysis were used.

Results

The physiotherapists participated most frequently in the following implementation methods: outreach visits, peer coaching, educational materials, and individual goal-setting. They also considered these methods to be the most important for implementation, contributing to support for learning, practice, memory, emotions, self-management, and time management. However, time management support from the manager was lacking.

Conclusions

The findings indicate that different mechanisms govern the initiation and maintenance of clinical behavior change. The impact mechanisms for initiation of clinical behavior change refers to the use of externally initiated multiple methods, such as feedback on practice, time management, and extrinsic motivation. The lack of self-regulation capability, intrinsic motivation, and continued support after the implementation intervention period were interpreted as possible mechanisms for the failure of maintaining the behavioral change over time.

Key factors supporting implementation of a training program for neonatal family- centered care - a qualitative study

Background

Traditionally, the care of infants in neonatal care units has been professionally centered, paying less attention to family support. In recent years, many interventions have been developed to improve family-centered care and thereby parent and infant outcomes. Understanding the key factors of implementation of these interventions would help improve clinical practice. The aim of this study was to describe the staff’s perceptions of the implementation of the Close Collaboration with Parents Training Program and to identify the barriers and facilitators of the implementation.

Methods

A descriptive qualitative interview study was conducted in eight neonatal intensive care units in Finland. Nineteen unit managers and 32 nurses were interviewed after their unit had finished the 1.5-year training program. Data were analyzed using thematic content analysis.

Results

Key factors facilitating the implementation of the training program were multidisciplinary commitment and the staff’s motivation to change their professional role to work as the parents’ facilitator. Observable benefits promoted the implementation, as well as experiential learning as a facilitation method. The role of mentor was remarkable as a facilitator. In addition, contextual elements such as support from leadership and proper timing were important.

Conclusions

Implementation of family-centered care is facilitated by staff who is prepared to accept parents as partners and adopt a new professional role. Enough time for preparation, readiness for the change, solid support from the leadership, and a multidisciplinary approach are needed as well. Mentoring was found to be one of the key factors facilitating the change.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4256-1) contains supplementary material, which is available to authorized users.

Facilitating Implementation of Research Evidence (FIRE): an international cluster randomised controlled trial to evaluate two models of facilitation informed by the Promoting Action on Research Implementation in Health Services (PARIHS) framework

BACKGROUND

Health care practice needs to be underpinned by high quality research evidence, so that the best possible care can be delivered. However, evidence from research is not always utilised in practice. This study used the Promoting Action on Research Implementation in Health Services (PARIHS) framework as its theoretical underpinning to test whether two different approaches to facilitating implementation could affect the use of research evidence in practice.

METHODS

A pragmatic clustered randomised controlled trial with embedded process and economic evaluation was used. The study took place in four European countries across 24 long-term nursing care sites, for people aged 60 years or more with documented urinary incontinence. In each country, sites were randomly allocated to standard dissemination, or one of two different types of facilitation. The primary outcome was the documented percentage compliance with the continence recommendations, assessed at baseline, then at 6, 12, 18, and 24 months after the intervention. Data were analysed using STATA15, multi-level mixed-effects linear regression models were fitted to scores for compliance with the continence recommendations, adjusting for clustering.

RESULTS

Quantitative data were obtained from reviews of 2313 records. There were no significant differences in the primary outcome (documented compliance with continence recommendations) between study arms and all study arms improved over time.

CONCLUSIONS

This was the first cross European randomised controlled trial with embedded process evaluation that sought to test different methods of facilitation. There were no statistically significant differences in compliance with continence recommendations between the groups. It was not possible to identify whether different types and "doses" of facilitation were influential within very diverse contextual conditions. The process evaluation (Rycroft-Malone et al., Implementation Science. doi: 10.1186/s13012-018-0811-0) revealed the models of facilitation used were limited in their ability to overcome the influence of contextual factors.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN11598502 . Date 4/2/10. The research leading to these results has received funding from the European Union's Seventh Framework Programme (FP7/2007-2013) under grant agreement no. 223646.

A realist process evaluation within the Facilitating Implementation of Research Evidence (FIRE) cluster randomised controlled international trial: an exemplar

BACKGROUND

Facilitation is a promising implementation intervention, which requires theory-informed evaluation. This paper presents an exemplar of a multi-country realist process evaluation that was embedded in the first international randomised controlled trial evaluating two types of facilitation for implementing urinary continence care recommendations. We aimed to uncover what worked (and did not work), for whom, how, why and in what circumstances during the process of implementing the facilitation interventions in practice.

METHODS

This realist process evaluation included theory formulation, theory testing and refining. Data were collected in 24 care home sites across four European countries. Data were collected over four time points using multiple qualitative methods: observation (372 h), interviews with staff (n = 357), residents (n = 152), next of kin (n = 109) and other stakeholders (n = 128), supplemented by facilitator activity logs. A combined inductive and deductive data analysis process focused on realist theory refinement and testing.

RESULTS

The content and approach of the two facilitation programmes prompted variable opportunities to align and realign support with the needs and expectations of facilitators and homes. This influenced their level of confidence in fulfilling the facilitator role and ability to deliver the intervention as planned. The success of intervention implementation was largely dependent on whether sites prioritised their involvement in both the study and the facilitation programme. In contexts where the study was prioritised (including release of resources) and where managers and staff support was sustained, this prompted collective engagement (as an attitude and action). Internal facilitators' (IF) personal characteristics and abilities, including personal and formal authority, in combination with a supportive environment prompted by managers triggered the potential for learning over time. Learning over time resulted in a sense of confidence and personal growth, and enactment of the facilitation role, which resulted in practice changes.

CONCLUSION

The scale and multi-country nature of this study provided a novel context to conduct one of the few trial embedded realist-informed process evaluations. In addition to providing an explanatory account of implementation processes, a conceptual platform for future facilitation research is presented. Finally, a realist-informed process evaluation framework is outlined, which could inform future research of this nature.

TRIAL REGISTRATION

Current controlled trials ISRCTN11598502 .

Psychiatric service staff perceptions of implementing a shared decision-making tool: a process evaluation study

PURPOSE

Shared decision making, SDM, in psychiatric services, supports users to experience a greater sense of involvement in treatment, self-efficacy, autonomy and reduced coercion. Decision tools adapted to the needs of users have the potential to support SDM and restructure how users and staff work together to arrive at shared decisions. The aim of this study was to describe and analyse the implementation process of an SDM intervention for users of psychiatric services in Sweden.

METHOD

The implementation was studied through a process evaluation utilizing both quantitative and qualitative methods. In designing the process evaluation for the intervention, three evaluation components were emphasized: contextual factors, implementation issues and mechanisms of impact.

RESULTS

The study addresses critical implementation issues related to decision-making authority, the perceived decision-making ability of users and the readiness of the service to increase influence and participation. It also emphasizes the importance of facilitation, as well as suggesting contextual adaptations that may be relevant for the local organizations.

CONCLUSION

The results indicate that staff perceived the decision support tool as user-friendly and useful in supporting participation in decision-making, and suggest that such concrete supports to participation can be a factor in implementation if adequate attention is paid to organizational contexts and structures.

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

Background

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

Methods

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

Results

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

Conclusion

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

Electronic supplementary material

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

Sustainability of knowledge implementation in a low- and middle- income context: Experiences from a facilitation project in Vietnam targeting maternal and neonatal health

BACKGROUND

In a previous trial in Vietnam, a facilitation strategy to secure evidence-based practice in primary care resulted in reduced neonatal mortality over a period of three years. While little is known as to what ensures sustainability in the implementation of community-based strategies, the aim of this study was to investigate factors promoting or hindering implementation, and sustainability of knowledge implementation strategies, by means of the former Neonatal Knowledge Into Practice (NeoKIP) trial.

METHODS

In 2014 we targeted all levels in the Vietnamese healthcare system: six individual interviews with representatives at national, provincial and district levels, and six focus group discussions with representatives at the commune level. The interviews were transcribed verbatim, translated to English, and analysed using inductive and deductive thematic analysis.

RESULTS

To achieve successful implementation and sustained effect of community-based knowledge implementation strategies, engagement of leaders and key stakeholders at all levels of the healthcare system is vital-prior to, during and after a project. Implementation and sustainability require thorough needs assessment, tailoring of the intervention, and consideration of how to attain and manage funds. The NeoKIP trial was characterised by a high degree of engagement at the primary healthcare system level. Further, three years post trial, maternal and neonatal care was still high on the agenda for healthcare workers and leaders, even though primary aspects such as stakeholder engagement at all levels, and funding had been incomplete or lacking.

CONCLUSIONS

The current study illustrates factors to support successful implementation and sustain effects of community-based strategies in projects in low- and middle-income settings; some but not all factors were represented during the post-NeoKIP era. Most importantly, trials in this and similar contexts require deliberate management throughout and beyond the project lifetime, and engagement of key stakeholders, in order to promote and sustain knowledge implementation.

Enabling Continuous Quality Improvement in Practice: The Role and Contribution of Facilitation

Facilitating the implementation of continuous quality improvement (CQI) is a complex undertaking. Numerous contextual factors at a local, organizational, and health system level can influence the trajectory and ultimate success of an improvement program. Some of these contextual factors are amenable to modification, others less so. As part of planning and implementing healthcare improvement, it is important to assess and build an understanding of contextual factors that might present barriers to or enablers of implementation. On the basis of this initial diagnosis, it should then be possible to design and implement the improvement intervention in a way that is responsive to contextual barriers and enablers, often described as “tailoring” the implementation approach. Having individuals in the active role of facilitators is proposed as an effective way of delivering a context-sensitive, tailored approach to implementing CQI. This paper presents an overview of the facilitator role in implementing CQI. Drawing on empirical evidence from the use of facilitator roles in healthcare, the type of skills and knowledge required will be considered, along with the type of facilitation strategies that can be employed in the implementation process. Evidence from both case studies and systematic reviews of facilitation will be reviewed and key lessons for developing and studying the role in the future identified.

PARIHS revisited: from heuristic to integrated framework for the successful implementation of knowledge into practice

Background

The Promoting Action on Research Implementation in Health Services, or PARIHS framework, was first published in 1998. Since this time, work has been ongoing to further develop, refine and test it. Widely used as an organising or conceptual framework to help both explain and predict why the implementation of evidence into practice is or is not successful, PARIHS was one of the first frameworks to make explicit the multi-dimensional and complex nature of implementation as well as highlighting the central importance of context. Several critiques of the framework have also pointed out its limitations and suggested areas for improvement.

Discussion

Building on the published critiques and a number of empirical studies, this paper introduces a revised version of the framework, called the integrated or i-PARIHS framework. The theoretical antecedents of the framework are described as well as outlining the revised and new elements, notably, the revision of how evidence is described; how the individual and teams are incorporated; and how context is further delineated. We describe how the framework can be operationalised and draw on case study data to demonstrate the preliminary testing of the face and content validity of the revised framework.

Summary

This paper is presented for deliberation and discussion within the implementation science community. Responding to a series of critiques and helpful feedback on the utility of the original PARIHS framework, we seek feedback on the proposed improvements to the framework. We believe that the i-PARIHS framework creates a more integrated approach to understand the theoretical complexity from which implementation science draws its propositions and working hypotheses; that the new framework is more coherent and comprehensive and at the same time maintains it intuitive appeal; and that the models of facilitation described enable its more effective operationalisation.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0398-2) contains supplementary material, which is available to authorized users.