Design and implementation of an integrated, continuous evaluation, and quality improvement system for a state-based home-visiting program

Contextual factors influencing the implementation of the obstetrics hemorrhage initiative in Florida

OBJECTIVE

The purpose of this study was to explore the multilevel contextual factors that influenced the implementation of the Obstetric Hemorrhage Initiative (OHI) among hospitals in Florida.

STUDY DESIGN

A qualitative evaluation was conducted via in-depth interviews with multidisciplinary hospital staff (n=50) across 12 hospitals. Interviews were guided by the Consolidated Framework for Implementation Research and analyzed in Atlas.ti using rigorous qualitative analysis procedures.

RESULT

Factors influencing OHI implementation were present across process (leadership engagement; engaging people; planning; reflecting), inner setting (for example, knowledge/beliefs; resources; communication; culture) and outer setting (for example, cosmopolitanism) levels. Moreover, factors interacted across levels and were not mutually exclusive. Leadership and staff buy-in emerged as important components influencing OHI implementation across disciplines.

CONCLUSION

Key contextual factors found to influence OHI implementation experiences can be useful in informing future quality improvement interventions given the institutional and provider-level behavioral changes needed to account for evolving the best practices in perinatology.

Using quality improvement to promote implementation and increase well child visits in home visiting

A key goal of home visiting is to connect children with medical homes through anticipatory guidance regarding recommended well child care (WCC). Substantial barriers to WCC among low socioeconomic families can limit achievement of this outcome. Quality improvement strategies have been widely adopted in healthcare but only recently implemented in home visiting to achieve program outcomes. The objective of this initiative was to increase the percentage of infants enrolled in home visiting who completed at least 3 recommended WCC visits in the first 6 months of life within a large, multi-model program comprised of 11 sites. A series of 33 quality improvement cycles were conducted at 3 sites involving 18 home visitors and 139 families with infants in the target age range. These were deployed sequentially, and changes within and across sites were monitored using trend charts over time. Adopted strategies were then implemented program-wide. Initiatives focused on staff training in WCC recommendations, data collection processes, monthly family tracking reports, and enhanced communication with primary care offices. Data were shared in iterative sessions to identify methods for improving adherence. Wide baseline variability across sites was observed, with the percentage of infants with recommended care ranging from 35% to 83%. Over the project timeline, the percentage of infants receiving at least 3 WCC visits in the first 6 months increased from 58% to 86%. Quality improvement within home visiting can be used to improve WCC adherence and provides an example of maximizing implementation of home visiting interventions.

Adherence and Dosage Contributions to Parenting Program Quality

OBJECTIVE

The 3 most frequently examined elements of treatment fidelity are adherence, dosage, and quality. The relationships between these fidelity elements are complex, and additional research is needed to provide clarity. Improving clarity may be especially relevant to parenting programs, which tend to include direct explicit instruction (DEI) elements (i.e., instruction, modeling, and practice). The adherence to and dosage of these DEI elements are frequently assumed to improve program quality; however, little information is available to determine if such adherence and dosage affect program quality. This study examines whether adherence to and dosage of DEI elements predict quality ratings for a widely disseminated, manualized parenting program.

METHOD

Adherence is defined as the percentage of intervention tasks completed for each DEI element. Dosage is defined as the number of minutes and seconds spent in each intervention DEI element. Treatment fidelity is assessed for 36 of 144 sessions across 10 program facilitators. A hierarchical linear regression analysis examines the contributions of adherence and dosage in the prediction of session quality ratings.

RESULTS

The analysis indicates that adherence accounts for a significant proportion of the variance (26%), whereas dosage contributes a nonsignificant proportion of variance (11%). Adherence to skill practice was the strongest individual predictor (β = .445, p < .01).

CONCLUSIONS

Findings suggest that ensuring a high degree of adherence can contribute to quality program delivery. However, more exploration is needed to better understand the ways in which adherence and dosage of DEI elements affect program quality.

Parental expectations of maternal and child health services

This article reports on survey research (N = 1,418) aimed at examining whether parental expectations of maternal and child health (MCH) services are influenced by group characteristics (e.g., socioeconomic status [SES], ethnicity, at risk of poverty) and/or individual parenting context variables (e.g., received social support) in a context where these services are available to all. The findings reveal that parents have different expectations about the technical and relational expertise of MCH nurses. However, the authors found only very weak associations between family characteristics and parental expectations, suggesting that individual differences matter more than SES and other more traditional distinctions. Implications for MCH services are made.

Intervention dose estimation in health promotion programmes: a framework and a tool. Application to the diet and physical activity promotion PRALIMAP trial

Background

Although the outcomes of health promotion and prevention programmes may depend on the level of intervention, studies and trials often fail to take it into account. The objective of this work was to develop a framework within which to consider the implementation of interventions, and to propose a tool with which to measure the quantity and the quality of activities, whether planned or not, relevant to the intervention under investigation. The framework and the tool were applied to data from the diet and physical activity promotion PRALIMAP trial.

Methods

A framework allowing for calculation of an intervention dose in any health promotion programme was developed. A literature reviews revealed several relevant concepts that were considered in greater detail by a multidisciplinary working group. A method was devised with which to calculate the dose of intervention planned and that is actually received (programme-driven activities dose), as well as the amount of non-planned intervention (non-programme-driven activities dose).

Results

Indicators cover the roles of all those involved (supervisors, anchor personnel as receivers and providers, targets), in each intervention-related groups (IRG: basic setting in which a given intervention is planned by the programme and may differ in implementation level) and for every intervention period. All indicators are described according to two domains (delivery, participation) in two declensions (quantity and quality). Application to PRALIMAP data revealed important inter- and intra-IRG variability in intervention dose.

Conclusions

A literature analysis shows that the terminology in this area is not yet consolidated and that research is ongoing. The present work provides a methodological framework by specifying concepts, by defining new constructs and by developing multiple information synthesis methods which must be introduced from the programme's conception. Application to PRALIMAP underlined the feasibility of measuring the implementation level. The framework and the tool can be used in any complex programme evaluation. The intervention doses obtained could be particularly useful in comparative trials.

Trial registration

PRALIMAP is registered at ClinicalTrials.gov under NCT00814554