Dissemination of heart health promotion in the Ontario Public Health System: 1989-1999

Assessing Capacity for Sustainability of Effective Programs and Policies in Local Health Departments

CONTEXT

Sustainability has been defined as the existence of structures and processes that allow a program to leverage resources to effectively implement and maintain evidence-based public health and is important in local health departments (LHDs) to retain the benefits of effective programs.

OBJECTIVE

Explore the applicability of the Program Sustainability Framework in high- and low-capacity LHDs as defined by national performance standards.

DESIGN

Case study interviews from June to July 2013. Standard qualitative methodology was used to code transcripts; codes were developed inductively and deductively.

SETTING

Six geographically diverse LHD's (selected from 3 of high and 3 of low capacity)

PARTICIPANTS

: 35 LHD practitioners.

MAIN OUTCOME MEASURES

Thematic reports explored the 8 domains (Organizational Capacity, Program Adaptation, Program Evaluation, Communications, Strategic Planning, Funding Stability, Environmental Support, and Partnerships) of the Program Sustainability Framework.

RESULTS

High-capacity LHDs described having environmental support, while low-capacity LHDs reported this was lacking. Both high- and low-capacity LHDs described limited funding; however, high-capacity LHDs reported greater funding flexibility. Partnerships were important to high- and low-capacity LHDs, and both described building partnerships to sustain programming. Regarding organizational capacity, high-capacity LHDs reported better access to and support for adequate staff and staff training when compared with low-capacity LHDs. While high-capacity LHDs described integration of program evaluation into implementation and sustainability, low-capacity LHDs reported limited capacity for measurement specifically and evaluation generally. When high-capacity LHDs described program adoption, they discussed an opportunity to adapt and evaluate. Low-capacity LHDs struggled with programs requiring adaptation. High-capacity LHDs described higher quality communication than low-capacity LHDs. High- and low-capacity LHDs described strategic planning, but high-capacity LHDs reported efforts to integrate evidence-based public health.

CONCLUSIONS

Investments in leadership support for improving organizational capacity, improvements in communication from the top of the organization, integrating program evaluation into implementation, and greater funding flexibility may enhance sustainability of evidence-based public health in LHDs.

Realistic Expectations: Investing in Organizational Capacity Building for Chronic Disease Prevention

Purpose.

This article presents findings that explore investment in organizational capacity building for chronic disease prevention. Specifically, this analysis examines variation in investment inputs, intervention outputs, and capacity changes to inform expectations of health-promotion capacity-building investment.

Design/Setting.

This multiple case study involving both qualitative and quantitative data is based on seven provincial dissemination projects involved in the Canadian Heart Health Initiative.

Methods.

Data on investment, number, and type of capacity-building activities and capacity changes come from a questionnaire, key informant interviews, and project report analysis. Quantitative data were analyzed descriptively and for trends, while qualitative data were analyzed thematically.

Results.

Per capita investments in capacity building ranged from a low of $0.21 in Ontario to $167.41 in Prince Edward Island. Multiple, tailored capacity-building interventions were used in each project. Mostly positive but modest changes were observed in at least five dimensions of capacity in all but one project.

Conclusion.

These findings reveal that capacity building for chronic disease prevention requires a long-term investment and is context specific. Even limited investment can produce interventions that appear to positively influence capacity for chronic disease prevention. The findings also suggest an urgent need to expand surveillance to include indicators of capacity-building investments and interventions to allow policy makers to make more informed decisions about investments in public health.

Implementing administrative evidence based practices: lessons from the field in six local health departments across the United States

BACKGROUND

Administrative evidence based practices (A-EBPs) are agency level structures and activities positively associated with performance measures (e.g., achieving core public health functions, carrying out evidence-based interventions). The objectives of this study were to examine the contextual conditions and explore differences in local health department (LHD) characteristics that influence the implementation of A-EBPs.

METHODS

Qualitative case studies were conducted based on data from 35 practitioners in six LHDs across the United States. The sample was chosen using an A-EBP score from our 2012 national survey and was linked to secondary data from the National Public Health Performance Standards Program. Three LHDs that scored high and three LHDs that scored low on both measures were selected as case study sites. The 37-question interview guide explored LHD use of an evidence based decision making process, including A-EBPs and evidence-based programs and policies. Each interview took 30-60 min. Standard qualitative methodology was used for data coding and analysis using NVivo software.

RESULTS

As might be expected, high-capacity LHDs were more likely to have strong leadership, partnerships, financial flexibility, workforce development activities, and an organizational culture supportive of evidence based decision making and implementation of A-EBPs. They were also more likely to describe having strong or important relationships with universities and other educational resources, increasing their access to resources and allowing them to more easily share knowledge and expertise.

CONCLUSIONS

Differences between high- and low-capacity LHDs in A-EBP domains highlight the importance of investments in these areas and the potential those investments have to contribute to overall efficiency and performance. Further research may identify avenues to enhance resources in these domains to create an organizational culture supportive of A-EBPs.

Diffusion of community empowerment strategies for Aedes aegypti control in Cuba: a muddling through experience

Effective participatory strategies in dengue control have been developed and assessed as small-scale efforts. The challenge is to scale-up and institutionalize these strategies within dengue control programs. We describe and critically analyze the diffusion process of an effective empowerment strategy within the Cuban Aedes aegypti control program, focusing on decision-making at the national level, to identify ways forward to institutionalize such strategies in Cuba and elsewhere. From 2005 to 2009, we carried out a process-oriented case study. We used participant observation, in-depth interviews with key informants involved in the diffusion process and document analysis. In a first phase, the data analysis was inductive. In a second phase, to enhance robustness of the analysis, emerging categories were contrasted with Rogers' five-stage conceptual model of the innovation-decision process, which was eventually used as the analytical framework. The diffusion of the empowerment strategy was a continuous and dynamic process. Adoption was a result of the perceived potential match between the innovative empowerment strategy and the performance gap of the Ae. aegypti control program. During implementation, the strategy was partially modified by top level Ae. aegypti control program decision-makers to accommodate program characteristics. However, structure, practices and organizational culture of the control program did not change significantly. Thus rejection occurred. It was mainly due to insufficient dissemination of know-how and underlying principles of the strategy by innovation developers, but also to resistance to change. The innovation-diffusion process has produced mitigated results to date, and the control program is still struggling to find ways to move forward. Improving the innovation strategy by providing the necessary knowledge about the innovation and addressing control program organizational changes is crucial for successful diffusion of empowerment strategies. Issues highlighted in this particular experience might be relevant in the innovation-diffusion process of other complex innovations within health systems.

Using social network analysis to identify key child care center staff for obesity prevention interventions: a pilot study

INTRODUCTION

Interest has grown in how systems thinking could be used in obesity prevention. Relationships between key actors, represented by social networks, are an important focus for considering intervention in systems.

METHOD

Two long day care centers were selected in which previous obesity prevention programs had been implemented. Measures showed ways in which physical activity and dietary policy are conversations and actions transacted through social networks (interrelationships) within centers, via an eight item closed-ended social network questionnaire. Questionnaire data were collected from (17/20; response rate 85%) long day care center staff. Social network density and centrality statistics were calculated, using UCINET social network software, to examine the role of networks in obesity prevention.

RESULTS

"Degree" (influence) and "betweeness" (gatekeeper) centrality measures of staff inter-relationships about physical activity, dietary, and policy information identified key players in each center. Network density was similar and high on some relationship networks in both centers but markedly different in others, suggesting that the network tool identified unique center social dynamics. These differences could potentially be the focus of future team capacity building.

CONCLUSION

Social network analysis is a feasible and useful method to identify existing obesity prevention networks and key personnel in long day care centers.

Translation from research to practice: community dissemination of a telephone-delivered physical activity and dietary behavior change intervention

PURPOSE

To describe the process of translating an evidence-based, telephone-delivered physical activity and dietary behavior change intervention from research into practice.

DESIGN

Descriptive case study.

SETTING/SUBJECTS

Nongovernment, primary medical care-based community health organization.

INTERVENTION

Telephone-delivered intervention targeting physical activity and diet in primary medical care patients.

MEASURES/ANALYSIS

Systematic documentation of process outcomes related to intervention adoption and adaptation.

RESULTS

Research-community partnerships were critical in facilitating translation, including (1) an initial competitive advantage within a State Health Department-funded preventive health initiative; (2) advocacy to ensure the adoption of the intervention, (3) subsequent support for the adaptation of program elements to ensure fit of the program with the community organization's objectives and capacities, while maintaining feasible elements of fidelity with the original evidence-based program; (4) the integration of program management and evaluation systems within the community organization; and (5) ongoing support for staff members responsible for program delivery and evaluation. Preliminary process evaluation of the Optimal Health Program supports the acceptability and feasibility of the program within community practice.

CONCLUSIONS

INTERVENTION characteristics central to adoption can be influenced by research-community partnerships. It is likely that evidence-based interventions will need to be adapted for delivery within the real world. Researchers should endeavor to provide training and support to ensure, as much as possible, fidelity with the original program, and that the relevant adaptations are evidence based.

A national survey of organizational transfer practices in chronic disease prevention in Canada

Underuse of best practices in chronic disease prevention (CDP) represents missed opportunities to promote healthy living and prevent chronic disease. Better understanding of how CDP programs, practices and policies (PPPs) are transferred from 'resource' organizations that develop them to 'user' organizations that implement them is crucial. The objectives of this work were to develop psychometrically sound measures of transfer practices occurring within resource organizations; describe the use of these transfer practices and identify correlates of the transfer process. Cross-sectional data were collected in structured telephone interviews with the person most knowledgeable about PPP transfer in 77 Canadian organizations that develop PPPs. Independent correlates of transfer were identified using multiple linear regression. The transfer practices most commonly used included: identification of barriers to PPP adoption/implementation, tailoring transfer strategies and designing a transfer plan. Skill at planning/implementing transfer, external sources of funding specifically allocated for transfer, type of resource organization, attitude toward process of collaboration and user-centeredness were all positively associated with the transfer process. These factors represent possible targets for interventions to improve transfer of CDP PPPs.

The role of nursing best practice champions in diffusing practice guidelines: a mixed methods study

BACKGROUND

While the importance of nursing best practice champions has been widely promoted in the diffusion of evidence-based practice, there has been little research about their role. By learning more about what champions do in guideline diffusion, the nursing profession can more proactively manage and facilitate the role of champions while capitalizing on their potential to be effective leaders of the health care system.

AIM

To determine how nursing best practice champions influence the diffusion of Best Practice Guideline recommendations.

METHODS

A mixed method sequential triangulation design was used involving two phases: (1) key informant interviews with 23 champions between February and July 2006 and (2) a survey of champions (N= 191) and administrators (N= 41) from September to October 2007. Qualitative findings informed the development of surveys and were used in interpreting quantitative information collected in phase 2.

RESULTS

Most interview and survey participants were female, employed full-time, and had worked in practice for over 20 years. Qualitative and quantitative findings suggest that champions influence the use of Best Practice Guideline recommendations most readily through: (1) dissemination of information about clinical practice guidelines, specifically through education and mentoring; (2) being persuasive practice leaders at interdisciplinary committees; and (3) tailoring the guideline implementation strategies to the organizational context.

CONCLUSIONS AND IMPLICATIONS

Our research suggests that nursing best practice champions have a multidimensional role that is well suited to navigating the complexities of a dynamic health system to create positive change. Understanding of this role can help service organizations and the nursing profession more fully capitalize on the potential of champions to influence and implement evidence-based practices to advance positive patient, organizational, and system outcomes.

Dissemination of effective physical activity interventions: are we applying the evidence?

BACKGROUND

Given sparse knowledge on dissemination, this study sought to explore key benefits, barriers and contextual factors that are perceived to be important to the adoption and implementation of the 'Community Guide's' evidence-based physical activity recommendations.

DESIGN

We conducted case studies in two states where extensive adoption and implementation of the Guide's recommendations have occurred and in two states where widespread dissemination has lagged. Interviews (n = 76) were semi-structured and included both quantitative and qualitative methods. Participant perceptions from the following areas were examined: (i) priority of physical activity, (ii) awareness of and ability to define the term 'evidence-based approaches' and (iii) awareness, adoption, facilitators, benefits, challenges and barriers to Guide adoption.

RESULTS

Key enabling factors among high capacity states included: funds and direction from the Centers for Disease Control and Prevention; leadership support; capable staff; and successful partnerships and collaborations. Restraining forces among low capacity states included: the Guide recommendations being too new; participants being too new to current job; lack of time and training on how to use the Guide recommendations; limited funds and other resources and lack of leadership.

CONCLUSION

To be effective, we must gain an understanding of contextual factors when designing for dissemination.

Can the Canadian Heart Health Initiative inform the population Health Intervention Research Initiative for Canada?

OBJECTIVES

The aim of the Population Health Intervention Research Initiative for Canada (PHIRIC) is to build capacity to increase the quantity, quality and use of population health intervention research. But what capacity is required, and how should capacity be created? There may be relevant lessons from the Canadian Heart Health Initiative (CHHI), a 20-year initiative (1986-2006) that was groundbreaking in its attempt to bring together researchers and public health leaders (from government and non-government organizations) to jointly plan, conduct and act on relevant evidence. The present study focused on what enabled and constrained the ability to fund, conduct and use science in the CHHI.

METHODS

Guided by a provisional capacity-building framework, a two-step methodology was used: a CHHI document analysis followed by consultation with CHHI leaders to refine and confirm emerging findings.

RESULTS

A few well-positioned, visionary people conceived of the CHHI as a long-term, coherent initiative that would have impact, and they then created an environment to enable this to become reality. To achieve the vision, capacity was needed to a) align science (research and evaluation) with public health policy and program priorities, including the capacity to study "natural experiments" and b) build meaningful partnerships within and across sectors.

CONCLUSION

There is now an opportunity to apply lessons from the CHHI in planning PHIRIC.

Determinants of health promotion action in primary health care: comparative study of health and home care personnel in four municipalities in Finland

AIMS

The purpose of this paper is to contribute to understanding which factors influence health promotion action in primary health care (PHC) on the municipal, i.e. local, level.

METHODS

A cross-sectional mail survey of all PHC personnel in four municipalities in Finland in 2002. The data were analysed by descriptive statistics, and univariate and multivariate logistic regression analyses.

RESULTS

A total of 417 (response rate 57%) healthcare professionals participated in the study; 65% of the personnel working in ambulatory care, 52% working in home care and 44% working in inpatient care were engaged in health promotion action (=higher than median engagement). Factors independently associated with engagement in health promotion were organizational values, reflected in perceived skill discretion and social support from coworkers, and the personnel's competence, reflected in knowledge about the health and living conditions of the population served. Further, the opportunities, reflected in cooperation with partners outside the organization were strongly associated with engagement in health promotion action.

CONCLUSIONS

The results suggest that working conditions such as possibilities for skill usage, reflection and development as well as collegial support enable higher engagement in health promotion action in PHC. However, access to data on the local population's health and living conditions, in addition to opportunities to cooperate with decision makers and partners in the community turned out to be as important. This should be taken into consideration when striving to reorient health services to health promotion.

Implementation matters: a review of research on the influence of implementation on program outcomes and the factors affecting implementation

The first purpose of this review was to assess the impact of implementation on program outcomes, and the second purpose was to identify factors affecting the implementation process. Results from over quantitative 500 studies offered strong empirical support to the conclusion that the level of implementation affects the outcomes obtained in promotion and prevention programs. Findings from 81 additional reports indicate there are at least 23 contextual factors that influence implementation. The implementation process is affected by variables related to communities, providers and innovations, and aspects of the prevention delivery system (i.e., organizational functioning) and the prevention support system (i.e., training and technical assistance). The collection of implementation data is an essential feature of program evaluations, and more information is needed on which and how various factors influence implementation in different community settings.

The effect of disseminating evidence-based interventions that promote physical activity to health departments

OBJECTIVES

We explored the effect of disseminating evidence-based guidelines that promote physical activity on US health department organizational practices in the United States.

METHODS

We implemented a quasi-experimental design to examine changes in the dissemination of suggested guidelines to promote physical activity (The Guide to Community Preventive Services) in 8 study states; the remaining states and the Virgin Islands served as the comparison group. Guidelines were disseminated through workshops, ongoing technical assistance, and the distribution of an instructional CD-ROM. The main evaluation tool was a pre- and postdissemination survey administered to state and local health department staffs (baseline n=154; follow-up n=124).

RESULTS

After guidelines were disseminated through workshops, knowledge of and skill in 11 intervention-related characteristics increased from baseline to follow-up. Awareness-related characteristics tended to increase more among local respondents than among state participants. Intervention adoption and implementation showed a pattern of increase among state practitioners but findings were mixed among local respondents.

CONCLUSIONS

Our exploratory study provides several dissemination approaches that should be considered by practitioners as they seek to promote physical activity in the populations they serve.

Evidence-based interventions to promote physical activity: what contributes to dissemination by state health departments

BACKGROUND

Evidence-based guidelines for promoting physical activity have been produced, yet sparse information exists on the dissemination of effective interventions. The purpose of this study was to better understand the dissemination of physical activity interventions across the United States, focusing particularly on evidence-based guidelines.

DESIGN

A cross-sectional study was conducted in the U.S. that was organized around a modified version of the diffusion of innovations theory.

SETTING/PARTICIPANTS

Respondents (n=49) were the physical activity contact person (e.g., program administrator, health educator) in each state or territorial health department.

MAIN OUTCOME MEASURES

Seven specific programs and policies relating to physical activity intervention were examined as dependent variables. Five additional domains--organizational climate, awareness, adoption, implementation, and maintenance--framed a set of independent variables.

RESULTS

The most important factor related to decision making was the availability of adequate resources. Most respondents (89.8%) were aware of evidence-based guidelines to promote physical activity. However, less than half of the respondents (41%) had the authority to implement evidence-based programs and policies. A minority of respondents reported having support from their state governor (35.4%) or from most of their state legislators (21.3%). Several key factors were associated with the adoption of evidence-based interventions, including the presence of state funding for physical activity, whether the respondent participated in moderate physical activity, presence of adequate staffing, and presence of a supportive state legislature.

CONCLUSIONS

Awareness of the importance of promoting physical activity is relatively high in state and territorial health departments; however, the levels of internal support within the health department appear to outweigh any outside support from elected officials.

Understanding Facilitators of and Barriers to Health Promotion Practice

The health promotion best practices literature is imbued with hope for knowledge mobilization, enhanced practice, and improved population health. Given constrained medical care systems, health promotion is key to reducing the significant burden of chronic disease. However, we have seen little evidence of change. This article investigates facilitators of, and barriers to, three stages of health promotion practice in public health organizations, interagency coalitions, and volunteer committees. The article focuses not on what works but why it does or does not, drawing on five case studies within the Canadian Heart Health Initiative. Results indicate that the presence or absence of appropriately committed and/or skilled people, funds and/or resources, and priority and/or interest are the most common factors affecting all stages of health promotion practice. The article extends the literature on internal and external factors affecting health promotion and highlights strategic influences to consider in support of effective health promotion practice.

Assessment of intervention intensity: experiences from a small-scale Swedish cardiovascular disease prevention programme

AIMS

To study the context of an intervention programme, including possible competing demands between an intervention and other health service assignments, and to develop a measure of intervention intensity.

METHODS

Data used include questionnaires and interviews with intervention staff, protocols, and reports from the intervention programme, and cross-sectional health surveys. A new Intervention Intensity Score (IIS) is used as an indicator of the intensity of the intervention.

RESULTS

Initially the intensity of support and activity of the programme was high and some cardiovascular risk factors such as cholesterol and daily smoking declined. There were favourable allocations of resources in the setting and enthusiasm. Later, disturbing changes in the organisation, competing demands within Primary Health Care (PHC), and an incipient decline of the intervention intensity occurred. These changes accelerated and finally the intervention intensity faded out, parallel to unfavourable risk factor changes. The Intervention Intensity Score (IIS) is useful as an indicator in the interpretation of programme effectiveness.

CONCLUSIONS

The amount and quality of support, the intervention process itself, and the intervention intensity were determining factors of the achievements of this intervention programme. The IIS measure used in this study provides a feasible way to interpret and understand achievements and shortcomings of the intervention programme.

Using linking systems to build capacity and enhance dissemination in heart health promotion: a Canadian multiple-case study

The purpose of this paper is to examine the utility of linking systems between public health resource and user organizations for health promotion dissemination and capacity building, and to identify factors related to the success of linking systems. The design is a parallel-case study using key informant interviews and content analysis of project reports (synthesized qualitative and quantitative data) of three provincial dissemination projects of the Canadian Heart Health Initiative-Dissemination Phase. Each provincial project used linking activities with public health user groups including meetings, skill building, resources, collaboration, networking and research feedback to facilitate capacity building for and implementation of heart health promotion activities. This paper presents empirical examples of linking system designs, activities, and qualitative and quantitative changes in the public health user groups' health promotion capacity, program delivery and sustainability. The findings indicate enhanced health promotion skills, partnerships, resources, infrastructure, and increased programming and sustainability in the targeted public health organizations of all three provincial projects. Identified barriers to the success of linking systems included lack of appropriately skilled personnel, funds, buy-in and leadership. We conclude that linking systems can be flexibly used to build capacity and disseminate health promotion innovations, and suggest conditions for success.