Moving towards a new vision: implementation of a public health policy intervention

What can healthcare systems learn from looking at tensions in innovation processes? A systematic literature review

Background

Until now, scholarship on innovation processes in healthcare systems lack an in-depth appreciation of tensions. Tensions often revolve around barriers and result from individual assessments and prioritizations that guide actions to eventually overcome these barriers. In order to develop a more differentiated understanding of tensions’ role in healthcare innovation processes, this paper aims to shed light on the multifaceted ways in which tensions emerge, are being dealt with, and how they hinder or, at times, facilitate innovation processes.

Methods

A systematic review of published and grey literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline. The review involved searching three databases for original research articles and manually searching citations. Twenty-nine original full texts were identified, evaluated, and coded. These include papers on innovation in healthcare systems that investigated innovation-related organizational tensions. The findings were synthesized into different types of tensions in healthcare system innovation and the descriptions of the conflicting elements. We also analyzed the investigated innovations by type, process stages, and across different countries and healthcare systems.

Results

A total of forty-two tensions were identified and grouped into nine categories. Organizing tensions were predominant, followed by learning/belonging, performing, and performing/organizing tensions. Tensions most frequently occurred in the implementation phase and in the form of a dilemma. Included studies were conducted mainly in government-funded healthcare systems.

Conclusion

Our data suggest that innovation processes in healthcare systems are impaired by conflicts between contradictory elements, working cultures, and convictions and the organizational and regulatory context. Since the majority of the tensions we collected in our study can be addressed, future policy-making and research should take advantage of this fact and develop strategies that significantly influence the successful management of tensions and thus improve the implementation of innovations.

Self-reported competences of public health nurses for developing needs-oriented local healthcare plans: A nationwide cross-sectional survey

AIM

To identify self-reported competencies of public health nurses for reflecting community healthcare needs in local healthcare plans.

DESIGN

We conducted a nationwide cross-sectional survey in Japan from October 7-November 30, 2019.

METHODS

We sent 2,185 self-reported questionnaires to public health nurses in Japan who had developed a local healthcare plan since 2013. Self-reported questionnaires included questions regarding demographic data and the reflection of community healthcare needs in local healthcare plans, and the involvement in local healthcare planning.

RESULTS

We analysed 1,042 questionnaires: 651 (62.5%) were from public health nurses who reported that they elicited and shared community views to be reflected for purposes of local healthcare planning (the reflecting group), and 391 (37.5%) of the remaining public health nurses who reported that they did not do so (the non-reflecting group). The logistic regression analysis revealed that public health nurses in the reflecting group were more likely to be in a managerial position, have colleagues who played an active role in healthcare planning, conduct a questionnaire survey, engage in group work, participate in a municipal healthcare planning committee with community-dwelling people, and identify the opinions of the professional organizations.

CONCLUSIONS

Identifying community healthcare needs through collaboration with community-dwelling people and professional organizations should be essential competencies for public health nurses (the reflecting group) in developing needs-oriented local healthcare plans.

IMPACT

Identification of their related competencies for developing a needs-oriented local healthcare plan as an upstream strategy to mitigate the prevalence of health inequities in each community.

Quantitative measures of health policy implementation determinants and outcomes: a systematic review

BACKGROUND

Public policy has tremendous impacts on population health. While policy development has been extensively studied, policy implementation research is newer and relies largely on qualitative methods. Quantitative measures are needed to disentangle differential impacts of policy implementation determinants (i.e., barriers and facilitators) and outcomes to ensure intended benefits are realized. Implementation outcomes include acceptability, adoption, appropriateness, compliance/fidelity, feasibility, penetration, sustainability, and costs. This systematic review identified quantitative measures that are used to assess health policy implementation determinants and outcomes and evaluated the quality of these measures.

METHODS

Three frameworks guided the review: Implementation Outcomes Framework (Proctor et al.), Consolidated Framework for Implementation Research (Damschroder et al.), and Policy Implementation Determinants Framework (Bullock et al.). Six databases were searched: Medline, CINAHL Plus, PsycInfo, PAIS, ERIC, and Worldwide Political. Searches were limited to English language, peer-reviewed journal articles published January 1995 to April 2019. Search terms addressed four levels: health, public policy, implementation, and measurement. Empirical studies of public policies addressing physical or behavioral health with quantitative self-report or archival measures of policy implementation with at least two items assessing implementation outcomes or determinants were included. Consensus scoring of the Psychometric and Pragmatic Evidence Rating Scale assessed the quality of measures.

RESULTS

Database searches yielded 8417 non-duplicate studies, with 870 (10.3%) undergoing full-text screening, yielding 66 studies. From the included studies, 70 unique measures were identified to quantitatively assess implementation outcomes and/or determinants. Acceptability, feasibility, appropriateness, and compliance were the most commonly measured implementation outcomes. Common determinants in the identified measures were organizational culture, implementation climate, and readiness for implementation, each aspects of the internal setting. Pragmatic quality ranged from adequate to good, with most measures freely available, brief, and at high school reading level. Few psychometric properties were reported.

CONCLUSIONS

Well-tested quantitative measures of implementation internal settings were under-utilized in policy studies. Further development and testing of external context measures are warranted. This review is intended to stimulate measure development and high-quality assessment of health policy implementation outcomes and determinants to help practitioners and researchers spread evidence-informed policies to improve population health.

REGISTRATION

Not registered.

Perspectives from South African dietitians on infant and young child feeding regulations

OBJECTIVE

This study aimed to determine the knowledge, perceptions and practices of dietitians in South Africa regarding the Regulations Relating to Foodstuffs for Infants and Young Children (R991).

DESIGN

A mixed methods, cross-sectional design was used.

SETTING

Quantitative data were collected using an online survey (n 282) and qualitative data by means of two focus group discussions (n 12).

PARTICIPANTS

Participants were dietitians registered with the Health Professions Council of South Africa.

RESULTS

Dietitians' average knowledge score was 64·8 % ± 12·5. Those working in infant and young child feeding had a 5 % higher knowledge score (95 % CI 1·4, 8·6, P = 0·01). Perceptions towards the Regulations were generally positive, and the majority of practices were compliant. Positive perceptions seemed to correlate with compliant practices. The most frequently selected enabler to the implementation of the Regulations was 'Increase in other initiatives which support, protect and promote breastfeeding', and the most frequently selected barrier was 'Lack of awareness of the Regulation among health care providers'. The major themes from the focus group discussions comprised: less knowledge among dietitians and mothers about products controlled under the Regulations, non-compliance of other health care providers, the dietitians' role in support and enforcement, the discrepancy between practice in private and public sectors and a lack of enforcement.

CONCLUSIONS

South Africa has taken a bold step in legislating the International Code of Marketing of Breast-milk Substitutes and should upscale programmes to ensure consistent monitoring and enforcing of the Regulations.

Developing a new health-related policy analysis tool: An action research cooperative inquiry approach

AIM

To develop a tool for the analysis of nursing, midwifery and health-related policy and professional guidance documents.

BACKGROUND

Analysis tools can aid both policy evaluation and policy development. However, no framework for analysing the content of professional regulation and guidance documents among health care professionals currently exists.

METHOD

This study used an action research, cooperative inquiry design. Data were generated from two integrative literature reviews and discussions held during the cooperative inquiry meetings.

RESULTS

A set of key themes to be considered in the development or evaluation of health policy or professional regulation and guidance documents were identified. These themes formed the basis of the six domains considered by the Health-related Policy Analysis Tool (HrPAT): Context, Process, Content, Stakeholder Consultation, Implementation and Evaluation.

CONCLUSION

Use of the HrPAT can assist in policy development, evaluation and implementation, as well as providing some retrospective analytical insights into existing health policies.

IMPLICATION FOR NURSING MANAGEMENT

Professional regulation documents, guidelines and policy reports should be capable of being scrutinized for their content, quality and developmental process. The HrPAT can assist relevant stakeholders in the development, analysis and evaluation of such documents, including local, service-level policies and guidelines.

Effectiveness of an educational program for mid-level Japanese public health nurses to improve program planning competencies: A preliminary randomized control trial

OBJECTIVE

To evaluate the effectiveness of an education program for mid-level Japanese public health nurses (PHNs) to improve their competencies in program planning, which will fulfill community health needs.

DESIGN

Randomized control trial.

SAMPLE

During 2017, 103 PHNs with 5-20 years of PHN work experience in Japan were enrolled and randomly allocated to the intervention (n = 51) or control group (n = 52).

MEASUREMENTS

The primary outcome measured competency in program planning based on Competency Measurement of Creativity for PHNs (CMC), knowledge, and skills regarding program planning.

INTERVENTION

Six web-based learning modules followed by two face-to-face group sessions.

RESULTS

The PHN participants averaged about 12 years of experience. In the intervention group, 25 PHNs completed all modules (49.0%). Post intervention, there were no statistically significant differences among any between-group CMC scores. However, the intervention group's CMC 3 score was significantly higher than that of the control group of ≥12 years of experience. Total knowledge and skill scores also improved significantly in the intervention group compared with the control group.

CONCLUSIONS

The results suggest that PHNs with ≥12 years of experience are a suitable target of this educational program, and should play a key role in program planning.

Embracing complexity and uncertainty to create impact: exploring the processes and transformative potential of co-produced research through development of a social impact model

The potential use, influence and impact of health research is seldom fully realised. This stubborn problem has caused burgeoning global interest in research aiming to address the implementation ‘gap’ and factors inhibiting the uptake of scientific evidence. Scholars and practitioners have questioned the nature of evidence used and required for healthcare, highlighting the complex ways in which knowledge is formed, shared and modified in practice and policy. This has led to rapid expansion, expertise and innovation in the field of knowledge mobilisation and funding for experimentation into the effectiveness of different knowledge mobilisation models. One approach gaining prominence involves stakeholders (e.g. researchers, practitioners, service users, policy-makers, managers and carers) in the co-production, and application, of knowledge for practice, policy and research (frequently termed integrated knowledge translation in Canada). Its popularity stems largely from its potential to address dilemmas inherent in the implementation of knowledge generated using more reductionist methods. However, despite increasing recognition, demands for co-produced research to illustrate its worth are becoming pressing while the means to do so remain challenging. This is due not only to the diversity of approaches to co-production and their application, but also to the ways through which different stakeholders conceptualise, measure, reward and use research. While research co-production can lead to demonstrable benefits such as policy or practice change, it may also have more diffuse and subtle impact on relationships, knowledge sharing, and in engendering culture shifts and research capacity-building. These relatively intangible outcomes are harder to measure and require new emphases and tools. This opinion paper uses six Canadian and United Kingdom case studies to explore the principles and practice of co-production and illustrate how it can influence interactions between research, policy and practice, and benefit diverse stakeholders. In doing so, we identify a continuum of co-production processes. We propose and illustrate the use of a new ‘social model of impact’ and framework to capture multi-layered and potentially transformative impacts of co-produced research. We make recommendations for future directions in research co-production and impact measurement.

Determinants of an integrated public health approach: the implementation process of Greenland's second public health program

Background

Greenland struggles with a high prevalence of smoking, alcohol and drug abuse. In response to the increasing need for preventive initiatives, the first public health program Inuuneritta was introduced in 2007. Internationally, frameworks focus primarily on the implementation of a single, well-described intervention or program. However, with the increasing need and emergence of more holistic, integrated approaches, a need for research investigating the process of policy implementation from launch to action arises. This paper aims to augment the empirical evidence on the implementation of integrated health promotion programs within a governmental setting using the case of Inuuneritta II. In this study, the constraining and enabling determinants of the implementation processes within and across levels and sectors were examined.

Methods

Qualitative methods with a transdisciplinary approach were applied. Data collection consisted of six phases with different qualitative methods applied to gain a comprehensive overview and understanding of Inuuneritta II’s implementation process. These methods included: observations and focus group discussions at the community health worker (CHW) conference, telephone interviews, document analysis, and a workshop on results dissemination.

Results

Enabling determinants influencing the implementation process of Inuuneritta II positively were high motivation among adopters, local prevention committees supporting community health workers, and the initiation of the central prevention committee. In contrast, constraining determinants were ambiguous program aims, high turnovers, siloed budgets and work environments, and an inconsistent and neglected central prevention committee.

Conclusion

Inuuneritta II provided a substantial framework for an integrated health policy approach. However, having a holistic and comprehensive program enabling an integrated approach is not sufficient. Inuuneritta II’s integrated approach does not harmonise with the government’s inflexible organisational structure resulting in insufficient implementation.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6253-4) contains supplementary material, which is available to authorized users.

A mixed methods evaluation of capturing and sharing practitioner experience for improving local tobacco control strategies

Objective

Practitioner experience is one type of evidence that is used in public health planning and action. Yet, methods for capturing and sharing experience are under-developed. We evaluated the reach, uptake and use of an example of capturing and sharing practitioner experience from tobacco control known as documentation of practice (DoP) reports.

Methods

The participatory, mixed methods approach included the following: a document review to capture data related to the extent and how DoP reports reached the target population; an online survey to assess awareness, use and perceptions about DoP reports; and semi-structured interviews to identify and explore examples of instrumental, conceptual and symbolic use of DoP reports. The samples for the survey and interviews included tobacco control practitioners from public health units in Ontario, Canada.

Results

Seventy-three individuals participated in the survey and 10 were interviewed. Awareness of at least one DoP report was high. The most common way of learning about DoP reports was email. DoP reports focused on policy issues had highest use; these reports were used in conceptual (helped raise awareness), instrumental (directly informed local policy development) and symbolic (confirmed a choice already made) ways. DoP reports may be improved with key messages, shorter development timelines, more relevant topic selection and dissemination to audiences beyond public health.

Conclusion

DoP reports are useful to public health practitioners working in tobacco control within Ontario; refinements to development and dissemination processes will enhance use. Future studies and adaptations of DoP reports could help improve use of practitioner experience as one source of evidence informing public health practice.

Electronic supplementary material

The online version of this article (10.17269/s41997-018-0153-3) contains supplementary material, which is available to authorized users.

The application of implementation science theories for population health: A critical interpretive synthesis

BACKGROUND AND PURPOSE

Over the last decade, the field of implementation science (IS) has yielded an array of theoretical approaches to clarify and understand how factors influence the application and scaling-up of evidence-based practice in health care. These developments have led to questions about whether IS theories and frameworks might be of value to population health researchers and decision makers. The purpose of this research was to conduct a critical interpretive synthesis to explore, if, and how, key IS theories and frameworks might inform population health interventions aimed at reducing the burden of illness across populations.

METHODS

An initial list of theories and frameworks was developed based on previous published research and narrowed to focus on theories considered as formative for the field of IS. A standardized data extraction form was used to gather key features of the theories and critically appraise their relevance to population health interventions.

RESULTS

Ten theories were included in the review and six deemed most applicable to population health based on their consideration of broader contextual and system-level factors. The remaining four were determined to have less relevant components for population health due to their limited consideration of macro-level factors, often focusing on micro (individual) and meso (organizational) level factors.

CONCLUSIONS

Theories and frameworks are important to guide the implementation and sustainability of population health interventions. The articulation of meso level factors common in IS theories may be of value to interventions targeted at the population level. However, some of the reviewed theories were limited in their consideration of broader contextual factors at the macro level (community, policy or societal). This critical interpretive synthesis also found that some theories lacked provision of practical guidance to address interventions targeting structural factors such as key social determinants of health (e.g., housing, income).