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PubMed2001

The implementation of venous leg ulcer guidelines: process analysis of the intervention used in a multi-centre, pragmatic, randomized, controlled trial.

The production and implementation of clinical practice guidelines is currently a high political priority and a rapidly developing field within healthcare in the United Kingdom (UK). Their purpose is to provide clinicians with a synthesis of the best available external evidence and operationalize the implementation of evidence-based practice. Despite indications that clinical guidelines can make a difference to the quality of patient care, there is some evidence that practitioners struggle with their application. The aim of this paper is to report one element of a trial undertaken by three collaborating universities in the Northern and Yorkshire Region of the UK health service during 1997-1998. The objective was to understand what makes guidelines acceptable and usable, or otherwise, to health professionals. The findings reported in this paper describe the process of care in those general practices that elected to implement guidelines for the management of patients with venous leg ulcers. We conclude that planning for training, resource and quality improvement processes must be built into a team's guidelines implementation procedures. A preliminary needs analysis of the contextual 'hurdles and levers' within each primary healthcare team is also necessary to identify individual issues that must be addressed if the process is to succeed. These findings provide some lessons for successful implementation of clinical guidelines in general. Recommendations for nursing policy makers, managers, practitioners and researchers are included.

Attitude of Health Personnel↗

PubMed2003

Methodology for evaluating physician order entry (POE) implementations.

The body of physician order entry (POE) implementations literature uses statistical evaluation methods to demonstrate changes in specified variables after POE implementation. To understand and manage the holistic impact of POE on the health care institution, a methodology that utilizes feedback to guide the POE implementation towards the satisfaction of stakeholder objectives is presented. Stakeholders jointly define quantitative and qualitative metrics for their objectives, establish target value vectors for the metrics that represent acceptable implementation outcomes and specify evaluation milestones. These are used to compare pre- and post-POE implementation clinical performance, enabling a socio-technical feedback-improvement cycle. A case study is provided to illustrate how the methodology is being used at Sunnybrook and Women's College Health Science Centre in Toronto, Canada.

Drug Prescriptions↗

PubMed2000

Use of scheme-based problem solving: an evaluation of the implementation and utilization of schemes in a clinical presentation curriculum.

CONTEXT: The University of Calgary has implemented a new curriculum which is organized according to 120 ways in which patients may present to a physician. Students are taught scheme-based problem solving rather than the more typical hypothetico-deductive or search and scan approach to problem resolution. OBJECTIVE: This study sought to determine the extent to which faculty and students were implementing and utilizing scheme-based problem solving. METHOD: All classes taught within the new clinical presentation curriculum were surveyed at the year end. Participants included four classes of first-year students and three classes of second-year students. Using a 5-point scale, students responded to survey items regarding scheme implementation and utilization. RESULTS: Data were analysed using MANOVA (multivariate analysis of variance) and revealed significant differences among classes in both first- and second-year students. Increments in scheme implementation and utilization by instructors and students were observed, although instructors' utilization of schemes lagged behind that of students. A levelling effect to the benefits of schemes for problem solving was also evident. First-year students reported schemes to be very useful for learning and organizing new information. CONCLUSION: Although it has taken time to implement curriculum change, the student response to schemes has been favourable. Faculty development and further generation of pictorial/spatial representations for all schemes, to ensure that all clinical presentations provide pathways that students can use for both learning and problem solving are recommended. Whether students who utilize schemes are more successful problem solvers is not yet known but will be the subject of study as soon as scheme delivery is predominant.

Adult↗

PubMed2003

Implementation of problem-based learning in Asian medical schools and students' perceptions of their experience.

BACKGROUND: Since the introduction of problem-based learning (PBL) at McMaster University in 1969, many medical schools in the USA, Canada and Europe have included PBL in their curricula. In the past decade, many medical schools in Asia have also done so. However, so far no one has questioned whether the outcomes expected of the learner in a PBL setting are applicable to students from different cultural upbringings. AIM: The aim of this study was to investigate the implementation of PBL in Asian medical schools, their students' perceptions of this new mode of teaching/learning and how the problems that have arisen may be overcome. METHOD: Published reports and conference presentations were gathered on the implementation of PBL in some Asian medical schools and comparisons of the experiences in PBL of Asian and students of other ethnic backgrounds. RESULTS: Most Asian medical schools and their students appear to be positive about adapting to PBL in their curriculum. The positive and negative observations appear to be similar to those experienced in non-Asian medical schools. The problems that arose for students in Asian medical schools in the early stages of implementing PBL appear to have been overcome after a period of adjustment with the help of supportive and open-minded tutors. The reports also suggested that trigger problems should be carefully designed to make them relevant and interesting for the students. CONCLUSION: Strong support from the academic administrators (dean and other staff responsible for implementation of the curriculum) in the introduction of PBL into the curriculum and careful training of both faculty and students appear to be key factors to ensure the successful implementation of PBL in Asian medical schools.

Asia↗

PubMedDate not supplied

The New England division Tell A Friend program implementation evaluation.

Tell A Friend (TAF) is the nationwide program of the American Cancer Society that aims to decrease breast cancer mortality by encouraging unscreened women to have mammograms using a peer-to-peer approach. An evaluation via the Collaborative Evaluation Fellows Project attempted to identify barriers and facilitators to successful implementation of TAF in the New England division. The proposed method included three surveys; this was revised because of a low response rate to the initial e-mailed survey. The actual method included one shortened survey and one follow-up survey. Results are presented for an initial and shortened survey for staff and a follow-up survey of respondents. Initial TAF implementation timelines were unrealistic, and the field staff encountered many barriers to implementation of TAF in the targeted communities. Changes are being made in training, management, and resources to ensure successful implementation. Continuous re-evaluation is planned to ensure the successful implementation and conduct of the program.

Breast Neoplasms↗

PubMed2001

Protocol implementation in hospital infection control practice: an Italian experience of preoperative antibiotic prophylaxis.

This study evaluates the effectiveness of a protocol implemented to induce behavioural modifications in healthcare workers (HCWs). A preoperative antibiotic prophylaxis protocol for surgical procedures in clean and clean-contaminated wounds was used. The study was conducted in a 300-bed Italian university hospital between 1998 and 1999. The protocol's impact was analysed by retrospective examination of the clinical records for selected common surgical procedures. The study also investigated the reasons for the low compliance with the protocol through a focus group methodology. We examined 723 surgical procedures and the overall compliance was 30.8% (56/182) before the implementation of the protocol and 45.2% (76/168) after 1 year (P< or = 0.01). During the same period compliance with the use of antibiotics increased when antibiotics were recommended by the protocol (5/115 vs. 19/109, P< or = 0.01) and use decreased when they were not (51/67 vs. 57/59, P< or = 0.01). As reported in the focus groups, reasons for low compliance included hospital policy weaknesses in protocol definition and implementation and the cultural behaviour of HCWs. Our results reinforce previous findings that monitoring the effectiveness of protocol implementation in the medical care setting is essential. Critical points that might increase the effectiveness of protocol implementation have also been identified.

Anti-Bacterial Agents↗

PubMed2004

Towards an accurate representation of electrostatics in classical force fields: efficient implementation of multipolar interactions in biomolecular simulations.

The accurate simulation of biologically active macromolecules faces serious limitations that originate in the treatment of electrostatics in the empirical force fields. The current use of "partial charges" is a significant source of errors, since these vary widely with different conformations. By contrast, the molecular electrostatic potential (MEP) obtained through the use of a distributed multipole moment description, has been shown to converge to the quantum MEP outside the van der Waals surface, when higher order multipoles are used. However, in spite of the considerable improvement to the representation of the electronic cloud, higher order multipoles are not part of current classical biomolecular force fields due to the excessive computational cost. In this paper we present an efficient formalism for the treatment of higher order multipoles in Cartesian tensor formalism. The Ewald "direct sum" is evaluated through a McMurchie-Davidson formalism [L. McMurchie and E. Davidson, J. Comput. Phys. 26, 218 (1978)]. The "reciprocal sum" has been implemented in three different ways: using an Ewald scheme, a particle mesh Ewald (PME) method, and a multigrid-based approach. We find that even though the use of the McMurchie-Davidson formalism considerably reduces the cost of the calculation with respect to the standard matrix implementation of multipole interactions, the calculation in direct space remains expensive. When most of the calculation is moved to reciprocal space via the PME method, the cost of a calculation where all multipolar interactions (up to hexadecapole-hexadecapole) are included is only about 8.5 times more expensive than a regular AMBER 7 [D. A. Pearlman et al., Comput. Phys. Commun. 91, 1 (1995)] implementation with only charge-charge interactions. The multigrid implementation is slower but shows very promising results for parallelization. It provides a natural way to interface with continuous, Gaussian-based electrostatics in the future. It is hoped that this new formalism will facilitate the systematic implementation of higher order multipoles in classical biomolecular force fields.

Algorithms↗

PubMed2003

Dynamic finite element implementation of nonlinear, anisotropic hyperelastic biological membranes.

We present a novel method for the implementation of hyperelastic finite strain, non-linear strain-energy functions for biological membranes in an explicit finite element environment. The technique is implemented in LS-DYNA but may also be implemented in any suitable non-linear explicit code. The constitutive equations are implemented on the foundation of a co-rotational uniformly reduced Hughes-Liu shell. This shell is based on an updated-Lagrangian formulation suitable for relating Cauchy stress to the rate-of-deformation, i.e. hypo-elasticity. To accommodate finite deformation hyper-elastic formulations, a co-rotational deformation gradient is assembled over time, resulting in a formulation suitable for pseudo-hyperelastic constitutive equations that are standard assumptions in biomechanics. Our method was validated by comparison with (1) an analytic solution to a spherically-symmetric dynamic membrane inflation problem, incorporating a Mooney-Rivlin hyperelastic equation and (2) with previously published finite element solutions to a non-linear transversely isotropic inflation problem. Finally, we implemented a transversely isotropic strain-energy function for mitral valve tissue. The method is simple and accurate and is believed to be generally useful for anyone who wishes to model biologic membranes with an experimentally driven strain-energy function.

Animals↗

PubMedDate not supplied

Quality assurance growing pains: a state perspective on implementing an organizational-wide quality system in environmental laboratories.

To implement an effective and efficient quality system in a network of established environmental testing laboratories requires a committed long-term effort that is potentially fraught with multiple obstacles. This presentation discusses one state's ongoing efforts at implementing such a system. First is the need to convince management of the rationale for a quality systems-based approach versus the traditional QA/QC program. Once development of a quality system has been sanctioned, a team-based approach utilizing project planning tools is a good way to approach the effort. Resources are assigned to the development of key quality system components, and generally a phased-deployment or roll-out works best. Once implementation is underway, assuring operational utilization and compliance with the quality system are vital steps in the process. Important to successful implementation is ongoing assessment and refinement of the quality system. Fundamental and key elements of the laboratory quality system are numerous and need to work in concert with each other. Quality system elements to be discussed in the presentation range from management and QA roles and functions to the typical documentation of laboratory policies and procedures. Numerous QA assessment tools and other vital quality system practices that play an important role in making a complete quality system are addressed. In addition, efforts must be undertaken to integrate the laboratory quality system with other management systems within the organization. The bottom line is that all environmental laboratories need a quality system more now than ever. Data users need it. Customers' expectations for data quality are high. USEPA policy and/or programs call for it. Additionally, good quality systems can benefit the organization in multiple ways and help avoid the "pay-me-now or pay-me-later" syndrome. In conclusion, all environmental testing laboratories (i.e., academic, private, commercial and especially governmental) need to invest in and implement a quality system based on a recognized standard (e.g., NELAC, ISO 17025, ANSI/ASQC E-4). The author recommends pursuing NELAP laboratory accreditation with a NELAP-recognized accrediting authority.

Environmental Monitoring↗

PubMedDate not supplied

Implementation of an out-of-hospital termination of resuscitation policy.

OBJECTIVE: To evaluate the implementation of an out-of-hospital termination of resuscitation policy in an urban EMS setting. METHODS: A descriptive study characterizing the implementation of an out-of-hospital termination of resuscitation policy in the Chicago EMS system. It includes a retrospective telemetry record review analyzing the utilization and compliance with the policy. The newly implemented policy involved field termination of resuscitation for all nontraumatic, adult cardiac arrest victims presenting in asystole who were not responsive to a standard trial of resuscitation. RESULTS: Over the three-month study period, 228 resuscitations of adult, nontraumatic cardiac arrest victims were identified and submitted for review. The group of 142 cardiac arrest victims who presented in asystole and received resuscitative efforts were categorized into four groups. Group I included 34 cardiac arrests for which resuscitation was terminated in the field following policy criteria. Group II included eight cardiac arrests for which resuscitation was terminated but the patients did not meet criteria for termination of resuscitation. Group III included 84 cardiac arrests for which resuscitation was not terminated because the patients did not meet criteria for out-of-hospital termination. Group IV included 16 cardiac arrests for which resuscitative efforts were continued, although the patients met indications for field termination. CONCLUSIONS: Field termination of resuscitation is practical in the setting of asystole unresponsive to aggressive resuscitative efforts. The implementation of such an out-of-hospital termination of resuscitation policy is complicated by many problems and is best accomplished by a gradual implementation process. Through this process all members of the EMS community can address practical and ethical issues and grow comfortable with the ongoing evolution of out-of-hospital therapy.

Aged↗

PubMed2004

Sharing of noninjection drug-use implements as a risk factor for hepatitis C.

This study examined sharing noninjection drug implements as a risk factor for hepatitis C (HCV) infection among women drug users (n = 123) with no history of drug injection. Participants were street-recruited from East Harlem, New York City, between October 1997 and June 1999. Participants were administered a survey measuring risk factors for HCV. Prevalence of HCV and HIV infections was 19.5% and 14.6%, respectively. Multiple logistic regression determined significant associations between sharing noninjection drug-use implements and HCV infection. "Ever shared both oral and intranasal noninjection drug implements" was independently associated with HCV infection [Odds ratio (OR) 2.83; Confidence interval (CI) 1.04, 7.72; p = 0.04]; "ever shared noninjected heroin implements with an injector" was a trend (OR 3.06; CI .85, 10.79; p = 0.08). The strongest association between sharing noninjection drug-use implements and HCV infection was found among HIV positive individuals (chi2 = 8.8, 1 d.f., p < 0.01). These findings, if supported by future research, indicate a need to reassess policies regarding HCV infection.

Administration, Intranasal↗

PubMed2005

Implementation of strategies to prevent and control the emergence and spread of antimicrobial-resistant microorganisms in U.S. hospitals.

OBJECTIVE: To examine the extent to which the strategies recommended by the National Foundation for Infectious Diseases (NFID)-Centers for Disease Control and Prevention (CDC) co-sponsored workshop, Antimicrobial Resistance in Hospitals: Strategies to Improve Antimicrobial Use and Prevent Nosocomial Transmission of Antimicrobial-Resistant Microorganisms, have been implemented and the relationship between the degree of implementation and hospital culture, leadership, and organizational factors. DESIGN: Survey. SETTING: A representative sample of U.S. hospitals stratified by teaching status, bed size, and geographic region. PARTICIPANTS: Infection control professionals. RESULTS: Surveyed hospitals had implemented strategies to optimize the use of antimicrobials and to detect, report, and prevent transmission of antimicrobial-resistant microorganisms. Multivariate analyses found that hospitals with a greater degree of implementation of the NFID-CDC strategic goals were more likely to have management support, education of staff, and interdisciplinary groups specifically to address these issues; they were also more likely to engage in benchmarking on broader quality of care indicators. CONCLUSIONS: Most surveyed hospitals had implemented some measures to address the NFID-CDC recommendations; however, hospitals need to do much more to improve antimicrobial use and to increase their efforts to detect, report, and control the spread of antimicrobial resistance. A supportive hospital administration must foster a culture of ongoing support, education, and interdisciplinary work groups focused on this important issue to successfully accomplish these goals.

Analysis of Variance↗

PubMed2004

Implementing the WISEWOMAN program in local health departments: staff attitudes, beliefs, and perceived barriers.

BACKGROUND: Although most health departments recognize the need for programs to reduce the risk of cardiovascular disease (CVD) among older, low-income women, they face numerous barriers to successfully implementing such programs. This paper explores counselors' attitudes and beliefs about patients and perceived barriers to implementing the North Carolina Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program. METHODS: Health departments were assigned to provide patients with either an enhanced intervention (EI) or a minimum intervention (MI). Cross-sectional baseline and 12-month follow-up surveys were completed by health department counselors designated to deliver the MI or EI. Both surveys addressed counselors' beliefs about patients' motivation and attitudes, their counseling practices, and their personal diet and physical activity behaviors and attitudes. The follow-up survey also addressed opinions about the feasibility of long-term WISEWOMAN implementation. RESULTS: Counselors were skeptical about patients' motivation to improve their lifestyle, citing high perceived cost and burden. At follow-up, EI counselors reported having higher self-efficacy for counseling, incorporating more behavioral change strategies, and spending more time counseling than did counselors at MI sites. They were also more likely to report making healthful personal lifestyle choices. All counselors identified lack of time as a major barrier to counseling, and most cited obtaining low-cost medications for patients, ensuring that patients made follow-up visits, and implementing the program with existing staff as key challenges to the long-term sustainability of WISEWOMAN. CONCLUSIONS: Our findings provide insight into the organizational challenges of implementing a CVD risk-reduction program for low-income women. We discuss ways in which intervention and training programs can be improved.

Adult↗

PubMed2004

Types and rate of implementation of palliative care team recommendations for care of hospitalized veterans.

BACKGROUND: Hospital-based interdisciplinary palliative care teams (PCTs) are increasingly being established to meet the growing demand for high quality care for patients with life-limiting illnesses in which the goal is comfort rather than cure. Two recent studies suggest that PCTs teams are highly effective in influencing care of patients within large academic medical centers. The current study examines whether the previously demonstrated success of palliative care teams within subspecialty academic health centers could be replicated in an urban Veterans Affairs medical center (VAMC). OBJECTIVE: To describe the characteristics of patients referred to, recommendations made by, and implementation rate of an interdisciplinary PCT in an urban VAMC. DESIGN: Retrospective, observational study. SETTING/SUBJECTS: One hundred patients referred by inpatient doctor to the PCT between October 1999 and March 2002 in a 214-bed VA hospital in the New York City area. MEASUREMENTS: Patient demographics, prevalence of five types of recommendations by the PCT and implementation rate by primary physician: (1) advance directives; (2) discharge planning; (3) pain management; (4) symptom management of dyspnea, delirium, constipation, nausea, anxiety, and depression; and (5) consultation orders for other services. RESULTS: The average number of recommendations per patient was 2.84 and 84.2% were implemented. The most frequent recommendations concerned discharge plans. The reasons recommendations were not implemented included: (1) patient or family refusal noted in the medical record, (2) the patient's clinical status changed, including patient death, and (3) the attending physician chose a different dose, medication, or route of administration than was recommended. CONCLUSIONS: Overall, most recommendations were implemented by the referring physicians. This finding is consistent with several prior studies demonstrating that PCTs in acute care can and do influence processes of care for hospitalized patients. Well-designed observational studies and randomized controlled trials of specific palliative care interventions and their effect on patient, family, and health care system outcomes are needed.

Academic Medical Centers↗

PubMed1997

The Vermont Telemedicine Project: initial implementation phases.

OBJECTIVE: A comprehensive rural telemedicine system was implemented between Fletcher-Allen Health Care (FAHC) and a number of community hospitals in three distinct phases. We sought to describe each phase of its implementation to date and evaluate the technology and provider acceptance, as well as overall usage. PHASE I: A room-based video conferencing system with T-1 connections to two rural hospitals was initiated. The primary use of this system was telepathology, which underwent a rigorous evaluation. The system was well accepted by both referring and consulting pathologists, and the diagnostic accuracy was high, 91.2%. PHASE II: A desktop telemedicine system utilizing ISDN transmission at 384 kbps was implemented to six additional hospitals. Continuing medical education as well as consultative services for virtually every medical specialty were offered. Evaluation included tracking usage logs at each site, review of forms filled out for conferences, and (3) review of forms filled out by providers for medical consultations and clinical care delivered over the system. Technology failure represented the most frequent source of problems, particularly with multipoint calls. Usage increased steadily so that by 6 months, there was an average of one documented use per day. The principal use was for care delivered by pathology, surgery, nephrology, and obstetrics and gynecology. Video quality was judged excellent (62%) or satisfactory (15%) in most cases, while audio quality was excellent in 31% of cases and satisfactory in 46%. Overall, referring providers felt that the system improved patient care in 85% of cases, while 100% of the consultants felt this. PHASE III: Because of technology problems encountered in Phase II, a new system was designed and implemented. The network was expanded to additional sites, including physicians' offices. Evaluation is continuing. PHASE IV: Implementation of a regional information system, including video teleconferencing to every to provider's office in the region, is in the initial stages. CONCLUSIONS: Problems with video conferencing technology hamper use, but once providers utilize telemedicine as a clinical tool, use increases steadily. Clinical use across multiple specialties is possible in a manner that most providers feel improves patient care.

Attitude of Health Personnel↗

PubMed2003

A qualitative evaluation of implementing a randomized controlled trial in general practice.

BACKGROUND: For findings of randomized controlled trials in primary care to be applicable, both the sample of clinicians implementing the trial and the recruited patients should be as representative as possible. The processes of conducting trials should be made "user-friendly" to clinician investigators in order to maximize their participation in research. Formal evaluations of trial implementation are unusual. This study reports clinicians' perspectives on acting as a clinician investigator in a randomized controlled trial (the SAVIT study) in general practice. OBJECTIVE: Our purpose was to explore clinicians' accounts of taking part in a randomized controlled trial in which subjects were recruited opportunistically during general practice consultations. METHOD: Individual semi-structured interviews were conducted with nine GPs and one practice nurse practising in the Bro Taf area of South Wales who recruited children into the SAVIT study. A structured interview guide was used and data were analysed using the qualitative method of pattern coding. RESULTS: Major emerging themes included recruitment difficulties and concerns about the safety of the study medication. Participants also outlined positive aspects of the study (clarity and simplicity of the study, potential benefits to clinicians and patients and study team follow-up of recruited patients). Recommendations for possible improvements in study implementation included the simplification and reduction of patient reading materials and improved presentation of study materials. CONCLUSIONS: Difficulty in recruiting patients was the most frequently mentioned problem by clinician investigators. Insufficient time in the consultation was perceived as the main barrier. Ingredients of successful trial implementation include good organization, simple documentation and study procedures, and the ability to allay concerns about patient safety. Findings from this evaluation may assist researchers in the design and implementation of future community-based randomized controlled trials.

Attitude of Health Personnel↗

PubMed1997

Challenges in implementing a budget-holding programme for primary care clinics.

In 1990, Kupat Holim Clalit (KHC), Israel's largest sick fund, initiated a demonstration programme for transforming a number of primary care clinics in the Negev district of southern Israel into autonomous budget-holding units. Four programme components were implemented in the nine participating clinics: allocation of a fixed budget; expansion of day-to-day decision-making authority; establishment of a computerized information system to produce monthly reports on expenditure; and provision of incentives for budgetary control. The research findings are based on a four-year evaluation of the programme, which involved a longitudinal case study conducted with multiple research tools: in-depth interviews, a staff survey, and analysis of relevant documents. This article analyzes the challenges involved in implementing the demonstration programme. It examines clinic staff evaluation of the implementation process (e.g. overall staff had a positive attitude toward it); assesses staff satisfaction with clinic participation in the programme (while only 33% were satisfied, only 21% said they would like the clinic to revert to the pre-programme model) and factors influencing this satisfaction (among them intrinsic benefits, perception of the programme as fair and age); and discusses the lessons to be learnt from the programme regarding effective implementation of organizational change. The main lessons indicate the importance of certain factors in implementing such programmes: (a) long-term management commitment to the programme; (b) appointment of agents of change/programme administrators; (c) establishment of a formal agreement between the parties involved; (d) establishment of communication channels between the parties involved; (e) intrinsic benefits for staff, perceived as incentives to economize; (f) reliable data, perceived to be reliable by the parties involved; (g) staff participation in the process of change; and (h) involvement of the participating unit as a single entity.

Budgets↗

PubMed2006

From innovation to practice: initiation, implementation and evaluation of a physician-based physical activity promotion programme in Finland.

In 2001, a collaborative Physical Activity Prescription Programme (PAPP) was started in Finland to increase physical activity (PA) counselling among physicians, especially in primary care. This article describes the initiation, implementation and evaluation of PAPP. Five actions were implemented to reach the programme goal: (i) developing a counselling approach for physicians; (ii) providing easy and open access to counselling material; (iii) facilitating physicians' uptake and adoption of the counselling approach; (iv) disseminating information about the counselling approach to physicians, health and exercise professionals and decision-makers and (v) raising financial resources to cover programme expenses. Evaluation was based on the dimensions of the RE-AIM framework: reach, effectiveness, adoption, implementation and maintenance. Effectiveness and adoption were evaluated with two questions added to the annual survey of the Finnish Medical Association to all practising physicians in the year 2002 (n = 16 692) and 2004 (n = 17 170). The 4-year PAPP was successful in reaching health care units (Reach), accomplishing most of the implementation actions (Implementation) and initiating local projects for institutionalizing the prescription-based counselling approach, 'Prex' (Maintenance). However, at the national level, the programme was not effective in increasing the frequency of asking about patients' PA habits (Effectiveness) or the frequency of using 'Prex' or other written material in PA counselling among physicians (Adoption). To improve the latter two, the duration of the programme would have had to be extended with more effort at strengthening physicians' confidence in PA counselling and knowledge about its effectiveness. Also, a more systematic approach would have been necessary to facilitate inter-sectoral network for adopting 'Prex' as a counselling tool at the local level.

Adult↗