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PubMed2000

Barriers to implementing South Africa's Termination of Pregnancy Act in rural KwaZulu/Natal.

INTRODUCTION: South Africa's Termination of Pregnancy Act, the most liberal abortion law in Africa, took effect early in 1997. In spite of the anticipated benefits to women's health, however, public reaction has been mixed. In the country's most populous province, KwaZulu/Natal, opposition is strong and most health care providers have refused to provide the service. This study explored attitudes and beliefs about abortion and the Termination of Pregnancy Act among primary care nurses and community members in a rural district in order to better understand barriers to implementation of the new law. METHODS: As part of a community survey on women's reproductive health (n = 138), questions on knowledge, attitudes and beliefs about abortion were asked, as well as awareness of the provisions of the Termination of Pregnancy Act. To better understand the perspectives of health care workers, a survey among primary care nurses on duty (n = 25) was also conducted. In-depth interviews were conducted with both nurses and women in the community to further pursue issues raised in the two surveys. RESULTS: Support for the Act was low (11%) among both community members and nurses, and few supported abortion on request (18 and 6%, respectively). Within each group, however, a clear hierarchy of support was observed: a majority of nurses (56%) and community members (58%) supported abortion in the case of rape or incest, or if the continued pregnancy would endanger a woman's health (61 and 56%, respectively), but few supported abortion for social or economic reasons. In-depth interviews revealed that abortion is seen as contrary to prevailing community norms; nurses were poorly informed about the Termination of Pregnancy Act and felt confused in their professional responsibilities. CONCLUSIONS AND RECOMMENDATIONS: Legalization alone cannot ensure implementation of abortion services. In South Africa, extensive media coverage prior to passage of the law ensured almost universal awareness of the Act, but little public education took place at the same time. In spite of general opposition to the law, however, there is an encouraging level of support for abortion in some circumstances. These findings suggest that abortion services can be implemented, even in conservative rural areas, but that a process of information dissemination and community consent prior to implementation is essential. Locating abortion within broader reproductive health services could be an effective way to improve access and acceptability.

Abortion, Legal↗

PubMed1998

A multiple case study of implementation in 10 local Project ASSIST coalitions in North Carolina.

Community health promotion relies heavily on coalitions to address a multitude of public health issues. In spite of their widespread use, there have been very few studies of coalitions at various stages of coalition development. The purpose of this study was to identify factors that facilitated or impeded coalition effectiveness in the implementation stage of coalition development. The research design was a multiple case study with cross-case comparisons. Each of the 10 local North Carolina Project ASSIST coalitions constituted a case. Data collection included: semi-structured interviews, observation, document review, and surveys of members and staff. Some of the major factors that facilitated implementation included: the ability of the coalition to provide its own vision, staff with the skills and time to work with the coalition, frequent and productive communication, cohesion or a sense of belonging on the coalition, and complexity of the coalition structure during the intervention phase. Barriers to effective implementation included: staff turnover and staff lacking community organization skills, dependence on the state-level staff during the planning phase and lack of member input into the action plan. Conflict contributed to staff turnover, reluctance to conduct certain activities and difficulty in recruiting members, all of which had implications for implementation.

Communication↗

PubMed2001

Determinants of implementing heart health: promotion activities in Ontario public health units: a social ecological perspective.

This paper reports the results of a study undertaken to explain levels of implementation of heart health promotion activities observed in Ontario public health agencies in 1997. Organizational-level data were collected by surveying all 42 health departments in 1994, 1996 and 1997 as part of the Canadian Heart Health Initiative Ontario Project. Guided by social ecological and organizational theories, the model examines relationships between implementation and four sets of possible determinants of activity: (1) the predisposition of agencies to undertake heart health promotion activities, (2) their capacity to undertake these activities, (3) internal organizational factors and (4) external system factors. A small set of five variables explains almost half of the variance in implementation (R2 = 0.46): organizational capacity (beta = 0.40), priority given to heart health (beta = 0.36), coordination of programs (beta = 0.19), use of resource centers (beta = 0.12) and participation in networks (beta = 0.09). The results suggest that models integrating organizational and socio-ecological theories can help us understand the implementation of community-based heart health promotion activities by public health agencies. Implications for future research, policy and practice are discussed.

Cardiovascular Diseases↗

PubMed2007

An agency capacity model to facilitate implementation of evidence-based behavioral interventions by community-based organizations.

The Centers for Disease Control and Prevention (CDC) implemented the Diffusion of Effective Behavioral Interventions Project to disseminate evidence-based behavioral interventions to community-based HIV prevention providers. Through development of intervention-specific technical assistance guides and provision of face-to-face, telephone, and e-mail technical assistance, a range of capacity-building issues were identified. These issues were linked to a proposed agency capacity model for implementing an evidence-based intervention. The model has six domains: organizational environment, governance, and programmatic infrastructure; workforce and professional development; resources and support; motivational forces and readiness; learning from experience; and adjusting to the external environment. We think this model could be used to implement evidence-based interventions by facilitating the selection of best-prepared agencies and by identifying critical areas of capacity building. The model will help us establish a framework for informing future program announcements and predecisional site visit assessments, and in developing an instrument for assessing agency capacity to implement evidence-based interventions.

Centers for Disease Control and Prevention, U.S.↗

PubMed1999

Auditing the implementation of SIGN (Scottish Intercollegiate Guidelines Network) clinical guidelines.

Clinical practice guidelines are increasingly being recognised as integral to the clinical effectiveness agenda. According to the recent Scottish White Paper, Scotland "leads the way in clinical effectiveness". The Scottish Intercollegiate Guidelines Network (SIGN), established in 1993, has produced over 20 clinical practice guidelines, and plans to produce at least as many more, while reviewing existing guidelines at a minimum of every two years. This represents a substantial investment of NHS resources. This paper investigates whether this investment is being recouped in Scottish NHS acute trusts via the implementation of SIGN guidelines, and whether their implementation is being audited properly. It is argued that without clinical audit, guideline implementation is unlikely to succeed. This has important ramifications for the implementation of clinical governance.

Accreditation↗

PubMed2003

Success factors for implementation of the balanced scorecard in a NHS multi-agency setting.

Even though the balanced scorecard (BSC) has become a highly popular performance management tool, usage in local public sector National Health Service (NHS) organisations is still rare. This paper conditionally outlines some grounds in supporting such usage. In particular underlying conceptual concerns with the BSC system and its implementation pitfalls require full consideration. This paper then outlines some factors to be taken into account for "successful" BSC implementation in a NHS multi-agency setting. These findings emerged from a series of focus groups that took place with contributors drawn from all the key organisations within the Bradford Health Action Zone. Finally, this paper argues that if key criteria are met, successful implementation of the BSC may then proceed. However, "blind" BSC implementation without consideration of these factors may result in potential "failure".

Benchmarking↗

PubMed2006

Toward evidence-based quality improvement. Evidence (and its limitations) of the effectiveness of guideline dissemination and implementation strategies 1966-1998.

OBJECTIVES: To determine effectiveness and costs of different guideline dissemination and implementation strategies. DATA SOURCES: MEDLINE (1966 to 1998), HEALTHSTAR (1975 to 1998), Cochrane Controlled Trial Register (4th edn 1998), EMBASE (1980 to 1998), SIGLE (1980 to 1988), and the specialized register of the Cochrane Effective Practice and Organisation of Care group. REVIEW METHODS INCLUSION CRITERIA: Randomized-controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series evaluating guideline dissemination and implementation strategies targeting medically qualified health care professionals that reported objective measures of provider behavior and/or patient outcome. Two reviewers independently abstracted data on the methodologic quality of the studies, characteristics of study setting, participants, targeted behaviors, and interventions. We derived single estimates of dichotomous process variables (e.g., proportion of patients receiving appropriate treatment) for each study comparison and reported the median and range of effect sizes observed by study group and other quality criteria. RESULTS: We included 309 comparisons derived from 235 studies. The overall quality of the studies was poor. Seventy-three percent of comparisons evaluated multifaceted interventions. Overall, the majority of comparisons (86.6%) observed improvements in care; for example, the median absolute improvement in performance across interventions ranged from 14.1% in 14 cluster-randomized comparisons of reminders, 8.1% in 4 cluster-randomized comparisons of dissemination of educational materials, 7.0% in 5 cluster-randomized comparisons of audit and feedback, and 6.0% in 13 cluster-randomized comparisons of multifaceted interventions involving educational outreach. We found no relationship between the number of components and the effects of multifaceted interventions. Only 29.4% of comparisons reported any economic data. CONCLUSIONS: Current guideline dissemination and implementation strategies can lead to improvements in care within the context of rigorous evaluative studies. However, there is an imperfect evidence base to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances. Decision makers need to use considerable judgment about how best to use the limited resources they have for quality improvement activities.

Evidence-Based Medicine↗

PubMed2006

Models, strategies, and tools. Theory in implementing evidence-based findings into health care practice.

This paper presents a case for careful consideration of theory in planning to implement evidence-based practices into clinical care. As described, theory should be tightly linked to strategic planning through careful choice or creation of an implementation framework. Strategies should be linked to specific interventions and/or intervention components to be implemented, and the choice of tools should match the interventions and overall strategy, linking back to the original theory and framework. The thesis advanced is that in most studies where there is an attempt to implement planned change in clinical processes, theory is used loosely. An example of linking theory to intervention design is presented from a Mental Health Quality Enhancement Research Initiative effort to increase appropriate use of antipsychotic medication among patients with schizophrenia in the Veterans Health Administration.

Antipsychotic Agents↗

PubMed2000

Implementing the integration of component services for reproductive health.

In the wake of the 1994 International Conference on Population and Development in Cairo, considerable activity has occurred both in national policymaking for reproductive health and in research on the implementation of the Cairo Program of Action. This report considers how effectively a key component of the Cairo agenda--integration of the management of sexually transmitted infections, including human immunodeficiency virus, with maternal and child health-family planning services--has been implemented. Quantitative and qualitative data are used to illuminate the difficulties faced by implementers of reproductive health programs in Ghana, Kenya, South Africa, and Zambia. In these countries, clear evidence is found of a critical need to reexamine the continuing focus on family planning services and the nature of the processes by which managers implement reproductive health policies. Implications of findings for policy and program direction are discussed.

Data Collection↗

PubMed1992

The longevity of Growing Healthy: an analysis of the eight original sites implementing the School Health Curriculum Project.

The status of the Growing Healthy curriculum (School Health Curriculum Project [SHCP]) was examined in the eight sites selected in 1969 by the National Clearinghouse on Smoking and Health to receive funded training and implementation support. A contact person from each site completed and returned a questionnaire pertaining to the district's continued implementation (institutionalization) of the SHCP. Most districts had not continued to implement the program. Reasons for discontinuation included loss of the "program champion" and insufficient administrative leadership. Districts continuing to implement the program generally were smaller in size, and employed a part-time coordinator for the SHCP. Recommendations for institutionalizing future instruction programs include identifying replacement program coordinators and other administrators to ensure continuity and support for the program over time, and conducting process and impact evaluations on program effects.

Curriculum↗

PubMed1998

Treatment of major depression before and after implementation of a behavioral health carve-out plan.

OBJECTIVE: The study examined utilization, payments, and quality indicators for treatment of major depressive disorder before and after the 1993 implementation of a behavioral health care carve-out plan for Massachusetts state employees who received medical coverage through indemnity plans or preferred provider organizations. METHODS: The sample of 2,259 enrollees with claims for treatment of major depressive disorder was drawn from the group of 39,541 persons continuously enrolled in preferred provider organizations or indemnity plans for fiscal years 1992 to 1995. A subsample of 243 users of inpatient services accounted for 352 admissions. Bivariate tests were used to compare utilization and quality indicators before and after implementation of the carve-out plan. Simple comparisons of current-year dollars were used. RESULTS: The proportion of enrollees with claims for treatment of major depressive disorder increased significantly under the carve-out plan. Inpatient utilization decreased substantially, mostly due to a significantly lower average length of stay (16 days before implementation of the carve-out plan and nine days after). Net inpatient payments fell 71 percent overall, 65 percent per admission, and 40 percent per day. The unadjusted proportion of discharged patients treated for major depressive disorder who were readmitted within 15 and 30 days did not change significantly. The unadjusted proportion of cases receiving follow-up within those time frames increased significantly. CONCLUSIONS: Implementation of a behavioral health carve-out plan may be accompanied by substantial reductions in inpatient utilization and payments for treatment of major depressive disorder. Descriptive findings suggest that such reductions may not have a detrimental impact on readmission and follow-up treatment rates within 30 days. However, this analysis did not control for patient characteristics, used short follow-up periods, and did not include some relevant outcome measures.

Behavior Therapy↗

PubMed2006

Changing practice: implementing validated paediatric pain assessment tools.

This study attempted to address a lack of evidence-based pain management by implementing validated pain assessment tools across a children's hospital. The method used was action research. The first part of this study where nurses' views of pain tools was elicited has already been reported (Simons and Macdonald, 2004). An action research cycle of negotiation, assessment, diagnosing, planning, action, evaluation and withdrawal was utilized. Data collection occurred at two points in time. Three age-appropriate tools were implemented hospital-wide supported by education and clinical input. A survey of nurses was carried out six months and 12 months post implementation of the tools. At the same time evaluation of the use of the tool was performed. Six months after education and implementation 23 percent of children on 10 wards had a pain tool in use. This had increased to 40 percent six months later. There were many inconsistencies between the replies the nurses gave in relation to their reported use of the tools and the actual use of the tools.

Child↗

PubMed2004

Strategies for the introduction and implementation of a guideline for the treatment of type 2 diabetics by general practitioners (GPs) of the Lazio region of Italy (IMPLEMEG study): protocol for a cluster randomised controlled trial [ISRCTN80116232].

BACKGROUND: Despite broad agreement on the necessity to improve quality of diabetic care through implementation of clinical guidelines, in Italy many people with diabetes still lack adequate care in general practice. In addition there is little evidence to support the choice of implementation strategies, especially in the Lazio region (central Italy), where comparative studies among general practitioners (GPs) are uncommon. The primary objective of the study is to assess the effectiveness of different strategies for the implementation of an evidence-based guideline for the management of non-complicated type 2 diabetes mellitus (DM) among GPs of the Lazio region. METHODS/DESIGN: Three-arm cluster-randomised trial (C-RCT). 252 GPs were randomised either to arm 1 (comprising a training module and administration of the guideline), or to arm 2 (administration of guideline without training), or to arm 3 (control arm), continuing current practice. Arm 1 participants attended a two-day course with CME credits. Data collection will be performed using current information systems. Patients' health data was also collected to describe diabetic populations cared for by GP participants. Process outcomes will be measured at the patient level and at the cluster level one year after the intervention. We will assess GPs' adherence to guideline recommendations for diabetes management relative to: 1) pharmacological management of diabetes; 2) pharmacological management of cardiovascular risk factors (hypertension and dislypidaemia); 3) measurement of glycosilated haemoglobin as the principal indicator of glycaemic control; 4) micro- and macrovascular complications assessment tests. Outcomes will be expressed as proportions of patients cared for by GPs who will have prescriptions of drugs, requests for tests and for outpatient appointment visits. To estimate the efficiency of resource use associated with the intervention a cost-effectiveness analysis will be carried out. The design of the study is based on three Cochrane and one Health Technology Assessment systematic reviews of guideline dissemination and implementation strategies.

Age Factors↗

PubMed1999

The implementation and enforcement of tobacco control laws: policy implications for activists and the industry.

We examine the process by which antitobacco laws and ordinances were implemented and enforced in seven states and nineteen localities. Our findings indicate that state- and local-level clean indoor air laws were rarely enforced by governmental agencies. Instead, these laws were largely self-enforcing in that changed social norms regarding appropriate smoking behavior led to generally high compliance rates. In contrast, teen access laws were not self-enforcing, but were often enforced through periodic vendor compliance checks. We also found that antitobacco forces did not devote a significant amount of attention of implementation and enforcement issues. Their focus was primarily on enacting new legislation and fighting tobacco industry attempts to weaken existing laws. Our results do not augur well for public health measures that require state-level enforcement and that are opposed by powerful and politically well-connected interests. For tobacco control laws to be effective, public health advocates need to consider the locus of enforcement responsibility and the sanctions available to the enforcement agency, such as license removal by local authorities. These results suggest that failure to specify such mechanisms in the legislation will lead to delays in implementing and enforcing the laws as well as to a number of compliance problems. Antitobacco coalitions will also need to become more actively involved in the implementation and enforcement process.

Adolescent↗

PubMed1997

The development and implementation of health policy: New Zealand and Hong Kong compared.

Contemporary health sector reform is frequently underpinned by market-influenced public policy "prescriptions." Such prescriptions provide details of what policies ought to look like, but little by way of how they should be implemented. This article compares the experience of New Zealand and Hong Kong, two locations in which recent health reforms were based upon the policy prescription. Where the respective health policies bear similarities, implementation styles differ with interesting consequences. New Zealand's apparent "success" in implementation may ultimately prove counterproductive; it seems more likely that Hong Kong, whose implementation success has been, to date, moderate, will achieve objectives of providing a better public health service.

Health Care Reform↗

PubMed2000

Organizational interventions to encourage guideline implementation.

Evidence-based guidelines hold considerable promise for continued improvement of health-care delivery. However, the availability of clinical practice guidelines does not automatically lead to changes in practice patterns. Using a "push-pull-capacity" model, this article describes strategies to improve guideline implementation for three types of organizations: national organizations, insurer and health-care organizations, and health-care purchasers. Push strategies focus on the guideline development process and include rigorous review and meta-analysis of peer-reviewed research, and use of multidisciplinary expert teams, subjecting guidelines to peer review and comment and using measurable clinical outcomes to define guidelines. PULL: strategies focus on creating a demand for guideline implementation and include professional organization endorsement, quality measures based on guideline-related outcomes, and guideline-based performance objectives in purchaser contracts and physician compensation agreements. Capacity strategies focus on systems that facilitate guideline implementation. Example strategies are providing benefit coverage and reimbursement for guideline-based treatment protocols, and implementing clinical information systems for population-based tracking, outcomes monitoring, and benchmarking feedback.

Delivery of Health Care↗

PubMed2005

Designing and implementing an electronic health record system in primary care practice in sub-Saharan Africa: a case study from Cameroon.

OBJECTIVE: To review the key issues related to the design and implementation of an electronic health record (EHR) system in urban primary health care (PHC) practice in Cameroon. METHODOLOGY: The goal of the project was to assess EHR as a tool to improve providers' performance, quality and continuity of care, and the availability of data in PHC practice in Cameroon. A locally designed EHR system called MEDCAB was developed. The system was based on the International Classification for Primary Care (ICPC) and was designed taking into consideration the PHC practice environment in Cameroon. An original cohort of 14 users was involved in the experiment. RESULTS: Users generally showed good acceptance of the system. Monitoring the use of the system at the early stages of implementation was important to ensure immediate response to users' comments and requests. Some of the key issues identified during the development and implementation of the system were: user involvement, the choice of an appropriate terminology, pre-existing data collection culture and leadership issues. Some positive achievements brought about by the system included promotion of good medical practice and routine availability of consultation data. CONCLUSION: Strengthening the medical record in general, and the EHR in particular, could contribute to its position as a valuable source of information for healthcare delivery, public health and policy making in Cameroon. Challenges to adoption are huge and successful implementation for any specific setting will require a comprehensive modelling of the local medical practice, the choice of an appropriate terminology and a co-ordinated approach involving all stakeholders.

Africa South of the Sahara↗

PubMedDate not supplied

[Implementation process evaluation of the Integrated Management Childhood Illness strategy in the Family Health Program, Pernambuco State, Brazil].

This evaluative study attempts to define the contextual determinants of the degree of implementation in the Integrated Management of Childhood Illnesses strategy in Pernambuco State, Brazil. A total of 33 Family Health Program teams were selected from 10 municipalities. In order to define the degree of implementation, the study used a specific score system and the process indicators provided by the strategy. Municipalities were classified as critical, unsatisfactory, and acceptable. All municipalities except for one presented an acceptable degree of implementation in relation to the structure. In relation to process evaluation, two municipalities received one follow-up visit and their scores were unsatisfactory. Four municipalities received two visits, and one was classified as unsatisfactory on the second follow-up visit, while another presented a critical score on the first follow-up visit. Among four municipalities that received three follow-up visits, one was classified as unsatisfactory in the three evaluations. Four municipalities achieved mean unsatisfactory scores, when considering the mean scores acquired in the three follow-up visits. There was no association between the organizational context and degrees of implementation.

Brazil↗