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PubMed2002

Implementation of a cross-cultural evidence-based medicine curriculum.

While principles of evidence-based medicine (EBM) are increasingly prevalent in medical education curricula in Europe and North America, medical educators elsewhere face formidable barriers to its implementation. We sought to determine the feasibility of implementing a learner-centered, case-based EBM curriculum among academic physicians in Kazan, Russia, facilitated by residents participating in an international health elective. This article reports that implementation of an EBM curriculum is feasible during a resident international health elective and that mutually beneficial educational exchanges represent an opportunity for teaching the tenets of EBM abroad.

Education, Medical↗

PubMedDate not supplied

Strategies for implementation of harm reduction in treatment settings.

Harm reduction is a set of strategies that we all use everyday to protect us from the harms of living in a complex world. Central to the principles of harm reduction is the need to respect the client's autonomy and develop a relationship of mutual collaboration with the goal of reducing drug- and alcohol-related harm. Additional principles stress the need to develop a hierarchy of client needs, a list that includes all other services, with the importance for each set by the client. Harm reduction implementation includes a range of interventions including abstinence. Some interventions are controversial, including needle exchange, but most are traditional health promotion activities such as videos, health fairs, and drug education. Essential to implementing harm reduction is a recognition that, even for those who wish to become abstinent, this goal is difficult to achieve and maintain. We must acknowledge this and stop the practice of imposing punitive sanctions on clients who use drugs while in treatment. Exclusion or expulsion from treatment settings does nothing to reduce drug use and greatly increases the harm to the client. In conclusion, just as we need to respect diversity among our clients, staff must find a way to respect each others' ideas and concerns as we develop new ways to implement harm reduction in our work.

Humans↗

PubMed2003

Early implementation of Proposition 36: criminal justice and treatment system issues in eight counties.

This article examines key differences emerging in implementation of California's Proposition 36 voter initiative across eight diverse large, medium, and small counties. The data were collected in 2001 in a key informant survey of county policymakers. Unlike most major California criminal justice initiatives of recent years, Proposition 36 represents a potential lessening of adjudicatory and penal controls rather than an increase in their severity, in this case in response to charges of drug use, possession, or transportation. Furthermore, Proposition 36 was written broadly enough to allow considerable discretion in implementation across the counties, including the specification of funding to support mandated provisions of the Act and division of oversight responsibilities among criminal justice and treatment stakeholders. Hence actual content and scope of criminal justice system procedural changes, and impact of the proposition on criminal justice and treatment systems and on arrestees, are likely to vary by county. The article identifies key approaches and decisions made in the sampled counties that are predicted to affect the proposition's impact in the areas of treatment versus criminal justice resources, prosecutorial implementation, defendant and defense responses, assessing criminal histories and treatment needs, treatment versus criminal justice supervisory responsibility, and procedural variations and client behavior.

California↗

PubMed2003

Implementation of a clinical dementia guideline. A controlled study on the effect of a multifaceted strategy.

OBJECTIVE: To assess the impact of a multifaceted implementation strategy aiming to improve GP adherence to a clinical guideline on dementia. DESIGN: Controlled before and after study using data records from regional laboratories. The guideline was mailed to all GPs. The multifaceted implementation strategy was planned with local GPs, and consisted of seminars, outreach visits, reminders and continuing medical education (CME) small group training. SETTING: Primary health care. SUBJECTS: 535 GP practices with 727 physicians in Denmark. MAIN OUTCOME MEASURES: The diffusion and use of the guideline was measured by a mailed survey. Adherence to guideline recommendations was monitored by data on laboratory tests from general practice in patient's > or = 65 years: thyroid stimulating hormone requested with vitamin B12 or methylmalonate. The use of these tests as part of a diagnostic evaluation of dementia was subsequently verified by a questionnaire to the practices. RESULTS: Of the GPs who read the guideline, 88% found it applicable in primary care. No increase in the adherence to guideline recommendations was observed regarding the use of laboratory tests or cognitive tests in the diagnostic evaluation of dementia in general practice. CONCLUSION: Although GPs regarded the guideline applicable in primary care, no change in practice adherence to guideline recommendations was detected after a multifaceted implementation.

Chi-Square Distribution↗

PubMed2004

Ethical dilemmas arising from implementation of the European guidelines on cardiovascular disease prevention in clinical practice. A descriptive epidemiological study.

OBJECTIVE: Our first objective is to describe total, age- and gender-specific prevalences of subjects in a well-defined population for whom medical follow-up is indicated due to unfavourably high blood pressure and/or cholesterol levels, as defined by the 2003 European guidelines on cardiovascular disease prevention in clinical practice. Our second objective is to highlight scientific questions and ethical dilemmas relating to implementation of the guidelines. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional population study comprising 62104 adult Norwegians aged 20-79 years who participated in The Nord-Tröndelag Health Study 1995--97. MAIN OUTCOME MEASURES: Total, age- and gender-specific point prevalences of individuals with total cholesterol > or =5 mmol/l and/or systolic blood pressure > or =140 mmHg and/or diastolic blood pressure > or =90 mmHg, or taking antihypertensive medication. MAIN RESULTS: In total, 76% of individuals aged 20-79 years have an "unfavourable" cardiovascular disease risk profile, according to guideline definitions. The point prevalence of individuals with cholesterol and/or blood pressure above the recommended cut-off points increases with age. By age 24, the prevalence reaches 50%. By age 49, it reaches 90%. Men below 50 years of age have higher combined risk prevalence than women. CONCLUSIONS AND IMPLICATIONS: Implementation of the 2003 European guidelines on CVD prevention would label a large majority of Norwegian adults as having unfavourably high cholesterol and/or blood pressure levels. The current biomedical standards appear to invalidate demographic health statistics. The theoretical basis on which the guidelines rest should thereby be scrutinized with regard to scientific methodology and consistency. Important ethical dilemmas arise at the point of guideline implementation, relating to risk labelling and medicalization, as well as resource allocation and sustainability within the healthcare system.

Adult↗

PubMed2006

Effectiveness of strategies to implement brief alcohol intervention in primary healthcare. A systematic review.

OBJECTIVE: To review systematically the available literature on implementation of brief alcohol interventions in primary healthcare in order to determine the effectiveness of the implementation efforts by the health are providers. KEY QUESTION: To what extent have the efforts to implement brief alcohol interventions in primary healthcare environments been successful? METHOD: Literature search from Medline, Cinahl, PsychLIT, Cochrane. SETTING: Primary healthcare. MATERIAL: A total of 11 studies encompassing 921 GPs, 266 nurses, 88 medical students, and 44 "non-physicians" from Europe, the USA, and Australia. MAIN OUTCOME MEASURES: Material utilization, screening, and brief intervention rates. ANSWER: Intervention effectiveness (material utilization, screening, and brief intervention rates) generally increased with the intensity of the intervention effort, i.e. the amount of training and/or support provided. Nevertheless, the overall effectiveness was rather modest. However, the studies examined were too heterogeneous, not scientifically rigorous enough, and applied too brief follow-up times to provide conclusive answers.

Alcohol Drinking↗

PubMedDate not supplied

Implementing women's cancer screening programs in American Indian and Alaska Native populations.

The National Breast and Cervical Cancer Early Detection Program provides funding to tribes and tribal organizations to implement comprehensive cancer screening programs using a program model developed for state health departments. We conducted a multiple-site case study using a participatory research process to describe how 5 tribal programs implemented screening services, and to identify strategies used to address challenges in delivering services to American Indian and Alaska Native women. We analyzed data from semistructured interviews with 141 key informants, 16 focus groups with 132 program-eligible women, and program documents. Several challenges regarding the delivery of services were revealed, including implementing screening programs in busy acute-care environments, access to mammography, providing culturally sensitive care, and providing diagnostic/treatment services in rural and remote locations. Strategies perceived as successful in meeting program challenges included identifying a "champion" or main supporter of the program in each clinical setting, using mobile mammography, using female providers, and increasing the capacity to provide diagnostic services at screening sites. The results should be of interest to an international audience, including those who work with health-related programs targeting indigenous women or groups that are marginalized because of culture, geographic isolation, and/or socioeconomic position.

Alaska↗

PubMed2006

Resistance to implementing Kangaroo Mother Care in developing countries, and proposed solutions.

BACKGROUND: Randomized clinical trials have shown that Kangaroo Mother Care (KMC) can decrease morbidity and mortality due to low birthweight. Between 1994 and 2004, 44 teams in 25 developing countries were trained in KMC in Bogotá, Colombia; however, not all the teams were successful in initiating their own programmes and, of those that started, not all replicated the validated model. AIM: To identify factors involved in unsuccessful KMC implementation and find solutions. METHODS: A study was conducted in which 17 open-ended questionnaires were sent by e-mail to the coordinators of functioning KMC programmes in 15 countries, and 15 site visits were made to institutes that reported problems in starting programmes. The information was classified according to the perceived obstacle and the KMC model component involved. RESULTS: The early-discharge component (including ambulatory follow-up) was that found most difficult to implement. Resistance from health professionals, mothers and families was often related to local cultural practices. CONCLUSION: Active surveillance for and appropriate identification of obstacles usually indicated the appropriate solution. Some of the obstacles were common to many second-generation KMC programmes, making this information valuable for the implementation of programmes.

Attitude of Health Personnel↗

PubMed2004

A baseline study of medication error rates at Baylor University Medical Center in preparation for implementation of a computerized physician order entry system.

OBJECTIVE: To determine baseline levels of medication errors and their root causes so as to highlight areas of potential process improvements and serve as a ruler against which to measure future improvements. DESIGN: A prospective pharmacist intervention study determining errors in 1014 medication orders at Baylor University Medical Center. Only errors in the process of medication ordering were documented; errors in drug administration were not considered. Root causes of errors were examined. RESULTS: The baseline medication error rate was 111.4 per 1000 orders (n = 1014). Most common were dosing errors (43.4 per 1000 orders), followed by frequency errors (19.7 per 1000 orders) and unavailable drug errors (12.8 per 1000 orders). Of the 113 total errors found, 52 (46%) had a transcription-based cause, i.e., an error in inputting the handwritten physician order into a computer system. System- or process-related root causes (such as duplicate orders or lack of crossover from one information system to another) accounted for 35.4% of the errors, and prescribing based causes (such as wrong dosage or nonformulary drugs) accounted for 18.6% of errors. CONCLUSIONS: Implementing a computerized physician order entry (CPOE) system would eliminate order-entry transcription-based errors. Its ability to resolve system/process-based and prescribing-based root causes of error is not as clear. Furthermore, the modification of processes due to implementation of CPOE could lead to new types of errors. Present processes must be redesigned according to evidence-based medicine, and future processes must be anticipated as technological changes occur. Such efforts-rather than outright reliance on technology--are more likely to lead to an error-free environment after CPOE is implemented.

Journal Article↗

PubMed2006

Overview and implementation of an intervention to prevent adherence failure among HIV-infected adults initiating antiretroviral therapy: lessons learned from Project HEART.

Project HEART, an acronym for Helping Enhance Adherence to Retroviral Therapy, was a prospective, controlled study to develop, implement, and evaluate a clinic-based behavioural intervention to prevent adherence failure among HIV-infected adults beginning their first highly active antiretroviral therapy (HAART) regimen (N = 227). In this paper, we describe the conceptualisation of the Project HEART adherence intervention, characteristics of the participants, and lessons learned implementing HEART in an inner-city clinic setting. A multi-component intervention, HEART combined enhanced education, reminders, adherence feedback, social support and adherence-focused problem solving in an integrated manner to address common cognitive, motivational, and social barriers to adherence. Unique components of the intervention included use of participant-identified adherence support partners and a standardized adherence barriers assessment to develop and implement individualised adherence plans. Lessons learned regarding the feasibility of using participant-identified support partners were as follows. Few participants eligible for the study had trouble identifying a support partner. Over 90% of support partners attended at least one intervention visit. Support partners were most available and amenable to participate early in the initiation of therapy. Participants' experiences as the 'supported' partner were generally positive. Though many participants faced barriers not easily addressed by this intervention (for example, housing instability), formally integrating support partners into the intervention helped to address many other common adherence barriers. Family and friends are an under-utilised resource in HIV medication adherence. Enlisting the help of support partners is a practical and economical approach to adherence counselling.

Adult↗

PubMed2006

Factors associated with teachers' implementation of HIV/AIDS education in secondary schools in Cape Town, South Africa.

This study investigated the factors influencing whether high school teachers implemented HIV/AIDS education. The independent variables included constructs derived from expectancy value theories, teachers' generic dispositions, their training experience, characteristics of their interactive context and the school climate. We conducted a postal survey of 579 teachers responsible for AIDS education in all 193 public high schools in Cape Town. Questionnaires were completed and returned by 324 teachers (56% response rate) from 125 schools. Many teachers (222; 70%) had implemented HIV/AIDS education during 2003, and female teachers were more likely to have implemented than males (74% vs. 58%). The teacher characteristics associated with teaching HIV/AIDS were previous training, self-efficacy, student-centeredness, beliefs about controllability and the outcome of HIV/AIDS education, and their responsibility. The existence of a school HIV/AIDS policy, a climate of equity and fairness, and good school-community relations were the school characteristics associated with teaching HIV/AIDS. These findings demonstrate the value of teacher training and school policy formulation. They also demonstrate the value and importance of interventions that go beyond a sexual health agenda, focussing on broader school development to improve school functioning and school climate.

Adult↗

PubMed1999

Implementation of a comprehensive AIDS education programme for schools in Masaka District, Uganda.

As part of a large IEC (Information, Education and Communication)/STD intervention trial, a 19-lesson, comprehensive school-based AIDS education programme was implemented and evaluated in 50 primary and 16 secondary schools in 12 parishes of Masaka District, Uganda. A series of three teacher-training and evaluation workshops spread over a year was held in each parish, between which teachers implemented the programme in the classroom. One hundred and forty-eight teachers were trained and about 3,500 students were subsequently exposed to the programme. Both teachers and students responded positively, which suggests that this type of programme has much to offer young people who attend school. However, some problems were encountered: language, programme content, community resistance to teaching about condoms, and several practical issues. Proposed solutions include flexibility with the English language policy, alternative approaches to role play activities, targeting influential individuals with information about the need for young people to learn about safer sex, and a parallel community-based IEC programme to facilitate community acceptance of the need for the programme. In addition, implementation may be incomplete unless comprehensive AIDS education is fully incorporated into the curriculum, and properly examined. These findings are placed in the context of other life skills/AIDS education programmes being introduced both in Uganda and elsewhere in Africa.

Acquired Immunodeficiency Syndrome↗

PubMed2004

Alignment of the policy planets: behind the implementation of the Northern Territory (Australia) Living With Alcohol programme.

The Northern Territory Living With Alcohol Programme (LWAP), implemented in Australia from 1991 to 2000, has been hailed as a successful example of a comprehensive public health alcohol policy, especially in its first 4 years--1991/92 to 1995/96. This paper draws upon a policy analysis of the LWAP currently in progress to identify and describe the factors that made implementation possible at this time. I argue that programme implementation was shaped by a remarkable alignment of agencies and actors in the political, fiscal, administrative and industrial domains. This alignment of forces, however, owed as much to contingency as to planning and did not endure. Although the policy itself remained unchanged and continued to generate significant achievements, the alignment of forces sustaining it began to fragment from late 1995 onwards. The paper concludes by exploring the implications of the analysis for alcohol policy in other domains, and for the relationship between evidence regarding effectiveness and other components of the policy process.

Alcoholism↗

PubMed2004

The implementation and evaluation of a community rehabilitation team: a case study.

PURPOSE: In the UK, intermediate care schemes have been implemented with short-term funding, targeted at reducing pressures on hospitals/nursing homes. Many have lacked a reliable evidence-base and there are few publications on one form of intermediate care, the community rehabilitation team (CRT). This study was conducted to establish whether one specific CRT should gain recurrent funding. METHODS: This qualitative case study took a multi-method, multi-perspective approach. Data sources included: three focus groups and 40 semi-structured interviews with patients, carers and health services/local authority/CRT staff, document review, and field notes. The resulting data were analysed thematically. RESULTS: The CRT was designed without sufficient reference to reliable evidence and consultation with local health/social services, and implemented against a background of cultural divides between and within these services. It was also hampered by an ambitious remit and premature attempts at outcome evaluation. Patients/carers were satisfied with interventions, functional gains and social aspects of input but there was no reliable evidence of cost-effectiveness. CONCLUSIONS: The study highlighted problems related to service implementation, which exposed flaws within current policy of providing short-term funding for schemes that must demonstrate cost-effectiveness quickly in order to gain recurrent funding.

Community Health Services↗

PubMed2000

Twenty-five strategies for improving the design, implementation and analysis of health services research related to alcohol and other drug abuse treatment.

While some aspects of addiction can be studied in laboratory or controlled settings, the study of long-term recovery management and the health services that support it requires going out into the community and dealing with populations and systems that are much more diverse and less under our control. This in turn raises many methodological challenges for the health service researchers studying alcohol and other drug abuse treatment. This paper identifies some of these challenges related to the design, measurement, implementation and effectiveness of health services research. It then recommends 25 strategies (and key primers) for addressing them: (1) identifying in advance all stakeholders and issues; (2) developing conceptual models of intervention and context; (3) identifying the population to whom the conclusions will be generalized; (4) matching the research design to the question; (5) conducting randomized experiments only when appropriate and necessary; (6) balancing methodological and treatment concerns; (7) prioritizing analysis plans and increasing design sensitivity, (8) combining qualitative and quantitative methods; (9) identifying the four basic types of measures needed; (10) identifying and using standardized measures; (11) carefully balancing measurement selection and modification; (12) developing and evaluating modified and new measures when necessary; (13) identifying and tracking major clinical subgroups; (14) measuring and analyzing the actual pattern of services received; (15) incorporating implementation checks into the design; (16) incorporating baseline measures into the intervention; (17) monitoring implementation and dosage as a form of quality assurance; (18) developing procedures early to facilitate tracking and follow-up of study participants; (19) using more appropriate representations of the actual experiment; (20) using appropriate and sensitive standard deviation terms; (21) partialing out variance due to design or known sources prior to estimating experimental effect sizes; (22) using dimensional, interval and ratio measures to increase sensitivity to change; (23) using path or structural equation models; (24) integrating qualitative and quantitative analysis into reporting; and (25) using quasi-experiments, economic or organizational studies to answer other likely policy questions. Most of these strategies have been tried and tested in this and other areas, but are not widely used. Improving the state of the art of health services research and bridging the gap between research and practice do not depend upon using the most advanced methods, but rather upon using the most appropriate methods.

Alcoholism↗

PubMedDate not supplied

Doe's quality system program: cooperative development and implementation.

Implementation of a Quality Systems approach to making defensible environmental program decisions depends upon multiple, interrelated components. Often, these components are developed independently and implemented at various facility and program levels in an attempt to achieve consistency and cost savings. The U.S. Department of Energy, Office of Environmental Management (DOE-EM) focuses on three primary system components to achieve effective environmental data collection and use. (1) Quality System guidance, which establishes the management framework to plan, implement, and assess work performed; (2) A Standardized Statement of Work for analytical services, which defines data generation and reporting requirements consistent with user needs; and (3) A laboratory assessment program to evaluate adherence of work performed to defined needs, e.g., documentation and confidence. This paper describes how DOE-EM fulfills these requirements and realizes cost-savings through participation in interagency working groups and integration of system elements as they evolve.

Cost-Benefit Analysis↗

PubMedDate not supplied

Implementation of depth-dependent soil concentrations in multimedia mass balance models.

In standard multimedia mass balance models, the soil compartment is modeled as a box with uniform concentrations, which often does not correspond with actual field situations. Therefore, the theoretically expected decrease of soil concentrations with depth was implemented in the multimedia model SimpleBox 3.0. The effects of this implementation on the model outcomes were explored for nine compounds in four environmental compartments. For compounds with a low penetration depth, the new model predicts substantially higher or lower concentrations in the vegetation compartment than the old model. For those compounds, predicted concentrations in surface water and air were higher in the new model, but the deviations from the old model were smaller than in the vegetation compartment. For compounds with a large penetration depth, the model adaptations show little effect. No field study was carried out to validate the results of the model calculations, but we did collect measured data on concentrations in vertical soil profiles from literature. According to those data, we concluded that the implementation of depth dependent soil concentrations might be a useful extension for steady state multimedia mass balance models. More field study has to be carried out to validate the model outcomes.

Databases, Factual↗

PubMed2006

Implementation of a best management practice (BMP) system for a clay mining facility in Taiwan.

The present paper describes the planning and implementation of a best management practice (BMP) system for a clay mining facility in Northern Taiwan. It is a challenge to plan and design BMPs for mitigating the impact of clay mining operations due to the fact that clay mining drainage typically contains very high concentrations of suspended solids (SS), Fe-ions, and [H+] concentrations. In the present study, a field monitoring effort was conducted to collect data for runoff quality and quantity from a clay mining area in Northern Taiwan. A BMP system including holding ponds connected in series was designed and implemented and its pollutant removal performance was assessed. The assessment was based on mass balance computations and an analysis of the relationship between BMP design parameters such as pond depth, detention time, surface loading rate, etc. and the pollutant removal efficiency. Field sampling results showed that the surface-loading rate is exponential related to the removing rate. The results provide the basis for a more comprehensive and efficient BMP implementation plan for clay mining operations.

Aluminum Silicates↗