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Towards implementing coordinated healthy lifestyle promotion in primary care: a mixed method study
Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för samhällsmedicin. Linköpings universitet, Medicinska fakulteten.ORCID-id: 0000-0001-6434-4855
Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för samhällsmedicin. Linköpings universitet, Medicinska fakulteten. Region Östergötland, Närsjukvården i västra Östergötland, Medicinska specialistkliniken.
Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för hälso- och sjukvårdsanalys. Linköpings universitet, Medicinska fakulteten.
2015 (Engelska)Ingår i: International Journal of Integrated Care, ISSN 1568-4156, E-ISSN 1568-4156, Vol. 15, artikel-id e030Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Background: Primary care is increasingly being encouraged to integrate healthy lifestyle promotion in routine care. However, implementation has been suboptimal. Coordinated care could facilitate lifestyle promotion practice but more empirical knowledge is needed about the implementation process of coordinated care initiatives. This study aimed to evaluate the implementation of a coordinated healthy lifestyle promotion initiative in a primary care setting.

Methods: A mixed method, convergent, parallel design was used. Three primary care centres took part in a two-year research project. Data collection methods included individual interviews, document data and questionnaires. The General Theory of Implementation was used as a framework in the analysis to integrate the data sources.

Results: Multi-disciplinary teams were implemented in the centres although the role of the teams as a resource for coordinated lifestyle promotion was not fully embedded at the centres. Embedding of the teams was challenged by differences among the staff, patients and team members on resources, commitment, social norms and roles.

Conclusions: The study highlights the importance of identifying and engaging key stakeholders early in an implementation process. The findings showed how the development phase influenced the implementation and embedding processes, which add aspects to the General Theory of Implementation.

Ort, förlag, år, upplaga, sidor
Utrecht, Netherlands: Utrecht University Library Open Access Journals , 2015. Vol. 15, artikel-id e030
Nyckelord [en]
Healthy lifestyle promotion; primary care; process evaluation; implementation; General Theory of Implementation; mixed methods
Nationell ämneskategori
Omvårdnad Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi Hälso- och sjukvårdsorganisation, hälsopolitik och hälsoekonomi
Identifikatorer
URN: urn:nbn:se:liu:diva-121491ISI: 000366093800003PubMedID: 26312058OAI: oai:DiVA.org:liu-121491DiVA, id: diva2:855805
Anmärkning

Funding agencies: Ostergotland County Council; Linkoping University

Tillgänglig från: 2015-09-22 Skapad: 2015-09-22 Senast uppdaterad: 2018-08-14Bibliografiskt granskad
Ingår i avhandling
1. Implementation of coordinated healthy lifestyle promotion in primary care: Process and outcomes
Öppna denna publikation i ny flik eller fönster >>Implementation of coordinated healthy lifestyle promotion in primary care: Process and outcomes
2015 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
Abstract [en]

Background: Implementation of healthy lifestyle promotion in routine primary has been suboptimal. There is emerging evidence that coordinating care can improve the efficiency and quality of care. However, more research is needed on the implementation of coordinated care in healthy lifestyle promotion, the role of patients in implementation and the long-term outcomes of implementation efforts.

Overall aim: To investigate the implementation of coordinated healthy lifestyle promotion in primary care in terms of process and outcomes, from the perspectives of both staff and patients.

Methods: In 2008, Östergötland county council commissioned primary care centres to implement a coordinated care initiative, lifestyle teams, to improve healthy lifestyle promotion routines. A lifestyle team protocol stipulated centres to: (1) create multi-professional teams, (2) appoint team managers, (3) hold team meetings, and (4) create in-house referral routines for at-risk patients. Paper I investigated the implementation process of three lifestyle teams during a two year period using a mixed method, convergent parallel design. A proposed theory of implementation process was used to analyse data from manager interviews, documents and questionnaires. Paper II explored patients’ role in implementation using grounded theory. Interview data from patients with varied experience of promotion was used. Paper III investigated implementation outcomes using a quasi-experimental, cross-sectional design that compared three intervention centres (lifestyle teams) with three control centres (no teams). Data were collected by staff and patient questionnaires and manager interviews at 3 and 5 years after commissioning. The RE-AIM framework was modified and used to define outcome variables: Reach of patients, Effectiveness (attitudes and competency among staff), Adoption among staff, Implementation fidelity to the lifestyle team protocol, and Maintenance of the results at 5-year follow-up.

Results: Paper I: The implementation process was complex including multiple innovation components and groups of adopters. The conditions for implementation, e.g. resources varied between staff and team members which challenged the embedding of the teams and new routines. The lifestyle teams were continuously redefined by team members to accommodate contextual factors, features of the protocol and patients. The lifestyle team protocol presented an infrastructure for practice at the centres. Paper II: A grounded theory about being healthy with three interconnected subcategories emerged from data: (1) conditions, (2) managing, and (3) interactions regarding being healthy. Being healthy represented a process of approaching a health ideal which occurred simultaneously with, and could contradict, a process of maximizing well-being. A typology of four patient types (resigned, receivers, co-workers, and leaders) illustrated how processes before, during and after healthy lifestyle promotion were interconnected. Paper III: Reach: significantly more patients at control centres received promotion compared to intervention centres at 3-year (48% and 41% respectively) and 5-year followups (44% and 36% respectively). Effectiveness: At 3-year follow-up, after controlling for clustering by centres, intervention staff were significantly more positive concerning perceived need for lifestyle teams; that healthy lifestyle promotion was prioritized at their centre and that there was adequate competency at individual and centre level regarding lifestyle promotion. At 5-year follow-up, significant differences remained regarding prioritization of lifestyle promotion at centre level. The majority of both intervention and control staff were positive towards lifestyle promotion. Adoption: No significant differences were found between control and intervention centres at 3 years (59% and 47% respectively) or at 5 years (45% and 36% respectively). Implementation fidelity: all components of the lifestyle team protocol had been implemented at all the intervention centres and at none of the control centres.

Conclusions: The implementation process was challenged by a complex interaction between groups of staff, innovation components and contextual factors. Although coordinated care are used for other conditions in primary care, the findings suggest that it is difficult to adopt similar routines for healthy lifestyle promotion. Findings suggest that the lifestyle team protocol did not fully consider social components of coordinated care or the varied conditions for change exhibited by adopters. Patients can be seen as coproducing implementation of healthy lifestyle promotion.

Ort, förlag, år, upplaga, sidor
Linköping: Linköping University Electronic Press, 2015. s. 92
Serie
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1464
Nationell ämneskategori
Omvårdnad Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi Hälso- och sjukvårdsorganisation, hälsopolitik och hälsoekonomi
Identifikatorer
urn:nbn:se:liu:diva-121492 (URN)10.3384/diss.diva-121492 (DOI)978-91-7519-043-3 (ISBN)
Disputation
2015-10-15, Belladonna, Hus 511-001, Campus US, Linköping, 09:00 (Svenska)
Opponent
Handledare
Tillgänglig från: 2015-09-22 Skapad: 2015-09-22 Senast uppdaterad: 2019-11-15Bibliografiskt granskad

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