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The Challenge of Changing Practice: Applying Theory in the Implementation of an Innovation in Swedish Primary Health Care
Linköping University, Department of Medical and Health Sciences, Division of Preventive and Social Medicine and Public Health Science. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Primary Health Care Centres.ORCID iD: 0000-0001-9116-8156
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: The translation of new knowledge, such as research findings, new tools or methods into health care practice has gained increased  interest in recent years. Important factors that determine implementation outcome have been identified, and models and checklists to be followed in planning as well as in carrying out an implementation process have been produced. However, there are still knowledge gaps regarding what approach should be used in which setting and for which problems. Primary health care (PHC) in Sweden is an area where there is a paucity of research regarding implementation of new methods into practice. The aim of the thesis was to apply theory in the study of the implementation of an innovation in Swedish PHC, and identify factors that influenced outcome.

Methods: The study was performed using a quasi-experimental design, and included six PHC units, two from each one of three county councils in the southeast part of Sweden. A computer-based lifestyle intervention tool (CLT) developed to facilitate addressing lifestyle issues, was introduced at the units. Two different strategies were used for the introduction, both aiming to facilitate the process: a theory-based explicit strategy and an implicit strategy requiring a minimum of effort. Data collection was performed at baseline, and after six, nine and 24 months. Questionnaires were distributed to staff and managers, and data was also collected from the CLT database and county council registers. Implementation outcome was defined as the proportion of eligible patients being referred to the CLT, and was also measured in terms of Reach, Effectiveness, Adoption, Implementation and Maintenance according to the RE-AIM framework. Interviews were performed in order to explore experiences of the implementation process as perceived by staff and managers.

Results: A positive organizational climate seemed to promote implementation. Organizational changes or staff shortages coinciding with the implementation process had a negative influence on outcome. The explicit implementation strategy seemed to be more effective than the implicit strategy in the short term, but the differences levelled out over time. The adopters’ perceptions of the implementation seemed to be influenced by the existing professional sub-cultures. Successful implementation was associated with positive expectations, perceptions of the innovation being compatible with existing routines and perceptions of relative advantage.

Conclusions: The general conclusion is that when theory was applied in the implementation of a lifestyle intervention tool in Swedish PHC, factors related to the adopters and to the innovation seemed to be more important over time than the strategy used. Staff expectations, perceptions of the innovation’s relative advantage and potential compatibility with existing routines were found to be positively associated with implementation outcome, and other major organizational changes concurrent with implementation seemed to affect the outcome in a negative way. Values, beliefs and behaviour associated with the existing sub-cultures in PHC appeared to influence how the implementation of an innovation was perceived by managers and the different professionals.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2012. , 108 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1269
Keyword [en]
Implementation; Primary Health Care; Public Health
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:liu:diva-73300ISBN: 978-91-7393-039-0 (print)OAI: oai:DiVA.org:liu-73300DiVA: diva2:473040
Public defence
2012-02-01, Aulan, Hälsans Hus, Campus US, Linköpings universitet, Linköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2012-02-10 Created: 2012-01-02 Last updated: 2013-09-30Bibliographically approved
List of papers
1. The importance of organizational climate and implementation strategy at the introduction of a new working tool in primary health care
Open this publication in new window or tab >>The importance of organizational climate and implementation strategy at the introduction of a new working tool in primary health care
2010 (English)In: Journal of Evaluation in Clinical Practice, ISSN 1356-1294, Vol. 16, no 6, 1326-1332 p.Article in journal (Refereed) Published
Abstract [en]

Rationale, aims and objectives The transmission of research findings into routine care is a slow and unpredictable process. Important factors predicting receptivity for innovations within organizations have been identified, but there is a need for further research in this area. The aim of this study was to describe contextual factors and evaluate if organizational climate and implementation strategy influenced outcome, when a computer-based concept for lifestyle intervention was introduced in primary health care (PHC). Method The study was conducted using a prospective intervention design. The computer-based concept was implemented at six PHC units. Contextual factors in terms of size, leadership, organizational climate and political environment at the units included in the study were assessed before implementation. Organizational climate was measured using the Creative Climate Questionnaire (CCQ). Two different implementation strategies were used: one explicit strategy, based on Rogers theories about the innovation-decision process, and one implicit strategy. After 6 months, implementation outcome in terms of the proportion of patients who had been referred to the test, was measured. Results The CCQ questionnaire response rates among staff ranged from 67% to 91% at the six units. Organizational climate differed substantially between the units. Managers scored higher on CCQ than staff at the same unit. A combination of high CCQ scores and explicit implementation strategy was associated with a positive implementation outcome. Conclusions Organizational climate varies substantially between different PHC units. High CCQ scores in combination with an explicit implementation strategy predict a positive implementation outcome when a new working tool is introduced in PHC.

Place, publisher, year, edition, pages
Blackwell Publishing Ltd, 2010
Keyword
implementation, life style, organizational climate, primary health care
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-65943 (URN)10.1111/j.1365-2753.2009.01336.x (DOI)000285763900048 ()
Note
This is the authors’ version of the following article: Siw Carlfjord, A Andersson and Per Nilsen, The importance of organizational climate and implementation strategy at the introduction of a new working tool in primary health care, 2010, JOURNAL OF EVALUATION IN CLINICAL PRACTICE, (16), 6, 1326-1332. which has been published in final form at: http://dx.doi.org/10.1111/j.1365-2753.2009.01336.x Copyright: Blackwell Publishing Ltd http://eu.wiley.com/WileyCDA/Brand/id-35.htmlAvailable from: 2011-02-28 Created: 2011-02-28 Last updated: 2013-09-30
2. Applying the RE-AIM framework to evaluate two implementation strategies used to introduce a tool for lifestyle intervention in Swedish primary health care
Open this publication in new window or tab >>Applying the RE-AIM framework to evaluate two implementation strategies used to introduce a tool for lifestyle intervention in Swedish primary health care
Show others...
2012 (English)In: Health Promotion International, ISSN 0957-4824, E-ISSN 1460-2245, Vol. 27, no 2, 167-176 p.Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to evaluate two implementation strategies for the introduction of a lifestyle intervention tool in primary health care (PHC), applying the RE-AIM framework to assess outcome. A computer-based tool for lifestyle intervention was introduced in PHC. A theory-based, explicit, implementation strategy was used at three centers, and an implicit strategy with a minimum of implementation efforts at three others. After 9 months a questionnaire was sent to staff members (n= 159) and data from a test database and county council registers were collected. The RE-AIM framework was applied to evaluate outcome in terms of reach, effectiveness, adoption and implementation. The response rate for the questionnaire was 73%. Significant differences in outcome were found between the strategies regarding reach, effectiveness and adoption, in favor of the explicit implementation strategy. Regarding the dimension implementation, no differences were found according to the implementation strategy. A theory-based implementation strategy including a testing period before using a new tool in daily practice seemed to be more successful than a strategy in which the tool was introduced and immediately used for patients.                 

Place, publisher, year, edition, pages
Oxford University Press, 2012
Keyword
Implementation; Primary health care; RE-AIM
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-73379 (URN)10.1093/heapro/dar016 (DOI)000304016100004 ()
Available from: 2012-01-13 Created: 2012-01-02 Last updated: 2017-12-08Bibliographically approved
3. Key factors influencing adoption of an innovation in primary health care: a qualitative study based on implementation theory
Open this publication in new window or tab >>Key factors influencing adoption of an innovation in primary health care: a qualitative study based on implementation theory
Show others...
2010 (English)In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 11, no 60Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Bridging the knowledge-to-practice gap in health care is an important issue that has gained interest in recent years. Implementing new methods, guidelines or tools into routine care, however, is a slow and unpredictable process, and the factors that play a role in the change process are not yet fully understood. There is a number of theories concerned with factors predicting successful implementation in various settings, however, this issue is insufficiently studied in primary health care (PHC). The objective of this article was to apply implementation theory to identify key factors influencing the adoption of an innovation being introduced in PHC in Sweden.

METHODS: A qualitative study was carried out with staff at six PHC units in Sweden where a computer-based test for lifestyle intervention had been implemented. Two different implementation strategies, implicit or explicit, were used. Sixteen focus group interviews and two individual interviews were performed. In the analysis a theoretical framework based on studies of implementation in health service organizations, was applied to identify key factors influencing adoption.

RESULTS: The theoretical framework proved to be relevant for studies in PHC. Adoption was positively influenced by positive expectations at the unit, perceptions of the innovation being compatible with existing routines and perceived advantages. An explicit implementation strategy and positive opinions on change and innovation were also associated with adoption. Organizational changes and staff shortages coinciding with implementation seemed to be obstacles for the adoption process.

CONCLUSION: When implementation theory obtained from studies in other areas was applied in PHC it proved to be relevant for this particular setting. Based on our results, factors to be taken into account in the planning of the implementation of a new tool in PHC should include assessment of staff expectations, assessment of the perceived need for the innovation to be implemented, and of its potential compatibility with existing routines. Regarding context, we suggest that implementation concurrent with other major organizational changes should be avoided. The choice of implementation strategy should be given thorough consideration.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-59064 (URN)10.1186/1471-2296-11-60 (DOI)
Available from: 2010-09-08 Created: 2010-09-08 Last updated: 2017-12-12Bibliographically approved
4. Experiences of the implementation of a tool for lifestyle intervention in primary health care: a qualitative study among managers and professional groups
Open this publication in new window or tab >>Experiences of the implementation of a tool for lifestyle intervention in primary health care: a qualitative study among managers and professional groups
2011 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 11, no 195Article in journal (Refereed) Published
Abstract [en]

Background:In recent years there has been increasing interest in transferring new knowledge into health care practices, a process often referred to as implementation. The various subcultures that exist among health care workers may be an obstacle in this process. The aim of this study was to explore how professional groups and managers experienced the implementation of a new tool for lifestyle intervention in primary health care (PHC). The computer-based tool was introduced with the intention of facilitating the delivery of preventive services.

Methods:Focus group interviews with staff and individual interviews with managers at six PHC units in the southeast of Sweden were performed 9 months after the introduction of the new working tool. Staff interviews were conducted in groups according to profession, and were analysed using manifest content analysis. Experiences and opinions from the different staff groups and from managers were analysed.

Results: Implementation preconditions, opinions about the lifestyle test, and opinions about usage were the main areas identified. In each of the groups, managers and professionals, factors related to the existing subcultures seemed to influence their experiences of the implementation. Managers were visionary, GPs were reluctant, nurses were open, and nurse assistants were indifferent.

Conclusion: This study indicates that the existing subcultures in PHC influence how the implementation of an innovation is perceived by managers and the different professionals. In PHC, an organization with several subcultures and an established hierarchical structure, an implementation strategy aimed at all groups did not seem to result in a successful uptake of the new method.

Place, publisher, year, edition, pages
BioMed Central, 2011
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-71112 (URN)10.1186/1472-6963-11-195 (DOI)000294735700002 ()
Available from: 2011-09-30 Created: 2011-09-30 Last updated: 2017-12-08
5. Sustained use of a tool for lifestyle intervention implemented in primary health care: a 2-year follow-up
Open this publication in new window or tab >>Sustained use of a tool for lifestyle intervention implemented in primary health care: a 2-year follow-up
2013 (English)In: Journal of Evaluation In Clinical Practice, ISSN 1356-1294, E-ISSN 1365-2753, Vol. 19, no 2, 327-334 p.Article in journal (Refereed) Published
Abstract [en]

Rational, aims and objectives: Sustainability of new methods implemented in health care is one of the most central issues in addressing the gap between research and practice, but is seldom assessed in implementation studies. The aim of this study was to evaluate the implementation of a new tool for lifestyle intervention in primary health care (PHC) 2 years after the introduction, and assess if the implementation strategy used influenced sustainability.

Method: A computer-based lifestyle intervention tool (CLT) was introduced at six PHC units in Sweden in 2008, using two implementation strategies: explicit and implicit. The main difference between the strategies was a 4-week test period followed by a decision session, included in the explicit strategy. Evaluations were performed after 6, 9 and 24 months. After 24 months, the RE-AIM framework was applied to assess and compare outcome according to strategy.

Results: A more positive outcome regarding Reach, Effectiveness, Adoption and Implementation in the explicit group could be almost completely attributed to one of the units. Maintenance was low and after 24 months, differences according to strategy were negligible.

Conclusion: After 24 months the most positive outcomes regarding all RE-AIM dimensions were found in one of the units where the explicit strategy was used. The explicit strategy per se had some effect on the dimension Effectiveness, but was not associated with sustainability overall. Staff at the most successful unit earlier had positive expectations regarding the CLT and found it compatible with existing routines.

Place, publisher, year, edition, pages
Wiley-Blackwell, 2013
Keyword
implementation, lifestyle, primary health care, sustainability
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-74877 (URN)10.1111/j.1365-2753.2012.01827.x (DOI)000315964800017 ()
Note

Funding Agencies|Medical Research Council of Southeast Sweden (FORSS)||Swedish Council for Working Life and Social Research (FAS)||

Available from: 2012-02-10 Created: 2012-02-10 Last updated: 2017-12-07Bibliographically approved

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