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Implementation of healthy lifestyle promotion in primary care: Patients as coproducers
Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Health Sciences.
Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in West Östergötland, Department of Medical Specialist in Motala.
Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
2014 (English)In: Patient Education and Counseling, ISSN 0738-3991, E-ISSN 1873-5134, Vol. 97, no 2, 283-290 p.Article in journal (Refereed) Published
Abstract [en]

Objectives: To explore and theorize how patients perceive, interpret, and reactin healthy lifestyle promotion situations in primary care and to investigate patients role in implementation of lifestyle promotion illustrated by typologies. Methods: Grounded theory was used to assess qualitative interview data from 22 patients with varied experience of healthy lifestyle promotion. Data were analyzed by constant comparative analysis. Results: A substantive theory of being healthy emerged from the data. The theory highlights the processes that are important for implementation before, during, and after lifestyle promotion. Three interconnected categories emerged from the data: conditions for being healthy, managing being healthy, and interactions about being healthy; these formed the core category: being healthy. A typology proposed four patient trajectories on being healthy: resigned, receivers, coworkers, and leaders. Conclusion: Patients coproduced the implementation of lifestyle promotion through the degree of transparency, which was a result of patients expectations and situation appraisals. Practice implications: Different approaches are needed during lifestyle promotion depending on a variety of patient-related factors. The typology could guide practitioners in their lifestyle promotion practice.

Place, publisher, year, edition, pages
Elsevier , 2014. Vol. 97, no 2, 283-290 p.
Keyword [en]
Implementation; Primary care; Lifestyle promotion; Grounded theory
National Category
Basic Medicine Clinical Medicine
URN: urn:nbn:se:liu:diva-112827DOI: 10.1016/j.pec.2014.07.033ISI: 000344824800020PubMedID: 25154336OAI: diva2:776837

Funding Agencies|Ostergotland County Council; Linkoping University [8811002010]

Available from: 2015-01-08 Created: 2014-12-17 Last updated: 2015-09-22Bibliographically approved
In thesis
1. Implementation of coordinated healthy lifestyle promotion in primary care: Process and outcomes
Open this publication in new window or tab >>Implementation of coordinated healthy lifestyle promotion in primary care: Process and outcomes
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
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.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2015. 92 p.
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1464
National Category
Nursing Public Health, Global Health, Social Medicine and Epidemiology Health Care Service and Management, Health Policy and Services and Health Economy
urn:nbn:se:liu:diva-121492 (URN)10.3384/diss.diva-121492 (DOI)978-91-7519-043-3 (print) (ISBN)
Public defence
2015-10-15, Belladonna, Hus 511-001, Campus US, Linköping, 09:00 (Swedish)
Available from: 2015-09-22 Created: 2015-09-22 Last updated: 2015-09-22Bibliographically approved

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