Barriers and facilitators in the implementation of an evidence-based health promotion intervention in a primary care setting: a qualitative study.

PURPOSE: This study aims to elucidate the health care organization, management and policy barriers and facilitators associated with implementation of an evidence-based health promotion intervention in primary care centers in the Basque Country, Spain. DESIGN/METHODOLOGY/APPROACH: Seven focus groups were conducted with 49 health professionals from six primary care centers participating in the Prescribing Healthy Life program. Text was analyzed using the Consolidated Framework for Implementation Research (CFIR) focusing on those constructs related to health care organization, management and policy. FINDINGS: The health promotion intervention was found to be compatible with the values of primary care professionals. However, professionals at all centers reported barriers to implementation related to: (1) external policy and incentives, (2) compatibility with existing workflow and (3) available resources to carry out the program. Specific barriers in these areas related to lack of financial and political support, consultation time constraints and difficulty managing competing day-to-day demands. Other barriers and facilitators were related to the constructs networks and communication, culture, relative priority and leadership engagement. A set of six specific barrier-facilitator pairs emerged. ORIGINALITY/VALUE: Implementation science and, specifically, the CFIR constructs were used as a guide. Barriers and facilitators related to the implementation of a health promotion program in primary care were identified. Healthcare managers and policy makers can modify these factors to foster a more propitious implementation environment. These factors should be appropriately monitored, both in pre-implementation phases and during the implementation process, in order to ensure effective integration of health promotion into the primary care setting.

Testing cost containment of future healthcare with maintained or improved quality-The COSTCARES project.

BACKGROUND: Increasing healthcare costs need to be contained in order to maintain equality of access to care for all EU citizens. A cross-disciplinary consortium of experts was supported by the EU FP7 research programme, to produce a roadmap on cost containment, while maintaining or improving the quality of healthcare. The roadmap comprises two drivers: person-centred care and health promotion; five critical enablers also need to be addressed: information technology, quality measures, infrastructure, incentive systems, and contracting strategies. METHOD: In order to develop and test the roadmap, a COST Action project was initiated: COST-CARES, with 28 participating countries. This paper provides an overview of evidence about the effects of each of the identified enablers. Intersections between the drivers and the enablers are identified as critical for the success of future cost containment, in tandem with maintained or improved quality in healthcare. This will require further exploration through testing. CONCLUSION: Cost containment of future healthcare, with maintained or improved quality, needs to be addressed through a concerted approach of testing key factors. We propose a framework for test lab design based on these drivers and enablers in different European countries.

Recommendations for Effective Intersectoral Collaboration in Health Promotion Interventions: Results from Joint Action CHRODIS-PLUS Work Package 5 Activities.

The burden of chronic disease in Europe continues to grow. A major challenge facing national governments is how to tackle the risk factors of sedentary lifestyle, alcohol abuse, smoking, and unhealthy diet. These factors are complex and necessitate intersectoral collaboration to strengthen health promotion, counter-act the social determinants of health, and reduce the prevalence of chronic disease. European countries have diverse intersectoral collaboration to encourage health promotion activities. In the Joint Action CHRODIS-PLUS success factors for intersectoral collaboration within and outside healthcare which strengthen health promotion activities were identified with a mixed method design via a survey of 22 project partners in 14 countries and 2 workshops. In six semi-structured interviews, the mechanisms underlying these success factors were examined. These mechanisms can be very context-specific but do give more insight into how they can be replicated. In this paper, 20 health promotion interventions from national programs in CHRODIS PLUS are explored. This includes community interventions, policy actions, integrated approaches, capacity building, and training activities. The interventions involved collaboration across three to more than six sectors. The conclusion is a set of seven recommendations that are considered to be essential for fostering intersectoral collaboration to improve health-promoting activities.

Supporting Innovative Person-Centred Care in Financially Constrained Environments: The WE CARE Exploratory Health Laboratory Evaluation Strategy.

The COST CARES project aims to support healthcare cost containment and improve healthcare quality across Europe by developing the research and development necessary for person-centred care (PCC) and health promotion. This paper presents an overview evaluation strategy for testing 'Exploratory Health Laboratories' to deliver these aims. Our strategy is theory driven and evidence based, and developed through a multi-disciplinary and European-wide team. Specifically, we define the key approach and essential criteria necessary to evaluate initial testing, and on-going large-scale implementation with a core set of accompanying methods (metrics, models, and measurements). This paper also outlines the enabling mechanisms that support the development of the "Health Labs" towards innovative models of ethically grounded and evidenced-based PCC.

Examining the influence of three types of social support on the mental health of mexican caregivers of individuals with traumatic brain injury.

OBJECTIVE: The aim of this study was to examine the influence of three types of social support (appraisal, belonging, and tangible) on caregiver mental health (anxiety, burden, depression, and satisfaction with life) among Mexican caregivers of individuals with traumatic brain injury. DESIGN: This is a cross-sectional study of 90 family caregivers from Hospital Civil Fray Antonio Alcade in Guadalajara, Mexico. RESULTS: More months spent caregiving was associated with decreases in all three types of social support. Older age and fewer years of education were associated with lower appraisal social support. More hours per week spent caregiving was associated with lower caregiver state anxiety and greater satisfaction with life. Appraisal, belonging, and tangible social support were all significantly correlated with more salubrious caregiver mental health outcomes, except satisfaction with life. Appraisal social support independently predicted lower caregiver depression. CONCLUSIONS: Particularly in Latin America, strong social support networks and family connections seem closely tied to key mental health outcomes such as depression. Rehabilitation interventions aimed at strengthening perceptions of social support of caregivers of individuals with traumatic brain injury that specifically target availability of advice may improve mental health and contribute to more optimal informal care for individuals with traumatic brain injury.

Evidence-based practice for acute low back pain in primary care: patient outcomes and cost of care.

Provider adherence with clinical practice guidelines (CPGs) for acute low back pain (LBP) and its impact on clinical outcomes and cost are controversial. A panel and cross-sectional design was used to determine the rate of provider adherence to the Department of Defense/Veteran's Administration CPG for Acute LBP which included ergonomic and psychosocial intervention. The relationship among adherent care, patient satisfaction, general health, functional outcome, and cost was examined. Direct health services and patient survey data 1 year before and 3 years following guideline implementation were analyzed. The sample consisted of 15,789 LBP cases (CPG) and 14,409 upper extremity cases used as controls (no CPG). Ten to 40% of LBP cases received CPG-adherent care across the 4 years. No differences were found between LBP and upper extremity diagnoses groups in the rates of change in the four outcomes over years. Multivariable regression analyses controlling for demographic variables and perceived health indicated that CPG adherence was related to better functional outcomes, Odds ratio (OR)=1.45 [95% CI=1.31-1.60] and lower healthcare costs (beta=-230.15, p<0.001). Cases receiving more adherent care also reported higher levels of patient satisfaction (beta=0.09, p<0.05) and general health, OR=1.44 [95% CI=1.29-1.60]. Higher levels of adherent care which included efforts to address both ergonomic and psychosocial factors in the course of acute back pain were related to better clinical outcomes and lower costs.