Strategies used throughout the scaling-up process of eConsult - Multiple case study of four Canadian Provinces.

BACKGROUND: eConsult is a model of asynchronous communication connecting primary care providers to specialists to discuss patient care. This study aims to analyze the scaling-up process and identify strategies used to support scaling-up efforts in four provinces in Canada. METHODS: We conducted a multiple case study with four cases (ON, QC, MB, NL). Data collection methods included document review (n = 93), meeting observations (n = 65) and semi-structured interviews (n = 40). Each case was analyzed based on Milat's framework. RESULTS: The first scaling-up phase was marked by the rigorous evaluation of eConsult pilot projects and the publication of over 90 scientific papers. In the second phase, provinces implemented provincial multi-stakeholder committees, institutionalized the evaluation, and produced documents detailing the scaling-up plan. During the third phase, efforts were made to lead proofs of concept, obtain the endorsement of national and provincial organizations, and mobilize alternate sources of funding. The last phase was mainly observed in Ontario, where the creation of a provincial governance structure and strategies were put in place to monitor the service and manage changes. CONCLUSIONS: Various strategies need to be used throughout the scaling-up process. The process remains challenging and lengthy because health systems lack clear processes to support innovation scaling-up.

Scaling-Up eConsult: Promising Strategies to Address Enabling Factors in Four Jurisdictions in Canada.

BACKGROUND: Effective healthcare innovations are often not scaled up beyond their initial local context. Lack of practical knowledge on how to move from local innovations to large-system improvement hinders innovation and learning capacity in health systems. Studying scale-up processes can lead to a better understanding of how to facilitate the scale-up of interventions. eConsult is a digital health innovation that aims to connect primary care professionals with specialists through an asynchronous electronic consultation. The recent implementation of eConsult in the public health systems of four Canadian jurisdictions provides a unique opportunity to identify different enabling strategies and related factors that promote the scaling up of eConsult across jurisdictions. METHODS: We conducted a narrative case study in four Canadian provinces, Quebec, Ontario, Manitoba, and Newfoundland & Labrador, over a 3-year period (2018-2021). We observed provincial eConsult committee meetings (n=65) and national eConsult forums (n=3), and we reviewed internal documents (n=93). We conducted semi-structured interviews with key actors in each jurisdiction (eg, researchers, primary care professionals, specialists, policy-makers, and patient partners) (n=40). We conducted thematic analysis guided by the literature on factors and strategies used to scale up innovations. RESULTS: We identified a total of 31 strategies related to six key enabling factors to scaling up eConsult, including: (1) multi-actor engagement; (2) relative advantage; (3) knowledge transfer; (4) strong evidence base; (5) physician leadership; and (6) resource acquisition (eg, human, material, and financial resources). More commonly used strategies, such as leveraging research infrastructure and bringing together various actors, were used to address multiple enabling factors. CONCLUSION: Actors used various strategies to scale up eConsult within their respective contexts, and these helped address six key factors that seemed to be essential to the scale-up of eConsult.

Case Management in Primary Care for Frequent Users of Health Care Services: A Realist Synthesis.

PURPOSE: Case management (CM) is a promising intervention for frequent users of health care services. Our research question was how and under what circumstances does CM in primary care work to improve outcomes among frequent users with chronic conditions? METHODS: We conducted a realist synthesis, searching MEDLINE, CINAHL, Embase, and PsycINFO (1996 to September 2017) for articles meeting the following criteria: (1) population: adult frequent users with chronic disease, (2) intervention: CM in a primary care setting with a postintervention evaluation, and (3) primary outcomes: integration of services, health care system use, cost, and patient outcome measures. Academic and gray literature were evaluated for relevance and robustness. Independent reviewers extracted data to identify context, mechanism, and outcome (CMO) configurations. Analysis of CMO configurations allowed for the modification of an initial program theory toward a refined program theory. RESULTS: Of the 9,295 records retrieved, 21 peer-reviewed articles and an additional 89 documents were retained. We evaluated 19 CM interventions and identified 11 CMO configurations. The development of a trusting relationship fostering patient and clinician engagement in the CM intervention was recurrent in many CMO configurations. CONCLUSION: Our refined program theory proposes that in the context of easy access to an experienced and trusted case manager who provides comprehensive care while maintaining positive interactions with patients, the development of this relationship fosters the engagement of both individuals and yields positive outcomes when the following mechanisms are triggered: patients and clinicians feel supported, respected, accepted, engaged, and committed; and patients feel less anxious, more secure, and empowered to self-manage.

Scaling up eConsult for access to specialists in primary healthcare across four Canadian provinces: study protocol of a multiple case study.

BACKGROUND: Canada has been referred to as the land of 'perpetual pilot projects'. Effective innovations often remain small in scale, with limited impact on health systems. Several innovations have been developed in Canada to tackle important challenges such as poor access to services and excessive wait times - one of the most promising innovations that has been piloted is eConsult, which is a model of asynchronous communication that allows primary care providers to electronically consult with specialists regarding their patients' medical issues. eConsult pilot projects have been shown to reduce wait times for specialist care, prevent unnecessary referrals and reduce health system costs. eConsult has been spread throughout Ontario as well as to certain regions in Manitoba, Quebec, and Newfoundland and Labrador. Our aim is to understand and support the scale-up process of eConsult in Ontario, Quebec, Manitoba, and Newfoundland and Labrador. Our specific objectives are to (1) describe the main components of eConsult relevant to the scale-up process in each province; (2) understand the eConsult scale-up process in each province and compare across provinces; (3) identify policy issues and strategies to scaling up eConsult in each province; and (4) foster cross-level and cross-jurisdictional learning on scaling up eConsult. METHODS: We will conduct a qualitative multiple case study to investigate the scaling up of eConsult in four Canadian provinces using a grey literature review, key stakeholder interviews (10 interviews/province), non-participant observations, focus groups and deliberative dialogues. We will identify the main components of eConsult to be scaled up using logic models (obj. 1). Scaling up processes will be analysed using strategies adapted from process research (obj. 2). Policy issues and strategies to scale-up eConsult will be analysed thematically (obj. 3). Finally, a symposium will foster pan-Canadian learning on the process of scaling up eConsult (obj. 4). DISCUSSION: This study will likely increase learning and support evidence-based policy-making across participating provinces and may improve the capacity for a pan-Canadian scale-up of eConsult, including in provinces where eConsult has not yet been implemented. This work is essential to inform how similar innovations can reshape our health systems in the evolving information age.

Characteristics of Case Management in Primary Care Associated With Positive Outcomes for Frequent Users of Health Care: A Systematic Review.

PURPOSE: Case management (CM) interventions are effective for frequent users of health care services, but little is known about which intervention characteristics lead to positive outcomes. We sought to identify characteristics of CM that yield positive outcomes among frequent users with chronic disease in primary care. METHODS: For this systematic review of both quantitative and qualitative studies, we searched MEDLINE, CINAHL, Embase, and PsycINFO (1996 to September 2017) and included articles meeting the following criteria: (1)population: adult frequent users with chronic disease, (2)intervention: CM in a primary care setting with a postintervention evaluation, and (3)primary outcomes: integration of services, health care system use, cost, and patient outcome measures. Independent reviewers screened abstracts, read full texts, appraised methodologic quality (Mixed Methods Appraisal Tool), and extracted data from the included studies. Sufficient and necessary CM intervention characteristics were identified using configurational comparative methods. RESULTS: Of the 10,687 records retrieved, 20 studies were included; 17 quantitative, 2 qualitative, and 1 mixed methods study. Analyses revealed that it is necessary to identify patients most likely to benefit from a CM intervention for CM to produce positive outcomes. High-intensity intervention or the presence of a multidisciplinary/interorganizational care plan was also associated with positive outcomes. CONCLUSIONS: Policy makers and clinicians should focus on their case-finding processes because this is the essential characteristic of CM effectiveness. In addition, value should be placed on high-intensity CM interventions and developing care plans with multiple types of care providers to help improve patient outcomes.

A systematic mixed studies review on Organizational Participatory Research: towards operational guidance.

BACKGROUND: Organizational Participatory Research (OPR) seeks organizational learning and/or practice improvement. Previous systematic literature reviews described some OPR processes and outcomes, but the link between these processes and outcomes is unknown. We sought to identify and sequence the key processes of OPR taking place with and within healthcare organizations and the main outcomes to which they contribute, and to define ideal-types of OPR. METHODS: This article reports a participatory systematic mixed studies review with qualitative synthesis A specialized health librarian searched MEDLINE, CINAHL, Embase Classic + Embase, PsycINFO, the Cochrane Library, Social Work Abstracts and Business Source Complete, together with grey literature data bases were searched from inception to November 29, 2012. This search was updated using forward citation tracking up to June 2014. Reporting quality was appraised and unclear articles were excluded. Included studies clearly reported OPR where the main research related decisions were co-constructed among the academic and healthcare organization partners. Included studies were distilled into summaries of their OPR processes and outcomes, which were subsequently analysed using deductive and inductive thematic analysis. All summaries were analysed; that is, data analysis continued beyond saturation. RESULTS: Eighty-three studies were included from the 8873 records retrieved. Eight key OPR processes were identified. Four follow the phases of research: 1) form a work group and hold meetings, 2) collectively determine research objectives, 3) collectively analyse data, and 4) collectively interpret results and decide how to use them. Four are present throughout OPR: 1) communication, 2) relationships; 3) commitment; 4) collective reflection. These processes contribute to extra benefits at the individual and organizational levels. Four ideal-types of OPR were defined. Basic OPR consists of OPR processes leading to achieving the study objectives. This ideal-type and may be combined with any of the following three ideal-types: OPR resulting in random additional benefits for the individuals or organization involved, OPR spreading to other sectors of the organization and beyond, or OPR leading to subsequent initiatives. These results are illustrated with a novel conceptual model. CONCLUSION: The model provides operational guidance to help OPR stakeholders collaboratively address organizational issues and achieve desired outcomes and more. REVIEW REGISTRATION: As per PROSPERO inclusion criteria, this review is not registered.

Building on a YMCA's health and physical activity promotion capacities: A case study of a researcher-organization partnership to optimize adolescent programming_.

School-based physical activity programs are only effective for increasing adolescents' school-based physical activity. To increase out-of-school-time physical activity, complementary community programs are warranted. Partnerships between universities and community organizations may help build the capacity of these organizations to provide sustainable programs. To understand capacity building processes and outcomes, we partnered with a YMCA to build on their adolescent physical activity promotion capacity. Together, we designed and implemented means to evaluate the YMCA teen program to inform program planning. For this qualitative case study, emails and interviews and meetings transcripts were collected over 2.5 years and analyzed using inductive and deductive thematic analysis. Findings illustrate that the YMCA's workforce and organizational development capacities (e.g., evaluation and health promotion capacity and competence) were increased through our partnership, resource allocation, and leadership. We responded to YMCA partners' perceived needs, yet guided them beyond those needs, successfully combining our complementary objectives, knowledge, and skills to generate an integrated program vision, rationale, and evaluation results. This provided YMCA partners with validation, reminders, and awareness. In turn, this contributed to programming and evaluation practice changes. In light of extant capacity building literature, we discuss how our partnership increased the YMCA's capacity to promote healthy adolescent programs.

What do we know about how to promote physical activity to adolescents? A mapping review.

To date, adolescent physical activity (PA) intervention research has focused on the school setting and suggests a need to extend interventions beyond this setting to influence teenagers' overall level of PA. But, the relative effectiveness of PA promotion strategies that can be part of such multi-setting interventions remains unknown. We completed a mapping review of PA intervention research that focused on increasing adolescents' level of PA to describe the sum of what has been learned in this area and to expose research and knowledge gaps. We searched data bases from 1993 to September 2014, included PA promotion intervention studies targeting 12- to 17-year-old youth and assessing changes in their level of PA, and used ecological and capacity building frameworks to review this research. The 46 included studies suggest that little is known about strategies targeting the interpersonal, organizational, community or policy levels of teenagers' PA behavior influences; our current knowledge remains concentrated in the intrapersonal domain and the school setting. We suggest avenues for researchers as well as practitioners who design and implement adolescent PA programs such that we further develop our research and practice knowledge base and develop programs to positively impact adolescents' PA behavior.

Delving into the social ecology of leisure-time physical activity among adolescents from south eastern Spain.

BACKGROUND: Worldwide, there is a growing concern with adolescents' low levels of physical activity (PA). We used a comprehensive social ecological framework to uncover factors associated with leisure-time physical activity (LTPA) among adolescents from southeastern Spain. METHODS: A population-based sample of 3249 adolescents aged 12-17 participated in a school-based survey in 2006. Potential correlates of participation in and level of LTPA were assessed through self-report. LTPA levels were also self-reported. We used gender-stratified logistic regression models to examine the associations among the variables of interest. RESULTS: Consistent with a social ecological perspective, analyses revealed several factors, corresponding to different levels of organization (demographic, biological, psychological, behavioral, social) and behavioral settings (family, peer group, school), significantly associated with LTPA. Some of these factors varied as a function of gender and depending on whether the outcome considered was nonparticipation vs. participation in LTPA or high vs. low level of involvement among participants. Overall, the findings highlight the role of health-related participation motives, significant others' attitudes toward PA, and grade in physical education as correlates of LTPA in this sample. CONCLUSIONS: Continued research is necessary to understand the complex interplay of factors and settings associated with adolescent LTPA and the role of gender.

Effects of a culturally tailored physical activity promotion program on selected self-regulation skills and attitudes in adolescents of an underserved, multiethnic milieu.

PURPOSE: To implement a culturally tailored physical activity (PA) promotion program (FunAction) and to assess its impact on five self-regulation skills and attitudes in adolescents. Design . The design and implementation of the FunAction program were informed by social marketing principles. The study used a quasi-experimental approach to assess the impact of the program on specific outcome variables. SETTING: A multiethnic, underserved middle school in Montreal, Quebec, Canada. SUBJECTS: The intervention group was made up of grade 8 students (n  =  165) and the control group was made up of grade 7 students (n  =  137). INTERVENTION: During the 16-week intervention, adolescents were able to choose from a variety of 45-minute cardiovascular PAs offered daily during their school lunch period. Adolescents participated in the activities on a voluntary basis. MEASURES: A self-report questionnaire was administered preintervention and postintervention to measure adolescents' scores on the following self-regulation skills and attitudes: self-control, self-esteem, attention/concentration, social competence, and interethnic relationships. ANALYSIS: Three-way repeated measures analyses of variance and correlational analyses were used. Results . A significant improvement was observed only in attention/concentration. Girls' attention/concentration scores improved significantly in the intervention group compared to the control group (F(1,127)  =  16.26, p < .001). The improvement in attention/concentration scores for boys in the intervention group was correlated with their frequency of participation in the program PAs (r  =  .24, p  =  .008). CONCLUSION: Using social marketing principles can help encourage adolescents from underserved, multiethnic milieus to participate in PA during their school lunch hour. Furthermore, voluntary participation in a culturally tailored PA program can improve youths' attention/concentration.

Role of individual and school factors in physical activity patterns of secondary-level Spanish students.

BACKGROUND: While the importance of individual and school factors as correlates of overall youth physical activity has been demonstrated by previous research, less is known about the relationship of these factors with specific patterns of physical activity during adolescence. Thus, the purpose of this study was to examine the association of selected individual and school factors with patterns of physical activity based on a sum index of physical activity in a population-based sample of Spanish adolescents. METHODS: One thousand and eighty-four students aged 12 to 17 years completed a self-report survey once during school hours. In addition to participation in physical activity outside of school hours, the following variables were included in the analysis: gender, age, weight status, physical self-perceptions, evaluation of the school physical education experience, and type of school (public vs private). Multinomial logistic regression was used to model the associations among the variables and to calculate odd ratios (ORs) and 95% confidence intervals (CIs) for each pattern of physical activity. RESULTS: The physical self-perceptions variable was the most consistent individual correlate of physical activity across participation patterns (ORs ranging from 4.29 to 1.88, CIs ranging from 2.16-8.54 to 1.10-3.21). Regarding the school variables included in this study, both were linked with participation in physical activity, but evaluation of the physical education experience showed the most consistent associations across activity patterns (ORs 2.49-2.17, CIs 1.49-4.15 to 1.25-3.74). CONCLUSION: Physical education programs may benefit adolescents with different physical activity participation preferences regardless of important individual characteristics and broader school factors.