Collaborative modeling of an implementation strategy: a case study to integrate health promotion in primary and community care.

BACKGROUND: Evidence-based interventions are more likely to be adopted if practitioners collaborate with researchers to develop an implementation strategy. This paper describes the steps to plan and execute a strategy, including the development of structure and supports needed for implementing proven health promotion interventions in primary and community care. RESULTS: Between 10 and 13 discussion and consensus sessions were performed in four highly-motivated primary health care centers involving 80% of the primary care staff and 21 community-based organizations. All four centers chose to address physical activity, diet, and smoking. They selected the 5 A's evidence-based clinical intervention to be adapted to the context of the health centers. The planned implementation strategy worked at multiple levels: bottom-up primary care organizational change, top-down support from managers, community involvement, and the development of innovative e-health information and communication tools. Shared decision making and practice facilitation were perceived as the most positive aspects of the collaborative modeling process, which took more time than expected, especially the development of the new e-health tools integrated into electronic health records. CONCLUSIONS: Collaborative modeling of an implementation strategy for the integration of health promotion in primary and community care was feasible in motivated centers. However, it was difficult, being hindered by the heavy workload in primary care and generating uncertainty inherent to a bottom-up decision making processes. Lessons from this experience could be useful in diverse settings and for other clinical interventions. Two companion papers report the evaluation of its feasibility and assess quantitatively and qualitatively the implementation process.

Efficiency of "Prescribe Vida Saludable", a health promotion innovation. Pilot phase / Eficiencia de «Prescribe Vida Saludable», una innovación de promoción de la salud. Fase piloto

Objective: "Prescribe Vida Saludable" (PVS) is an organisational innovation designed to optimise the promotion of multiple healthy habits in primary healthcare. It aims to estimate the cost effectiveness and cost-utility of prescribing physical activity in the pilot phase of the PVS programme, compared to the routine clinical practice of promoting physical activity in primary healthcare. Methods: An economic evaluation of the quasi-experimental pilot phase of PVS was carried out. In the four control centres, a systematic sample was selected of 194 patients who visited the centre in a single year and who did not comply with physical activity recommendations. In the four intervention centres, 122 patients who received their first physical activity prescription were consecutively enrolled. The costs were evaluated from the perspective of the PVS programme using bottom-up methodology. The effectiveness (proportion of patients who changed their physical activity) as well as the utility were evaluated at baseline and after 3 months. The incremental cost-utility ratio (ICUR) and the incremental cost-effectiveness ratio (ICER) were calculated and a sensitivity analysis was performed with bootstrapping and 1,000 replications. Results: Information was obtained from 35% of control cases and 62% of intervention cases. The ICUR was Euros1,234.66/Quality Adjusted Life Years (QALY) and the ICER was Euros4.12. In 98.3% of the simulations, the ICUR was below the Euros30,000/QALY threshold. Conclusions: The prescription of physical activity was demonstrably within acceptable cost-utility limits in the pilot PVS phase, even from a conservative perspective (AU)

Objetivo: Prescribe Vida Saludable (PVS) es una innovación organizativa para optimizar la promoción de múltiples hábitos saludables en atención primaria. El objetivo es estimar el coste-efectividad y el coste-utilidad de la prescripción de actividad física en el pilotaje del programa PVS, respecto a la práctica clínica habitual de promoción de la actividad física en atención primaria. Métodos: Se llevó a cabo una evaluación económica del pilotaje cuasi experimental PVS. En los cuatro centros de control se seleccionó una muestra sistemática de 194 pacientes que visitaron el centro durante 1 año y que no cumplían las recomendaciones de actividad física. En los cuatro centros de intervención se captaron consecutivamente 122 pacientes que recibieron la primera prescripción de actividad física. Los costes se evaluaron desde la perspectiva del programa PVS con la metodología bottom-up. Tanto la efectividad (proporción de pacientes que modificaron su actividad física) como la utilidad fueron evaluadas basalmente y a los 3 meses. Se calcularon la razón de coste-utilidad incremental (RCUI) y la razón de coste-efectividad incremental (RCEI), y se realizó el análisis de sensibilidad con bootstrapping con 1000 repeticiones. Resultados: Se obtuvo información de un 35% de los casos control y de un 62% de los casos con intervención. La RCUI fue de 1234,66 Euros por año de vida ajustado por calidad (AVAC) y la RCEI fue de 4,12 Euros. En un 98,3% de las simulaciones el RCUI estuvo por debajo del umbral de 30.000 Euros/AVAC. Conclusiones: La prescripción de actividad física se muestra en unos límites aceptables de coste-utilidad en el pilotaje de PVS, incluso desde una perspectiva conservadora (AU)

Efficiency of "Prescribe Vida Saludable", a health promotion innovation. Pilot phase.

OBJECTIVE: "Prescribe Vida Saludable" (PVS) is an organisational innovation designed to optimise the promotion of multiple healthy habits in primary healthcare. It aims to estimate the cost effectiveness and cost-utility of prescribing physical activity in the pilot phase of the PVS programme, compared to the routine clinical practice of promoting physical activity in primary healthcare. METHODS: An economic evaluation of the quasi-experimental pilot phase of PVS was carried out. In the four control centres, a systematic sample was selected of 194 patients who visited the centre in a single year and who did not comply with physical activity recommendations. In the four intervention centres, 122 patients who received their first physical activity prescription were consecutively enrolled. The costs were evaluated from the perspective of the PVS programme using bottom-up methodology. The effectiveness (proportion of patients who changed their physical activity) as well as the utility were evaluated at baseline and after 3 months. The incremental cost-utility ratio (ICUR) and the incremental cost-effectiveness ratio (ICER) were calculated and a sensitivity analysis was performed with bootstrapping and 1,000 replications. RESULTS: Information was obtained from 35% of control cases and 62% of intervention cases. The ICUR was €1,234.66/Quality Adjusted Life Years (QALY) and the ICER was €4.12. In 98.3% of the simulations, the ICUR was below the €30,000/QALY threshold. CONCLUSIONS: The prescription of physical activity was demonstrably within acceptable cost-utility limits in the pilot PVS phase, even from a conservative perspective.

The implementation of health promotion in primary and community care: a qualitative analysis of the 'Prescribe Vida Saludable' strategy.

BACKGROUND: The impact of lifestyle on health is undeniable and effective healthy lifestyle promotion interventions do exist. However, this is not a fundamental part of routine primary care clinical practice. We describe factors that determine changes in performance of primary health care centers involved in piloting the health promotion innovation 'Prescribe Vida Saludable' (PVS) phase II. METHODS: We engaged four primary health care centers of the Basque Healthcare Service in an action research project aimed at changing preventive health practices. Prescribe Healthy Life (PVS from the Spanish "Prescribe Vida Saludable) is focused on designing, planning, implementing and evaluating innovative programs to promote multiple healthy habits, feasible to be performed in routine primary health care conditions. After 2 years of piloting, centers were categorized as having high, medium, or low implementation effectiveness. We completed qualitative inductive and deductive analysis of five focus groups with the staff of the centers. Themes generated through consensual grounded qualitative analysis were compared between centers to identify the dimensions that explain the variation in actual implementation of PVS, and retrospectively organized and assessed against the Consolidated Framework for Implementation Research (CFIR). RESULTS: Of the 36 CFIR constructs, 11 were directly related to the level of implementation performance: intervention source, evidence strength and quality, adaptability, design quality and packaging, tension for change, learning climate, self-efficacy, planning, champions, executing, and reflecting and evaluating, with -organizational tracking added as a new sub-construct. Additionally, another seven constructs emerged in the participants' discourse but were not related to center performance: relative advantage, complexity, patients' needs and resources, external policy and incentives, structural characteristics, available resources, and formally appointed internal implementation leaders. Our findings indicate that the success of the implementation seems to be associated with the following components: the context, the implementation process, and the collaborative modelling. CONCLUSIONS: Identifying barriers and enablers is useful for designing implementation strategies for health promotion in primary health care centers that are essential for innovation success. An implementation model is proposed to highlight the relationships between the CFIR constructs in the context of health promotion in primary care.

Feasibility of an implementation strategy for the integration of health promotion in routine primary care: a quantitative process evaluation.

BACKGROUND: Process evaluation is recommended to improve the understanding of underlying mechanisms related to clinicians, patients, context and intervention delivery that may impact on trial or program results, feasibility and transferability to practice. The aim of this study was to assess the feasibility of the Prescribe Healthy Life (PVS from the Spanish "Prescribe Vida Saludable") implementation strategy for enhancing the adoption and implementation of an evidence-based health promotion intervention in primary health care. METHODS: A descriptive study of 2-year implementation indicators for the PVS clinical intervention was conducted in four primary health care centers. A multifaceted collaborative modeling implementation strategy was developed to enhance the integration of a clinical intervention to promote healthy lifestyles into clinical practice. Process indicators were assessed for intervention reach, adoption, implementation, sustainability and their variability at center, practice, and patient levels. RESULTS: Mean rates of adoption by means of active collaboration among the three main professional categories (family physicians, nurses and administrative personnel) were 75% in all centers. Just over half of the patients that attended (n = 11650; 51.9%) were reached in terms of having their lifestyle habits assessed, while more than a third (33.7%; n = 7433) and almost 10% (n = 2175) received advice or a printed prescription for at least one lifestyle change, respectively. Only 3.7% of the target population received a repeat prescription. These process indicators significantly (p < 0.001) varied by center, lifestyle habit and patient characteristics. Sustainability of intervention components changed thorough the implementation period within centers. CONCLUSIONS: The implementation strategy used showed moderate-to-good performance on process indicators related to adoption, reach, and implementation of the evidence-based healthy lifestyle promotion intervention in the context of routine primary care. Sources of heterogeneity and instability in these indicators may improve our understanding of factors required to attain adequate program adoption and implementation through improved implementation strategies.

Health promotion in primary care: how should we intervene? A qualitative study involving both physicians and patients.

BACKGROUND: The effects of tobacco, physical exercise, diet, and alcohol consumption on morbidity and mortality underline the importance of health promotion and prevention (HPP) at the primary health care (PHC) level. Likewise, the deficiencies when putting such policies into practice and assessing their effectiveness are also widely recognised. The objectives of this research were: a) to gain an in-depth understanding of general practitioners' (GPs) and patients' perceptions about HPP in PHC, and b) to define the areas that could be improved in future interventions. METHODS: Qualitative methodology focussed on the field of health services research. Information was generated on the basis of two GP-based and two patient-based discussion groups, all of which had previously participated in two interventions concerning healthy lifestyle promotion (tobacco and physical exercise). Transcripts and field notes were analysed on the basis of a sociological discourse-analysis model. The results were validated by triangulation between researchers. RESULTS: GPs and patients' discourses about HPP in PHC were different in priorities and contents. An overall explanatory framework was designed to gain a better understanding of the meaning of GP-patient interactions related to HPP, and to show the main trends that emerged from their discourses. GPs linked their perceptions of HPP to their working conditions and experience in health services. The dimensions in this case involved the orientation of interventions, the goal of actions, and the evaluation of results. For patients, habits were mainly related to ways of life particularly influenced by close contexts. Health conceptions, their role as individuals, and the orientation of their demands were the most important dimensions in patients' sphere. CONCLUSIONS: HPP activities in PHC need to be understood and assessed in the context of their interaction with the conditioning trends in health services and patients' social micro-contexts. On the basis of the explanatory framework, three development lines are proposed: the incorporation of new methodological approaches according to the complexity of HPP in PHC; the openness of habit change policies beyond the medical services; and the effective commitments in the medium to long term by the health services themselves at the policy management level.

Distribución de la circunferencia de la cintura y de la relación circunferencia de la cintura con respecto a la talla según la categoría del índice de masa corporal en los pacientes atendidos en consultas de endocrinología y nutrición / Distribution of waist circumference and waist-to-height ratio by categories of body mass index in patients attended in endocrinology and nutrition units

Introducción La circunferencia de cintura (CC) y la relación circunferencia de cintura/talla (CT) son medidas antropométricas muy utilizadas en la práctica clínica para valorar la grasa visceral y por tanto el riesgo cardiovascular. Sin embargo, los umbrales de riesgo para diferentes rangos de índice de masa corporal (IMC) no han sido suficientemente validados.ObjetivoDeterminar la distribución de CC y CT en función de los puntos de corte de IMC actualmente vigentes para definir el sobrepeso y la obesidad.Material y métodosSe determinó la CC, la CT y el IMC en 3521 pacientes adultos (mayores de 18 años) atendidos en las consultas de endocrinología y nutrición.ResultadosEl 20,8% (734) de los pacientes eran diabéticos. El 82,1% de los pacientes diabéticos eran obesos, así como el 75% de los no diabéticos. Los umbrales de riesgo (..) (AU)

Introduction Waist circumference (WC) and the waist-to-height ratio (WHtR) are anthropometric measures widely used in clinical practice to evaluate visceral fat and the consequent cardiovascular risk. However, risk thresholds should be standardized according to body mass index (BMI).ObjectiveTo determine the distribution of WC and WHtR according to the BMI cut-points currently used to describe overweight and obesity.Materials and methodsWC, WHtR and BMI were measured in 3521 adult patients (>18 years) attended in Endocrinology and Nutrition units.ResultsA total of 20.8% (734 patients) were diabetic. Obesity was found in 82.1% of diabetic patients and in 75% of non-diabetic patients. The WC thresholds proposed by the National Institute of Health (..) (AU)

[Distribution of waist circumference and waist-to-height ratio by categories of body mass index in patients attended in endocrinology and nutrition units]. / Distribución de la circunferencia de la cintura y de la relación circunferencia de la cintura con respecto a la talla según la categoría del índice de masa corporal en los pacientes atendidos en consultas de endocrinología y nutrición.

INTRODUCTION: Waist circumference (WC) and the waist-to-height ratio (WHtR) are anthropometric measures widely used in clinical practice to evaluate visceral fat and the consequent cardiovascular risk. However, risk thresholds should be standardized according to body mass index (BMI). OBJECTIVE: To determine the distribution of WC and WHtR according to the BMI cut-points currently used to describe overweight and obesity. MATERIALS AND METHODS: WC, WHtR and BMI were measured in 3521 adult patients (>18 years) attended in Endocrinology and Nutrition units. RESULTS: A total of 20.8% (734 patients) were diabetic. Obesity was found in 82.1% of diabetic patients and in 75% of non-diabetic patients. The WC thresholds proposed by the National Institute of Health (102 cm in men, 88 cm in women), Bray (100 cm in men, 90 cm in women) and the International Diabetes Federation (94 cm in men, 80 cm in women) were exceeded by 92.9%, 94.8% and 98.4% of obese men, 96.8%, 95.5% and 99.7% of obese women, 79.1%, 83.1% and 90% of diabetic men and 95.5%, 81.5% and 97.4% of diabetic women, respectively. Thresholds adapted to the degree of obesity (90, 100, 110 and 125 cm in men and 80, 90, 105 and 115cm in women for normal BMI, overweight, obesity I and obesity greater than I) were exceeded by 58.4% of obese men, 54.2% of obese women, 57.5% of diabetic men and 60.7% of diabetic women. WC was higher in men, and BMI and the WHtR were higher in women. The WC of diabetic women equalled that of men, and WC, WHtR and BMI were higher in diabetic than in non-diabetic women (p<0.001). WC (p<0.005), WHtR (p<0.001) and BMI (p<0.5) were also higher in diabetic than in non-diabetic men. CONCLUSION: WC and WHtR thresholds by BMI discriminated diabetic and obese patients better than single thresholds, and can be represented graphically by the distribution of percentile ranks of WC and WHtR by BMI.ik.

Modelling innovative interventions for optimising healthy lifestyle promotion in primary health care: "prescribe Vida Saludable" phase I research protocol.

BACKGROUND: The adoption of a healthy lifestyle, including physical activity, a balanced diet, a moderate alcohol consumption and abstinence from smoking, are associated with large decreases in the incidence and mortality rates for the most common chronic diseases. That is why primary health care (PHC) services are trying, so far with less success than desirable, to promote healthy lifestyles among patients. The objective of this study is to design and model, under a participative collaboration framework between clinicians and researchers, interventions that are feasible and sustainable for the promotion of healthy lifestyles in PHC. METHODS AND DESIGN: Phase I formative research and a quasi-experimental evaluation of the modelling and planning process will be undertaken in eight primary care centres (PCCs) of the Basque Health Service--OSAKIDETZA, of which four centres will be assigned for convenience to the Intervention Group (the others being Controls). Twelve structured study, discussion and consensus sessions supported by reviews of the literature and relevant documents, will be undertaken throughout 12 months. The first four sessions, including a descriptive strategic needs assessment, will lead to the prioritisation of a health promotion aim in each centre. In the remaining eight sessions, collaborative design of intervention strategies, on the basis of a planning process and pilot trials, will be carried out. The impact of the formative process on the practice of healthy lifestyle promotion, attitude towards health promotion and other factors associated with the optimisation of preventive clinical practice will be assessed, through pre- and post-programme evaluations and comparisons of the indicators measured in professionals from the centres assigned to the Intervention or Control Groups. DISCUSSION: There are four necessary factors for the outcome to be successful and result in important changes: (1) the commitment of professional and community partners who are involved; (2) their competence for change; (3) the active cooperation and participation of the interdisciplinary partners involved throughout the process of change; and (4) the availability of resources necessary to facilitate the change.

Médicos y pacientes ante la promoción de estilos de vida saludables en atención primaria / Doctors and patients to the promotion of healthy lifestyles in primary care

Objetivos: profundizar en las percepciones de los médicos de familia y de los pacientes acerca las actividades de promoción ante el tabaco, ejercicio, alcohol y dieta. Metodología: metodología cualitativa. Obtención de la información mediante dos grupos de discusión de médicos y dos de pacientes que habían participado en intervenciones previas. Como modelo de análisis se utilizo el análisis sociológico del discurso. Resultados: las actividades de promoción de la salud AP son percibidas de modo diferente por los médicos y los pacientes en función de sus correspondientes contextos sanitarios y sociales. Dichas perspectivas y contextos pueden representarse en torno a dos ejes: uno, de interrelación profesionales sanitarios-pacientes, y otro entre el polo de orientación más biomédica, parcelar y orientado a la enfermedad y el polo que representa las visiones más integrales y orientadas a la salud. Conclusiones: los resultados de la investigación permiten identificar los principales factores sanitarios y extra-sanitarios percibidos por los médicos y pacientes como condicionantes de sus comportamientos y configurar un marco interpretativo de su significado para ambos agentes en el contexto de la APS.

Objective: to deepen our knowledge of family physician's and patients perceptions of the promotion activities for health behaviors in smoking, exercise, diet and alcohol consumption. Methodology: qualitative methodology. Information was obtained by conducting two discussion groups with physicians and two with patients who had previously participated and two with patients who had previously participated in some interventions. Data were analyzed using the sociological discourse model. Validation was carried out by triangulation among researchers. Results: health promotion activities are differently perceived by doctors and patients depending on their health services and social contexts. These perspectives and contexts can be graphically represented around two axes: the first one interrelates doctors and patients, and the second one between a biomedical and disease oriented pole, and another pole representing a more integral and health oriented vision of promotion. Conclusions: the obtained results allow us to identify the main health and non-health related factors perceived by doctors and patients as influencing their behaviors. The data will also allow for the construction of a framework in which to interpret the meaning of the promotion activities within the relationship of both agents in the context of the Primary Health Care.

Is integration of healthy lifestyle promotion into primary care feasible? Discussion and consensus sessions between clinicians and researchers.

BACKGROUND: The adoption of a healthy lifestyle, including physical activity, a healthy diet, moderate alcohol consumption and abstinence from smoking, is associated with a major decrease in the incidence of chronic diseases and mortality. Primary health-care (PHC) services therefore attempt, with rather limited success, to promote such lifestyles in their patients. The objective of the present study is to ascertain the perceptions of clinicians and researchers within the Basque Health System of the factors that hinder or facilitate the integration of healthy lifestyle promotion in routine PHC setting. METHODS: Formative research based on five consensus meetings held by an expert panel of 12 PHC professionals with clinical and research experience in health promotion, supplied with selected bibliographic material. These meetings were recorded, summarized and the provisional findings were returned to participants in order to improve their validity. RESULTS: The Health Belief Model, the Theory of Planned Action, the Social Learning Theory, "stages of change" models and integrative models were considered the most useful by the expert panel. Effective intervention strategies, such as the "5 A's" strategy (assess, advise, agree, assist and arrange) are also available. However, none of these can be directly implemented or continuously maintained under current PHC conditions. These strategies should therefore be redesigned by adjusting the intervention objectives and contents to the operation of primary care centres and, in turn, altering the organisation of the centres where they are to be implemented. CONCLUSION: It is recommended to address optimisation of health promotion in PHC from a research perspective in which PHC professionals, researchers and managers of these services cooperate in designing and evaluating innovative programs. Future strategies should adopt a socio-ecological approach in which the health system plays an essential role but which nevertheless complements other individual, cultural and social factors that condition health. These initiatives require an adequate theoretical and methodological framework for designing and evaluating complex interventions.

Leptina, obesidad e hipertensión arterial / Leptin, obesity, and arterial hypertension

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Predictors of long-term outcome of a smoking cessation programme in primary care.

BACKGROUND: It would be helpful for general practitioners to know which smokers are the most or the least likely to achieve long-term cessation, so that efforts in promoting lifestyle changes can be prioritised. AIM: To identify predictors of abstinence and assess effectiveness over a two-year follow-up of a smoking cessation programme in routine general practice. DESIGN OF STUDY: Quasi-experimental non-randomised controlled trial. SETTING: Primary healthcare centres of the Basque Health Service, Spain. METHOD: All smokers attending seven intervention (n = 1203) and three control (n = 565) practices during one year (from September 1995 to October 1996) were included. The associations between attempts to stop smoking, relapses, and sustained biochemically confirmed abstinence between 12 and 24 months' follow-up, with baseline characteristics and patients' preference with regard to three possible therapeutic options, were assessed by means of logistic regression and survival analyses. RESULTS: Sustained abstinence was biochemically confirmed in 7.3% of smokers in the intervention practices (relative probability = 2.8, 95% confidence interval [CI] = 1.6 to 4.7; probability difference = 4.7%, 95% CI = 2.7% to 6.7%); in 5% of smokers who received advice and a handout (adjusted odds ratio [AOR] = 1.9, 95% CI = 1.0 to 3.4), in 16% who received advice, a handout and follow-up (AOR = 6.6, 95% CI = 2.9 to 14.6), and in 22% who received advice, a handout, follow-up and nicotine patches (AOR = 13.1, 95% CI = 6.6 to 25.9). Positive predictors included previous attempts to stop smoking (AOR = 1.8, 95% CI = 1.1 to 2.7), and age (for each 10 years AOR = 1.32, 95% CI = 1.13 to 1.44). The Fagerström nicotine dependence score was negatively associated (for each point AOR = 0.89, 95% CI = 0.82 to 0.97). CONCLUSION: The intensity of the programme can be tailored to the probability of long-term cessation estimated by the statistical model including these predictors.