Implementing a Text Messaging Intervention to Engage Fathers in Home Visiting.

PURPOSE: This "From the Field" article reports on the Text4Dad text messaging intervention designed to engage fathers in home visiting. We introduce implementation process components from our pilot study across three Healthy Start home visitation sites. DESCRIPTION: Three Fatherhood Community Health Workers (F-CHWs) and three fathers from one Text4Dad site were interviewed. Using content analysis, we examined the experiences of F-CHWs who implemented Text4Dad and program participants who used Text4Dad. ASSESSMENT: Results highlighted five implementation process components related to: (1) F-CHWs' use of Text4Dad and enrolling fathers; (2) F-CHWs' interactions with fathers, perceptions of Text4Dad content, and integration of Text4Dad into home visits with fathers; (3) training and technical assistance for F-CHWs; (4) father program participants' acceptability and usability of Text4Dad; and (5) fathers' barriers to interactive use of Text4Dad. CONCLUSION: The F-CHWs were able to successfully enroll fathers into Text4Dad. F-CHWs and fathers found Text4Dad content acceptable to their circumstances. Text4Dad technology was viewed as usable, with some limitations. F-CHWs experienced challenges accessing the Text4Dad platform while on home visits. Results suggested that F-CHWs did not use Text4Dad to facilitate interaction, and accordingly, fathers had a lower than anticipated response rate to texts sent by their F-CHWs. We conclude with future directions for improving the implementation of text messaging programs in community-based fatherhood programs.

Theory-based implementation of physical activity programs in worksite health promotion settings: a systematic review.

Worksites are important settings for implementing health promotion programs. Evidence for sustainable upscaling of physical activity (PA) programs and critical evaluation of the implementation process are scarce. In this article, we address the following research questions: (i) To what extent is the implementation process of PA programs theoretically informed? (ii) What characterizes the implementation process of PA programs in theory driven studies? (iii) Which facilitators and barriers are identified in the implementation process and at what level? We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The databases Medline (Ovid) and Sportdiscuss (Ebsco) were searched for peer-reviewed original articles published in English (2000-2020), from a European, North American, New Zealand and Australian context. Reported implementation components and facilitators/barriers (F/Bs) were detected, interpreted and analyzed according to implementation theory. Appraisal of methodological quality on included studies was executed. Of 767 eligible studies, 17 studies were included, 11 of which conducted a theory-based process evaluation of the implementation. They implemented composite PA programs, at two or more levels with internal or mixed implementation teams. F/Bs were most frequently related to the implementation component 'fidelity', corresponding to organizational and implementer level, and the component 'reach' corresponding to program and participant level. Notably, only one study reported F/Bs on the socio-political level. Despite more frequent use in recent years of theory-based implementation, few studies reported implementation effectiveness. Major challenges regarding incoherent use of theoretical concepts and scarcity of empirically tested frameworks are discussed.

Physical activity (PA) programs are popular health promotion initiatives in worksites. However, most PA programs are difficult to maintain and upscale, leading to misachievement of expected results. In this study, we address what drives or hampers the implementation of PA programs in a worksite health promotion setting. We specifically address how current theoretical frameworks add value to the implementation processes. The databases Medline (Ovid) and Sportdiscuss (Ebsco) were searched for peer-reviewed original articles. Reported implementation components and facilitators/barriers were detected, interpreted and analyzed according to implementation theory. Of 767 eligible studies, 17 studies were included for investigation. The World Health Organization has long called for more theory-based implementation of health promotion programs. Eleven studies explicitly invoked current theories in describing program implementation strategies. We find those implementing PA programs showing greater theoretical engagement compared to a sample from prior years, while nonetheless few recent studies reported overall implementation effectiveness. Implications for stakeholders of our results are discussed.

Clinical Ethics Committee in an Oncological Research Hospital: two-years Report.

RESEARCH QUESTION AND AIM: Clinical Ethics Committees (CECs) aim to support healthcare professionals (HPs) and healthcare organizations to deal with the ethical issues of clinical practice. In 2020, a CEC was established in an Oncology Research Hospital in the North of Italy. This paper describes the development process and the activities performed 20 months from the CEC's implementation, to increase knowledge about CEC's implementation strategy. RESEARCH DESIGN: We collected quantitative data related to number and characteristics of CEC activities carried out from October 2020 to June 2022 using the CEC internal database. Data were reported descriptively and compared with data from the literature to provide a complete overview of the CEC's development and implementation process. PARTICIPANTS AND RESEARCH CONTEXT: The study has been conducted at the local health authority (LHA) of Reggio Emilia. It is a report of the activities provided by the CEC, where no HPs or patients were involved. ETHICAL CONSIDERATIONS: The report is part of a larger study named EVAluating a Clinical Ethics Committee implementation process (EvaCEC), which has been approved by the Local Ethics Committee (AUSLRE Protocollo n° 2022/0026554 of 24/02/2022). EvaCEC is also the first author's PhD project. FINDINGS: In total, the CEC performed 7 ethics consultations (EC), published three policies related to particular ethical questions of clinical and organizational practice, provided one educational online course on ethics consultation targeting employed HPs, and promoted a specific dissemination process among the different departments of the LHA. According to our results, the CEC widely fulfilled the standard threefold set of clinical ethics support services tasks (namely, ethics consultation, ethics education, and policy development), but further investigations are needed to evaluate the CEC's impact on clinical practice. CONCLUSION: Our findings may increase knowledge regarding the composition, role, and tasks of a CEC in an Italian setting, informing future strategies and efforts to regulate these institutions officially.

Clinical implementation of routine diagnostic laparoscopy to guide initial treatment in patients with advanced-stage epithelial ovarian cancer in Dutch clinical practice: Evaluation of support and a budget impact analysis.

OBJECTIVE: In patients with advanced-stage epithelial ovarian cancer (EOC), a diagnostic laparoscopy (DLS) to determine treatment regime prevents futile laparotomies and seems cost-neutral. The uptake of DLS in current practice is unknown. We evaluated the clinical application of routine DLS in treatment planning in patients with advanced-stage EOC in the Netherlands. METHODS: The implementation was evaluated over the period 2017-2019, using a health technology assessment including clinical, organizational, and economic factors. Barriers for implementation were identified and DLS use was assessed using semi-structured surveys with healthcare professionals. Data from the Dutch Gynecological Oncology Audit were used to determine (un)successful CRS rates. To assess the economic impact, we performed a budget impact analysis (BIA) of the combined interventions of DLS and primary CRS. RESULTS: The DLS use to guide treatment planning increased from 16% to 20%. The majority of the centers did not support routine DLS implementation, mainly because of logistic barriers and its invasive nature. The primary CRS rate of all CRS decreased from 44% to 36%, in favor of interval CRS. The unsuccessful primary CRS rate decreased from 15% to 9% resulting in fewer patients needed a second interval CRS. Consequently, total health care costs decreased from €4.457.496 to €4.274.751. CONCLUSIONS: The implementation of routine DLS for guiding treatment planning in patients with advanced-stage EOC has limited support in the Netherlands. Over the years, total health care costs decreased. For current practice, it is advised that a DLS is useful in case it is uncertain whether a successful primary CRS is feasible based on conventional work-up.

Can systematic implementation support improve programme fidelity by improving care providers' perceptions of implementation factors? A cluster randomized trial.

BACKGROUND: Investigations of implementation factors (e.g., collegial support and sense of coherence) are recommended to better understand and address inadequate implementation outcomes. Little is known about the relationship between implementation factors and outcomes, especially in later phases of an implementation effort. The aims of this study were to assess the association between implementation success (measured by programme fidelity) and care providers' perceptions of implementation factors during an implementation process and to investigate whether these perceptions are affected by systematic implementation support. METHODS: Using a cluster-randomized design, mental health clinics were drawn to receive implementation support for one (intervention) and not for another (control) of four evidence-based practices. Programme fidelity and care providers' perceptions (Implementation Process Assessment Tool questionnaire) were scored for both intervention and control groups at baseline, 6-, 12- and 18-months. Associations and group differences were tested by means of descriptive statistics (mean, standard deviation and confidence interval) and linear mixed effect analysis. RESULTS: Including 33 mental health centres or wards, we found care providers' perceptions of a set of implementation factors to be associated with fidelity but not at baseline. After 18 months of implementation effort, fidelity and care providers' perceptions were strongly correlated (B (95% CI) = .7 (.2, 1.1), p = .004). Care providers perceived implementation factors more positively when implementation support was provided than when it was not (t (140) = 2.22, p = .028). CONCLUSIONS: Implementation support can facilitate positive perceptions among care providers, which is associated with higher programme fidelity. To improve implementation success, we should pay more attention to how care providers constantly perceive implementation factors during all phases of the implementation effort. Further research is needed to investigate the validity of our findings in other settings and to improve our understanding of ongoing decision-making among care providers, i.e., the mechanisms of sustaining the high fidelity of recommended practices. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03271242 (registration date: 05.09.2017).

Sugar-sweetened beverage tax implementation processes: results of a scoping review.

Taxing sugar-sweetened beverages (SSB) is seen as a win-win situation for governments. It is argued that SSB taxes are relatively easy to implement from a practical perspective compared to for example other nutrition policies. However, the implementation of SSB taxation laws does not happen by itself. Therefore, this work examines implementation processes for SSB taxation in terms of (1) pre-implementation context, (2) taxation instruments used and (3) interactions in the implementation process. Ten databases and grey literature were systematically searched for studies reporting on SSB taxation implementation processes up to February 2020. All studies (N = 1248) were screened independently by two reviewers according to predefined criteria. The selection of variables to be extracted was based on the policy cycle heuristic and informed by intervention implementation research. Information on the process of implementing SSB taxation is limited. Only six cases based on three publications were identified, indicating a gap in this research area. SSB taxation implementation was accomplished by hiring a subcontractor for the implementation or using pre-existing tax collection structures. Political and public support within the implementation process seems to be supportive for the city of Berkeley and for Portugal but was not reported for the Pacific Islands. However, the existing data are very limited, and further research on SSB taxation implementation processes is needed to determine whether the aim of the policy and the envisaged outcome are linked in practice. Registration The protocol was registered with the Open Science Framework (OSF) (osf.io/7w84q/).

[As Advanced Practice Nurse actively shaping nursing practice - A reflection]. / Als Advanced Practice Nurse aktiv die Pflegepraxis mitgestalten.

As Advanced Practice Nurse actively shaping nursing practice - A reflection Abstract. Background: The development of Advanced Practice Nurses (APN-roles) in Germany in the acute inpatient setting is heavily dependent on context factors. Establishing APN-roles in patient care represents a significant organisational development process. In the year 2010 the Florence-Nightingale-Hospital in Düsseldorf began the implementation of APN-roles. Aim: To reflect our experiences in the development of APN-roles and furthermore the identification of influencing factors. Understanding facilitators and barriers intends to support future APN-role developments and interventions. Methods: Four Advanced Practice Nurses carried out a partially structured review, with the help of the Consolidated Framework for Implementation Research (CFIR). For this purpose, the cyclical process of critical self-reflection according to Titchen (2009) was used. Results: The influencing factors were summarised in categories. The categories presented are: support from management, recognising the need for change, professional expertise, presence on site, self-efficacy and personal characteristics and role clarity. Discussion: The implementation of APN-roles requires time and perseverance, both from the organization as well as from the respective Advanced Practice Nurse. To achieve role clarity is, in this process, substantial. Boundaries and Transfer: This review presents context-related results. However, the identified influencing factors could provide a helpful framework for future implementation processes and developments of APN-roles.

Unraveling the Complexity in the Design and Implementation of Bundled Payments: A Scoping Review of Key Elements From a Payer's Perspective.

Policy Points Because bundled payments are relatively new and require a different type of collaboration among payers, providers, and other actors, their design and implementation process is complex. By sorting the 53 key elements that contribute to this complexity into specific pre- and postcontractual phases as well as the actors involved in the health system, this framework provides a comprehensive overview of this complexity from a payer's perspective. Strategically, the design and implementation of bundled payments should not be approached by payers as merely the introduction of a new contracting model, but as part of a broader transformation into a more sustainable, value-based health care system. CONTEXT: Traditional fee-for-service (FFS) payment models in health care stimulate volume-driven care rather than value-driven care. To address this issue, increasing numbers of payers are adopting contracts based on bundled payments. Because their design and implementation are complex, understanding the elements that contribute to this complexity from a payer's perspective might facilitate their adoption. Consequently, the objective of our study was to identify and structure the key elements in the design and implementation of bundled payment contracts. METHODS: Two of us independently and systematically examined the literature to identify all the elements considered relevant to our objective. We then developed a framework in which these elements were arranged according to the specific phases of a care procurement process and actors' interactions at various levels of the health system. FINDINGS: The final study sample consisted of 147 articles in which we identified the 53 elements included in the framework. These elements were found in all phases of the pre- and postcontractual procurement process and involved actors at different levels of the health care system. Examples of elements that were cited frequently and are typical of bundled payment procurement, as opposed to FFS procurement, are (1) specification of care services, patients' characteristics, and corresponding costs, (2) small and heterogeneous patient populations, (3) allocation of payment and savings/losses among providers, (4) identification of patients in the bundle, (5) alignment of the existing care delivery model with the new payment model, and (6) limited effects on quality and costs in the first pilots and demonstrations. CONCLUSIONS: Compared with traditional FFS payment models, bundled payment contracts tend to introduce an alternative set of (financial) incentives, touch on almost all aspects of governance within organizations, and demand a different type of collaboration among organizations. Accordingly, payers should not strategically approach their design and implementation as merely the adoption of a new contracting model, but rather as part of a broader transformation toward a more sustainable value-based health care system, based less on short-term transactional negotiations and more on long-term collaborative relationships between payers and providers.

Implementing collaborative care to reduce depression for rural native American/Alaska native people.

BACKGROUND: The purpose of this study was to identify the effects of Collaborative Care on rural Native American and Alaska Native (AI/AN) patients. METHODS: Collaborative Care was implemented in three AI/AN serving clinics. Clinic staff participated in training and coaching designed to facilitate practice change. We followed clinics for 2 years to observe improvements in depression treatment and to examine treatment outcomes for enrolled patients. Collaborative Care elements included universal screening for depression, evidence-based treatment to target, use of behavioral health care managers to deliver the intervention, use of psychiatric consultants to provide caseload consultation, and quality improvement tracking to improve and maintain outcomes. We used t-tests to evaluate the main effects of Collaborative Care and used multiple linear regression to better understand the predictors of success. We also collected qualitative data from members of the Collaborative Care clinical team about their experience. RESULTS: The clinics participated in training and practice coaching to implement Collaborative Care for depressed patients. Depression response (50% or greater reduction in depression symptoms as measured by the PHQ-9) and remission (PHQ-9 score less than 5) rates were equivalent in AI/AN patients as compared with White patients in the same clinics. Significant predictors of positive treatment outcome include only one depression treatment episodes during the study and more follow-up visits per patient. Clinicians were overall positive about their experience and the effect on patient care in their clinic. CONCLUSIONS: This project showed that it is possible to deliver Collaborative Care to AI/AN patients via primary care settings in rural areas.

Building an innovative Chagas disease program for primary care units, in an urban non- endemic city.

BACKGROUND: On an absolute basis, Argentina is the country with the largest affected population with Chagas Disease (ChD). This constitutes a significant public health issue. As a consequence of Argentina's migratory patterns, there has been a significant increase of affected population in urban centers. An innovative project for early diagnosis and timely treatment of ChD was designed for Municipal Primary Care Facilities of La Plata City, a non- endemic area, in line with a proposal from the Pan-American Health Organization. The project was a public -private intervention. The objectives of this study were to demonstrate the feasibility of the primary healthcare level for early diagnosis and timely treatment of ChD; to design and implement a tailor made program and to innovate in a public-private association. METHODS: The healthcare barriers for early diagnosis and timely treatment for the population with ChD of La Plata were analyzed. The four dimensions described by Peters et al. (Ann N Y Acad Sci 1136:161-71, 2008) were used. The baseline was measured during a previous pilot project and the same items were evaluated at the end of 2017. The model from Damschroder et al. (Implement Sci 4:50, 2009) was used during the implementation process. RESULTS: With all the information gathered during this investigation, a "patient-centered" model was designed. During the program, 17,894 people were serologically tested for ChD, 1,394 were positive and 1,035 were treated. Additionally, 3,750 children from 46 public schools were evaluated for risk factors of ChD. CONCLUSIONS: This project showed the feasibility of the primary healthcare level for early diagnosis and timely treatment of ChD. Tailor made programs and public-private associations should be considered for vulnerable populations in emerging economies in order to enhance efforts and obtain better results. This program may be replicated in other countries of Latin America were Chagas is a main public health issue and, with the corresponding adaptations, for other neglected diseases as well.

The implementation of the coaching on lifestyle (CooL) intervention: lessons learnt.

BACKGROUND: Combined lifestyle interventions (CLIs) are designed to help people who are overweight or obese maintain a healthy new lifestyle. The CooL intervention is a CLI in the Netherlands, in which lifestyle coaches counsel adults and children (and/or their parents) who are obese or at high risk of obesity to achieve a sustained healthier lifestyle. The intervention consists of coaching on lifestyle in group and individual sessions, addressing the topics of physical activity, dietary behaviours, sleep, stress management and behavioural change. The aim of this study was to evaluate the implementation process of the Coaching on Lifestyle (CooL) intervention and its facilitating and impeding factors. METHODS: Mixed methods were used in this action-oriented study. Both quantitative (number of referrals, attendance lists of participants and questionnaires) and qualitative (group and individual interviews, observations, minutes and open questions) data were collected among participants, lifestyle coaches, project group members and other stakeholders. The Consolidated Framework for Implementation Research was used to analyse the data. RESULTS: CooL was evaluated by stakeholders and participants as an accessible and useful programme, because of its design and content and the lifestyle coaches' approach. However, stakeholders indicated that the lifestyle coaches need to become more familiar in the health care network and public sectors in the Netherlands. Lifestyle coaching is a novel profession and the added value of the lifestyle coach is not always acknowledged by all health care providers. Lifestyle coaches play a crucial role in ensuring the impact of CooL by actively networking, using clear communication materials and creating stakeholders' support and understanding. CONCLUSION: The implementation process needs to be strengthened in terms of creating support for and providing clear information about lifestyle coaching. The CooL intervention was implemented in multiple regions, thanks to the efforts of many stakeholders. Lifestyle coaches should engage in networking activities and entrepreneurship to boost the implementation process. It takes considerable time for a lifestyle coach to become fully incorporated in primary care. TRIAL REGISTRATION: NTR6208 ; date registered: 13-01-2017; retrospectively registered; Netherlands Trial Register.

Incorporation of Universal Prevention Curriculum into established academic degree study programme: qualitative process evaluation.

OBJECTIVE: Comprehensive bachelor's, master's, and doctorate-level curricula of Addiction Studies (Addictology) were developed and implemented at Charles University (First Faculty of Medicine) between 2003 and 2012. This Prague model combines three evidence-based approaches to addressing substance use - prevention, treatment, and public health - into a balanced professionalised discipline. Graduates from this programme are licensed by the State Authority as addictology, a regulated profession in the Czech Republic. Professionals with these degrees are recognised as healthcare professionals, can perform directly in the field and can be contracted by health insurance companies. In 2016, it was decided to integrate the Universal Prevention Curriculum (UPC) into these programmes of study. The UPC was developed by a group of prevention researchers from the United States. This article describes the technical steps involved when adapting the UPC into an established university degree programme. We describe the requirements needed for successful implementation and reaccreditation. Finally, we examine both barriers and enhancers of the adoption of UPC as a university programme. METHODS: A qualitative process evaluation study was conducted on the activities carried out in 2017-2018, demarcated by a successful university accreditation of the new curricula combining the original Prague model and the UPC curriculum. Field records, observation methods, official documents, curricular documents, syllabuses, content analysis, and thematic analysis were used for this process. RESULTS: We identified three clusters of issues and challenges during the adaptation and implementation process: technical (developing a new credit scheme, adopting new terminology using local and culture-specific examples, and cancelling, establishing, and/or fusing particular courses, identifying some critical issues for any practical implementation of the UPC); teaching staff-related (team work, involving motivated and qualified staff for moving from a national to an international perspective); and content and contextual (the conflict between different theoretical perspectives such as public health vs. mental health and drug use prevention vs. risk behaviour prevention). CONCLUSION: The adaptation of the UPC had a significant impact on study profiles and competencies. Such an implementation necessarily requires a team of staff members with sufficient capacities to be able to coordinate the process, facilitating each step and supervising it. The current adaptation of the UPC involved specific merging procedures to fit in with existing courses and emphasising an international perspective. This process opened a national discussion about the implementation of the UPC in the system of life-long education programmes and training. Beginning in September 2019, when the first group of students will attend this new model of Addictology studies, we will continue our evaluation of the implementation process and the factors that played a role in either hindering or supporting the implementation. The findings from this evaluation will be used to make adjustments to the curriculum.

National Addiction-specific Institutional Infrastructure - fundamental prerequisite for successful implementation of specialized academic degree study programmes: a case study in historical perspective.

OBJECTIVE: Human resources are crucial for addiction treatment and prevention services, as well as for science and research. The aim of this historical case study is to explain and demonstrate the role of specialized university academic degree study programmes in addictions in the context of a national institutional infrastructure. This specific group of very highly specialized academic programmes represents the highest level of professional development and is producing a totally new generation of addiction specialists with a very distinctive professional identity. METHODS: The study protocol is based on a case study research design and the case is defined as the historical development of addiction specialized institutions closely related to self-help, prevention, and treatment activities on the historical territory of the Czech Republic. We identified relevant historical sources related to establishing and/or running activities or institutions according to the categories specified in our concept of the national institutional infrastructure. All the materials and sources that were collected were sorted according to a timeline and categories of institutions and we systematically determined the first recorded activity/institution in each particular category. For this simple sorting system we used open and selected coding according to Grounded Theory. RESULTS: The public health model developed by Thomas Babor recognizes six different structural mechanisms to support university-based programmes in addiction studies: specialized journals, research centres, professional societies, specialized libraries and documentation centres, training and education programmes and institutions, and funding agencies. We attempted to redefine the concept of addiction studies within the broader context of the addiction field and added three additional mechanisms of support: public interest groups, self-help groups, and service providers. Using a historical case study in the Czech Republic, we demonstrate the potential for a broader context and interaction between these support mechanisms and academic institutions hosting academic programmes in addiction studies. CONCLUSION: The process of establishing integrated addiction studies programmes at Charles University in the Czech Republic had its origins in, and support from, various national institutions and professional organizations. This allowed the university to develop academic programmes at the bachelor's, master's, and Ph.D. levels. The availability of career opportunities for advanced-level addiction professionals in the Czech Republic was also a critically important factor in developing sustainable academic programmes in addiction studies. Our experience is that the creation of successful and sustainable academic programmes for addiction professionals is difficult to achieve without broad infrastructure support, national advocacy efforts, and legislative change at the national level.

Developing policies and actions in response to missed nursing care: A consensus process.

AIM: To support the development of appropriate policies and actions in the field of missed nursing care (MNC). BACKGROUND: There has been an ever-growing international debate on MNC, interventions that nurses have identified as necessary for their patients, but which for various reasons they are unable to provide or are forced to delay. Despite MNC's relevance, its translation into policies and actions has not been documented to date. METHOD: A consensus development method was employed involving (a) a nominal group composed of experts in the field, policymakers and the President of the Regional Nursing Professional Boards, and (b) 218 nurses appointed primarily at the managerial levels. RESULTS: A total of eight consensus statements were approved and organized in a series of sub-statements designed to (1) render the concept of MNC culturally acceptable in the Italian context, with the agreement that compromised nursing care (CNC) is the best term to be used in this field, as a synonym for MNC; (2) measure CNC as a strategy to increase patient safety; (3) select an appropriate CNC measurement tool; (4) optimize CNC measurement; (5) conduct effective CNC data analysis; (6) design and implement interventions to prevent and/or minimize CNC; (7) assess and disseminate findings on interventions' effectiveness; and (8) provide final remarks on the way to move forward. CONCLUSIONS: We developed a process to introduce the phenomenon of MNC in the Italian culture and agreed firstly on the term compromised nursing care, which better reflects MNC's meaning according to the context and facilitates an open discussion on the phenomenon both within and outside the profession. The following consensus statements emerged represent a systematic approach, starting from the measurement and finishing with the re-measurement of the occurrence of MNC after having implemented concrete actions. IMPLICATIONS FOR NURSING MANAGEMENT: The approved consensus statements can guide decision-makers to develop concrete policies and actions that promote the improvement of quality of care and patients' safety by minimizing and/or preventing MNC's occurrence.

Improving the normalization of complex interventions: part 1 - development of the NoMAD instrument for assessing implementation work based on normalization process theory (NPT).

BACKGROUND: Understanding and measuring implementation processes is a key challenge for implementation researchers. This study draws on Normalization Process Theory (NPT) to develop an instrument that can be applied to assess, monitor or measure factors likely to affect normalization from the perspective of implementation participants. METHODS: An iterative process of instrument development was undertaken using the following methods: theoretical elaboration, item generation and item reduction (team workshops); item appraisal (QAS-99); cognitive testing with complex intervention teams; theory re-validation with NPT experts; and pilot testing of instrument. RESULTS: We initially generated 112 potential questionnaire items; these were then reduced to 47 through team workshops and item appraisal. No concerns about item wording and construction were raised through the item appraisal process. We undertook three rounds of cognitive interviews with professionals (n = 30) involved in the development, evaluation, delivery or reception of complex interventions. We identified minor issues around wording of some items; universal issues around how to engage with people at different time points in an intervention; and conceptual issues around the types of people for whom the instrument should be designed. We managed these by adding extra items (n = 6) and including a new set of option responses: 'not relevant at this stage', 'not relevant to my role' and 'not relevant to this intervention' and decided to design an instrument explicitly for those people either delivering or receiving an intervention. This version of the instrument had 53 items. Twenty-three people with a good working knowledge of NPT reviewed the items for theoretical drift. Items that displayed a poor alignment with NPT sub-constructs were removed (n = 8) and others revised or combined (n = 6). The final instrument, with 43 items, was successfully piloted with five people, with a 100% completion rate of items. CONCLUSION: The process of moving through cycles of theoretical translation, item generation, cognitive testing, and theoretical (re)validation was essential for maintaining a balance between the theoretical integrity of the NPT concepts and the ease with which intended respondents could answer the questions. The final instrument could be easily understood and completed, while retaining theoretical validity. NoMAD represents a measure that can be used to understand implementation participants' experiences. It is intended as a measure that can be used alongside instruments that measure other dimensions of implementation activity, such as implementation fidelity, adoption, and readiness.

Improving the normalization of complex interventions: part 2 - validation of the NoMAD instrument for assessing implementation work based on normalization process theory (NPT).

INTRODUCTION: Successful implementation and embedding of new health care practices relies on co-ordinated, collective behaviour of individuals working within the constraints of health care settings. Normalization Process Theory (NPT) provides a theory of implementation that emphasises collective action in explaining, and shaping, the embedding of new practices. To extend the practical utility of NPT for improving implementation success, an instrument (NoMAD) was developed and validated. METHODS: Descriptive analysis and psychometric testing of an instrument developed by the authors, through an iterative process that included item generation, consensus methods, item appraisal, and cognitive testing. A 46 item questionnaire was tested in 6 sites implementing health related interventions, using paper and online completion. Participants were staff directly involved in working with the interventions. Descriptive analysis and consensus methods were used to remove redundancy, reducing the final tool to 23 items. Data were subject to confirmatory factor analysis which sought to confirm the theoretical structure within the sample. RESULTS: We obtained 831 completed questionnaires, an average response rate of 39% (range: 22-77%). Full completion of items was 50% (n = 413). The confirmatory factor analysis showed the model achieved acceptable fit (CFI = 0.95, TLI = 0.93, RMSEA = 0.08, SRMR = 0.03). Construct validity of the four theoretical constructs of NPT was supported, and internal consistency (Cronbach's alpha) were as follows: Coherence (4 items, α = 0.71); Collective Action (7 items, α = 0.78); Cognitive Participation (4 items, α = 0.81); Reflexive Monitoring (5 items, α = 0.65). The normalisation scale overall, was highly reliable (20 items, α = 0.89). CONCLUSIONS: The NoMAD instrument has good face validity, construct validity and internal consistency, for assessing staff perceptions of factors relevant to embedding interventions that change their work practices. Uses in evaluating and guiding implementation are proposed.

Implementing Assisted Peritoneal Dialysis in Renal Care: a Chinese-German Perspective.

Assisted PD (assPD) is an option of home dialysis treatment for dependent end-stage renal patients and worldwide applied in different countries since more than 40 years. China and Germany shares similar trends in demographic development with a growing proportion of elderly referred to dialysis treatment. So far number of patients treated by assPD is low in both countries. We analyze experiences in the implementation process, barriers, and benefits of ass PD in the aging population to provide a model for sustainable home dialysis treatment with PD in both countries. Differences and similarities of different factors (industrial, patient and facility based) which affect utilization of assPD are discussed. AssPD should be promoted in China and Germany to realize the benefits of home dialysis for the aging population by providing a structured model of implementation and quality assurance.

Facilitators and barriers to adaptive implementation of the Meeting Centers Support Program (MCSP) in three European countries; the process evaluation within the MEETINGDEM study.

ABSTRACTBackground:In the MEETINGDEM project, the Meeting Centers Support Program (MCSP) was adaptively implemented and evaluated in three European countries: Italy, Poland, and the United Kingdom. The aim of this study was to investigate overall and country-specific facilitators and barriers to the implementation of MCSP in these European countries. METHODS: A qualitative multiple case study design was used. Based on the theoretical model of adaptive implementation, a checklist was composed of potential facilitators and barriers to the implementation of MCSP. This checklist was administered among stakeholders involved in the implementation of MCSP to trace the experienced facilitators and barriers. Twenty-eight checklists were completed. RESULTS: Main similarities between countries were related to the presence of suitable staff, management, and a project manager, and the fact that the MCSP is attuned to needs and wishes of people with dementia and informal caregivers. Main differences between countries were related to: communication with potential referrers, setting up an inter-organizational collaboration network, receiving support of national organizations, having clear discharge criteria for the MCSP and continuous PR in the region. CONCLUSION: The results of this study provide insight into generic and country specific factors that can influence the implementation of MCSP in different European countries. This study informs further implementation and dissemination of MCSP in Europe and may also serve as an example for the dissemination and implementation of other effective psychosocial support interventions for people with dementia and their informal caregivers across and beyond Europe.

Determinants of an integrated public health approach: the implementation process of Greenland's second public health program.

BACKGROUND: Greenland struggles with a high prevalence of smoking, alcohol and drug abuse. In response to the increasing need for preventive initiatives, the first public health program Inuuneritta was introduced in 2007. Internationally, frameworks focus primarily on the implementation of a single, well-described intervention or program. However, with the increasing need and emergence of more holistic, integrated approaches, a need for research investigating the process of policy implementation from launch to action arises. This paper aims to augment the empirical evidence on the implementation of integrated health promotion programs within a governmental setting using the case of Inuuneritta II. In this study, the constraining and enabling determinants of the implementation processes within and across levels and sectors were examined. METHODS: Qualitative methods with a transdisciplinary approach were applied. Data collection consisted of six phases with different qualitative methods applied to gain a comprehensive overview and understanding of Inuuneritta II's implementation process. These methods included: observations and focus group discussions at the community health worker (CHW) conference, telephone interviews, document analysis, and a workshop on results dissemination. RESULTS: Enabling determinants influencing the implementation process of Inuuneritta II positively were high motivation among adopters, local prevention committees supporting community health workers, and the initiation of the central prevention committee. In contrast, constraining determinants were ambiguous program aims, high turnovers, siloed budgets and work environments, and an inconsistent and neglected central prevention committee. CONCLUSION: Inuuneritta II provided a substantial framework for an integrated health policy approach. However, having a holistic and comprehensive program enabling an integrated approach is not sufficient. Inuuneritta II's integrated approach does not harmonise with the government's inflexible organisational structure resulting in insufficient implementation.

Implementation of an interprofessional medication adherence program for HIV patients: description of the process using the framework for the implementation of services in pharmacy.

BACKGROUND: The community pharmacy center of the Department of Ambulatory Care and Community Medicine of the Policlinique Médicale Universitaire (PMU), Lausanne, Switzerland developed and implemented an interprofessional medication adherence program for chronic patients (IMAP). In 2014, a project was launched to implement the IMAP for HIV patients in a public non-academic hospital with the collaboration of community pharmacists in the Neuchâtel area (Switzerland). This article aims to describe the different implementation stages and strategies of the project. METHODS: A posteriori description of the implementation process, including the conceptualization strategies and stages (exploration, preparation, operation, sustainability) using the Framework for the Implementation of Services in Pharmacy (FISpH). RESULTS: In 2014, an attending infectious disease physician and a nurse at a public hospital (Neuchâtel, Switzerland) contacted the PMU to implement the IMAP in their setting in collaboration with community pharmacies. Five volunteer community pharmacies in Neuchâtel were trained to deliver the program. Three factors were found to be essential to the successful launch and progress of the implementation project: the experience of the community pharmacy center of the PMU with the IMAP, the involvement of the PMU research team, and collaboration with an external start up (SISPha) to train and support pharmacists. During the operation stage, the most important strategy developed was that of regular meetings between all stakeholders. These allowed healthcare professionals to discuss the implementation progress, to address each stakeholder's expectations, and to exchange experiences to facilitate interprofessional collaboration and program delivery. Structural changes allowed the formalization of the activities at the hospital and in a community pharmacy. This formalization was identified as the transition step between the operation and the sustainability stages. CONCLUSIONS: The transfer of the IMAP for HIV patients to a non-academic setting and its implementation are feasible. However, implementation of a new model of pharmacy service such as IMAP implies a deep change in practice. A transitional external support and the allocation of sufficient resources to carry out the IMAP are essential for its long-term sustainability.