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PubMed2001

Determinants of implementing heart health: promotion activities in Ontario public health units: a social ecological perspective.

This paper reports the results of a study undertaken to explain levels of implementation of heart health promotion activities observed in Ontario public health agencies in 1997. Organizational-level data were collected by surveying all 42 health departments in 1994, 1996 and 1997 as part of the Canadian Heart Health Initiative Ontario Project. Guided by social ecological and organizational theories, the model examines relationships between implementation and four sets of possible determinants of activity: (1) the predisposition of agencies to undertake heart health promotion activities, (2) their capacity to undertake these activities, (3) internal organizational factors and (4) external system factors. A small set of five variables explains almost half of the variance in implementation (R2 = 0.46): organizational capacity (beta = 0.40), priority given to heart health (beta = 0.36), coordination of programs (beta = 0.19), use of resource centers (beta = 0.12) and participation in networks (beta = 0.09). The results suggest that models integrating organizational and socio-ecological theories can help us understand the implementation of community-based heart health promotion activities by public health agencies. Implications for future research, policy and practice are discussed.

Cardiovascular Diseases↗
PubMed2002

[Current initiatives in Germany for translating national guidelines into reality - a survey].

The role of practice guidelines as a tool for quality management in health care is now widely accepted in Germany- not only by health professionals, but also in politics. The physicians' professional associations as well as health care authorities (physicians' self-governmental bodies) and parliament introduced several incentives and regulations, aiming at a regular use of guidelines in health care. Among these the German guideline clearinghouse with the systematic approach towards identification, dissemination, and implementation of best available evidence-based guidelines, as well as the country-wide implementation of disease management guidelines seem to be effective and efficient in quality management as well as in patient care management in the German health care system. The article gives an overview on background, procedures and barriers to country-wide implementation of clinical practice guidelines within a social security health care system.

Forecasting↗
PubMed2006

Methodologic challenges in disseminating evidence-based interventions to promote physical activity.

During the past decade, numerous intervention studies have been published on the effectiveness of programs to promote active living; however, few studies have addressed the dissemination of effective physical activity interventions. Both community settings and healthcare settings are important locations for dissemination of evidence-based programs and policies. A major gap in the existing literature involves the appropriate methodologic approaches for planning, evaluating, and reporting on dissemination efforts for effective and promising interventions in these locations. To address this gap, two hypothetical dissemination studies are presented: a quasi-experimental study of local health agencies (Scenario 1) and a group-randomized trial of clinical practices (Scenario 2). These studies help to elucidate the barriers and opportunities for implementing evidence-based physical activity interventions across different settings. Based on the scenarios, the existing literature, and the authors' experience, dissemination challenges that researchers and practitioners may experience (i.e., issues of design, measures of outcomes and external validity, the balance between fidelity and adaptation to local settings, and the review and funding of dissemination science) are discussed. Researchers, practitioners, and policymakers are invited to address the issues outlined in this article in order to bridge the gap between the generation of new knowledge on efficacious physical activity interventions and widespread application of these approaches in community and clinical settings.

Community Health Services↗
PubMed2002

Community-oriented primary care in action: a Dallas story.

Dallas County, Texas, is the site of the largest urban application of the community-oriented primary care (COPC) model in the United States. We summarize the development and implementation of Dallas's Parkland Health & Hospital System COPC program. The complexities of implementing and managing this comprehensive community-based program are delineated in terms of Dallas County's political environment and the components of COPC (assessment, prioritization, community collaboration, health care system, evaluation, and financing). Steps to be taken to ensure the future growth and development of the Dallas program are also considered. The COPC model, as implemented by Parkland, is replicable in other urban areas.

Catchment Area, Health↗
PubMed2003

[Health promotion and health care system reform in Poland].

The development of health promotion is determined by the defined changes of health situation of population, which occur in time. Contemporary methods of health promotion were initiated in 1970's, when the problem of increase of civilization (behavioural) diseases strongly related to lifestyles, was noticed. Health promotion programmes in Poland in spite of many achievements in the conceptualization phase, encounter difficulties in implementation, because of lack of appropriate structural solutions and financial support for this important public health area.

Health Behavior↗
PubMed2004

Regionalization: making sense of the Canadian experience.

This paper revisits the purposes and achievements of regionalization, a decade after its widespread implementation across Canada, and considers to what extent changes in healthcare concepts, emphasis and delivery can reasonably be attributed to it. The authors address four main questions. What, conceptually, is regionalization in healthcare, and what distinguishes it as a structure? How was regionalization intended to contribute to the achievement of the goals for the health system articulated in the 1980s and 1990s? How has regionalization been implemented in Canada, and how have these factors affected its potential to achieve its intended impact? And finally, with the experience gained over the last decade, how might we now (re)design regionalization to better contribute to health system goals? In Canada, regionalization of healthcare has entailed more than devolution and decentralization of services from provincial governments to regional authorities. It included consolidation of authority from local boards and agencies, and some centralization of services. Regionalization was the remedy proposed for the diagnosis of fragmentation and incoherence made by commissions across the country in the 1980s. Regionalization addressed the organizational dimensions of the perceived problems, but provincial governments added goals unrelated to structural change to its mandate. The authors assess the potential impact of regionalization on health system goals and take stock of current Canadian circumstances. Even where regionalization's impact is theoretically high, there are many practical limits to its effect. Although it can facilitate or impede change, in the end the will and actions of provincial governments, providers and other actors in the health system are fundamental to attaining more substantive goals. Many health reform goals require nothing less than a transformation of how society views health, and in the culture of healthcare delivery. Further, the authors argue that the implementation of regionalization in Canada has been limited. Devolution has typically been halting and provisional; there has been little stability; and there have been constraints on the ability to act. These limitations have reduced its potential effect. The authors conclude with proposals for increasing regionalization's contribution to health reform goals. These include a more stable and transparent provincial-RHA relationship, information and measures to better align resources to needs, increased regional-level system integration and changes to organizational culture and practice in the health system.

Canada↗
PubMed2001

[From "Burden of disease" research to the conception of an integrated care system for substance abuse in Ontario].

The paradigm of evidence-based medicine has become one of the building blocks of modern health policy in established market economies. Based on this paradigm, a monitoring system for treatment of substance abuse has been developed in the Canadian province of Ontario. This monitoring system comprises four main elements: availability of treatment places, utilization of specialized health services, costs of treatment and outcome indicators. The paper discusses difficulties in implementing the system and gives some indications on future developments.

Ambulatory Care Facilities↗
PubMed2001

Managing externally financed projects: the Integrated Primary Health Care Project in Bolivia.

Bolivia is one of the poorest countries in Latin America. Health indicators are very poor, communicable diseases are prevalent and, coupled with malnutrition, remain the major killers of children under 5 years old. The Integrated Primary Health Care Project (PROISS) was a US$39 million project executed by the Ministry of Health (MOH), 50% financed by the World Bank and aimed at improving primary health care in the four largest Bolivian municipalities. The implementation of the project started in 1990 and ended in 1997. During implementation it went through three distinct phases: Phase 1 (1990-94) was a period characterized by conflict and confusion; Phase 2 (1995-mid-1996) documented major improvements in coverage and service quality; and Phase 3 (mid-1996-97) witnessed the decline of the project. This paper explores the factors that contributed to the success and the decline of the project, draws lessons for project managers and international agencies involved in the definition and implementation of social sector projects, and discusses the unlikelihood that externally financed projects can have a sustainable impact on the development of the health sector of recipient countries.

Bolivia↗
PubMed2001

Health for All in the Twenty-First Century, World Health Organization renewal, and equity in health: a commentary.

Health for All in the Twenty-first Century is the document presenting the global health policy adopted by the World Health Organization (WHO) in 1998, which reaffirms and updates the vision of Alma-Ata. This article provides a synopsis of the document and a commentary, concentrating on the issue of equity, which is central to WHO policy, and discussing cultural differences that underpin the notion of equity. The meaning of "equity" implies measurement, and the authors develop an approach to definitions of social strata and data issues that are used to quantify health differences. Finally, they discuss the way in which policies invoking equity are implemented into programs and present a rights-based approach as a case study of one way in which policy is being translated into action.

Health Plan Implementation↗
PubMed2000

Healthy City Kwachon 21 Project: a community health promotion programme in Korea.

Disease patterns of Koreans changed from infectious disease to non-infectious disease in the 1970's. Even though there has been a need for a health promotion programme, it was hard to find the programme in the community before 1985 in Korea. In 1985, the Public Health Promotion Law was enacted and the Korean government started to encourage local government to plan and conduct community health promotion programs. Healthy City Kwachon 21 (HCK21) is a health promotion programme for all residents in Kwachon, a city which has about 70,000 population and is located adjacent to Seoul, Korea. HCK21 launched in 1998 with three guiding principles: 1) programs should be accessible to all citizens; 2) Programmes should stimulate strong community participation and 3) Programmes should change environment and society. The long term goal of HCK21 is to increase the healthy life span of citizens in Kwachon. HCK21 is a collaborative project between Kwachon and the Institute for Health Promotion of the Graduate School of Health Science and Management, Yonsei University. It has seven components: 1) Publication of Monthly Health Newsletter; 2) Smoking Cessation and Tobacco Prevention Program; 3) Community Nutrition Program; 4) Maternal and Women's Health Programme; 5) Programme for Development of District Health Management Information System; 6) Hypertension Prevention and Control Programme and 7) Physical Activity Programme. HCK21 is now being implemented in the third year program since the program conducted in 1998 and 1999 was successful with received support from the citizens. It is recommended that HCK21 be a model for an integrated community-based health promotion programme in developing countries.

Adolescent↗
PubMed1993

Diffusion of a school-based substance abuse prevention program: predictors of program implementation.

BACKGROUND: The present study addresses diffusion of a psychosocial-based substance abuse prevention program, including: (a) teacher adoption, implementation, and maintenance; (b) teacher characteristics associated with implementation; (c) the relationship between integrity of program delivery and program outcomes; and (d) the effectiveness of teacher training and school principal involvement in increasing implementation. METHODS: Participants were teachers (n = 60), school principals (n = 25), and fifth-grade students (n = 1147) from four Los Angeles area school districts. Districts were randomly assigned to an intensive or brief teacher training condition. Schools were randomly assigned to a principal-intervention or a no-principal-intervention condition. Assessments included teacher and principal self-reports, classroom observations of program delivery, and evaluation of immediate program outcomes. RESULTS: During the first year, 78% of trained teachers implemented one or more program lessons. During the second year, only 25% maintained implementation of the program. Implementors reported fewer years of teaching experience and stronger self-efficacy, enthusiasm, preparedness, teaching methods compatibility, and principal encouragement than did nonimplementors. The principal intervention increased rates of implementation, but the intensive teacher training did not. Integrity of program delivery was positively associated with immediate program outcomes. CONCLUSIONS: Program implementation was highly variable, suggesting that widespread teacher use of psychosocial-based programs cannot be taken for granted. Strategies for increasing implementation and maintenance need to be developed.

Alcoholism↗
PubMedDate not supplied

Rationale for tobacco cessation interventions for youth.

Tobacco use is the leading cause of preventable death in the United States. Four of every five persons who use tobacco begin before they reach adulthood; more than 3,000 young persons begin smoking each day. In addition, smoking is addictive-three of four teenagers who smoke have made at least one serious, yet unsuccessful, effort to quit. The importance of tobacco use cessation programs for youth is addressed in Healthy People 2000: National Health Promotion and Disease Prevention Objectives and in recently passed legislation related to the Goals 2000 National Education Goals. CDC's Guidelines for School Health Programs to Prevent Tobacco Use and Addiction states that tobacco cessation programs are needed to help young persons who already use tobacco. In 1994, both the Surgeon General's Report, Preventing Tobacco Use among Young People, and the Institute of Medicine's report, Growing Up Tobacco Free, indicated that there were very few effective cessation programs for youth and that more research is needed in this area. This project convened experts to provide recommendations on the design of a tobacco cessation intervention for youth, including helping pregnant teenagers who smoke to stop. This program is based on effective adult cessation programs with modifications relevant to adolescent development. During the first year the major foundational work for this project was accomplished. A database of key contacts and other related interventions in tobacco cessation for youth was developed, a review and analysis of prevalence and trends in adolescent smoking were conducted, and a cooperative agreement with the American Medical Association was established to complete the design, implementation, and evaluation of an effective tobacco cessation program for youth. During the second project year, this program was tested through quasi-experimental research at various school-based health clinics throughout the country. The third year involved follow-up data collection and program modification based on the results. Plans for dissemination of the intervention to youth-serving agencies across the nation will be developed. This is a 3-year project.

Adolescent↗
PubMed2001

Implementing managed competition in Israel.

As of January 1, 1995, Israel's National Health Insurance (NHI) Law laid the foundations for regulating competition among the country's four private, not-for-profit sick funds. Prior to NHI the sick funds (SFs) had competed without governmental control. Extensive research on NHI implementation and the behavior of the sick funds (SFs) after passage of NHI reveals a paradoxical development: The NHI bill drew on the rhetoric of managed competition and did indeed establish a legal and structural framework for regulating competition among the SFs. Nevertheless, in practice, SF autonomy was constrained and competition over provision of statutory care was limited. Rather than fostering competition, the main thrust of the NHI reforms was to enhance central government's control over SF expenses in order to constrain government expenditures. The NHI reforms did encourage the SFs to cut costs and make visible service improvements. However, the reforms did not lead the SFs to reorganize, expand the scope of their services, or improve clinical quality, as the reformers had hoped. Nor did the reforms help eliminate the SF's operating deficits or insure financial stability for the whole health system. Furthermore, the reforms had unanticipated and undesired outcomes, including aggressive and illegal marketing by SFs and collaboration among SFs to restrict the extent of care provided under compulsory insurance. The Israeli case suggests that the theory of managed competition contains unrealistic assumptions about the types of competitive behavior that result from exposure to managed competition and the capacity of government and health providers to monitor quality. In addition to stemming from universal limitations to the managed competition model, the implementation pattern in Israel reflects local, historical forces and the interplay of Israel's powerful health system actors.

Facility Regulation and Control↗
PubMed2006

Implementation of the Healthy Cities' principles and strategies: an evaluation of the Israel Healthy Cities network.

The Israel network of Healthy Cities has been operating since 1990, and the first evaluation of its performance was carried out in 2004. The objectives were to evaluate the level of implementation of the 'Healthy Cities' principles and strategies in each network city and to assess the contribution of the network to its member cities. Coordinators of 18 active healthy cities participated in the study by completing a questionnaire with the aid of key informants in the municipality. The survey covered six dimensions of Healthy Cities' principles and strategies, and each was analyzed as a sum of scores of separate components and measures, converted to a 0-10 scale. Cities were found to differ in their performances. The dimension of intersectoral collaboration received the highest mean score (8.0 +/- 1.6), while the environmental protection dimension received the lowest one (4.5 +/- 2.2). Time investment by the coordinator of > 20 h a week is significantly associated with a higher score on the management dimension (7.8 versus 4.4 where the coordinator invests 20 h a week or less, P < 0.001). Previous work experience in either public health or community work was associated with higher scores of the community participation and intersectoral partnership dimensions (6.9 versus 5.2 and 8.5 versus 6.8, respectively, P < 0.05). Political support was associated with the city equity policy dimension (8.1 versus 4.8 in cities with high versus low political support, P < 0.01). Coordinator's participation in the network's activities is associated with better scores on all the dimensions except for environmental protection. It appears that political commitment and support is a significant enabling condition, which, together with the capacity building of the coordinator, may lead to better implementation of Healthy Cities' policy. Environmental issues should be incorporated into training sessions to enhance the environmental protection dimension.

Adult↗
PubMedDate not supplied

[Facing the challenge... Towards a National Program of Adolescence Health Care in Mexico, 2001-2006].

OBJECTIVE: To present the process in the design, development and implementation of Mexico's National Adolescent Health Program. MATERIALS AND METHODS: In efforts to arrive at a consensus regarding the health care priorities for Mexico's adolescent population, 37 public and private institutions dedicated to adolescent health care and social issues were invited to participate in a strategic analysis regarding a joint action plan for health promotion in adolescents with special emphasis on resilience as protective factor. The definition of the action plan involved the participation of 190 health professionals responsible for child and adolescent health programs in the discussion and drafting of the National Health Program. RESULTS: The steps and issues discussed by the 37 participating institutions leading to the development of the National Health Plan are reviewed. CONCLUSIONS: The product of this exercise led to the elaboration of a consensus document that served as the framework for Mexico's National Adolescent Health Plan and that now serves 23.5 million adolescents between 10 and 19 years of age. This action plan was been reviewed by the World Health Organization, which cited Mexico as one of the eight model countries addressing adolescent health.

Adolescent↗
PubMed2005

Mobile dental vans: planning considerations and productivity.

OBJECTIVES: Many children, especially those from lower socio-economic families, have limited access to dental care, transportation problems and poor appointment attendance. Mobile dental clinics have been implemented in many communities to address these issues. METHODS: Structured surveys were sent to the three mobile programs in Connecticut to collect information on the age of the program, issues encountered in planning and implementation, and ongoing costs and productivity. RESULTS: Each mobile clinic had two operatories and operated 140-200 days per year. Programs provided 2921-3417 diagnostic and preventive procedures and 359-721 treatment procedures per year for an average daily production of 18-24 procedures. All programs required external funding to remain financially solvent. CONCLUSION: Implementation and management of these programs is complicated. However, they provide an innovative solution to bringing dental care to underserved children and when operated in conjunction with schools can eliminate transportation problems and missed appointments.

Child↗
PubMed2001

Implementing AIDS policy in post-apartheid South Africa.

In common with the rest of the Southern African sub-continent. South Africa is currently experiencing a serious HIV epidemic. When it came into power in 1994, the new, Mandela-led government immediately mobilised funds and adopted a far-reaching AIDS Plan for the country. However, the implementation of AIDS policy in the first four years after 1994 has been characterised by a lack of progress and a breakdown of trust and co-operation, both within government and between government and NGOs. This paper outlines the political context which shaped the development of the AIDS Policy, then examines the difficulties of implementing a comprehensive response to AIDS in a country undergoing restructuring at every level. It questions the notion of "inadequate political will" as an explanation for lack of progress. Involvement by politicians has, in fact, been experienced as a double-edged sword in South Africa, with inappropriate, "quick-fix" actions creating conflict and hampering a more longer-term, effective response. The paper also highlights the importance of groupings outside of government in promoting effective policy actions, and the types of leadership required to mobilise a broad range of actors around a common vision. It concludes by emphasising the need to develop approaches to policy implementation rooted in the possibilities and constraints of the local situation, rather than relying on universal blue-prints developed out of context.

Communicable Disease Control↗
PubMed2006

Pilot testing of the Restorative Care Intervention: impact on residents.

The purpose of this pilot study was to test the feasibility and effectiveness of a two-tiered motivational intervention, the Res-Care Intervention, on nursing home residents. Twenty-one residents consented to participate in the study. The residents were 88.3 (+/- 4.9) years of age, had lived in the facility 1.6 (+/- 3.4) years, were women (93%), White (93%), and unmarried (85%). Although there were some positiv trends, there was not a statistically significant difference in any of the resident outcomes following implementation of the Res-Care Intervention. The findings have been used to revise the Res-Care Intervention to include additional education needs for the nursing assistants, revisions in the motivational intervention for the nursing assistants and nurses, clarification of documentation and motivational techniques to improve documentation, and implementation of a more comprehensive treatment fidelity plan.

Activities of Daily Living↗