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PubMed2005

Scaling up integrated management of childhood illness to the national level: achievements and challenges in Peru.

This paper presents the first published report of a national-level effort to implement the Integrated Management of Childhood Illness (IMCI) strategy at scale. IMCI was introduced in Peru in late 1996, the early implementation phase started in 1997, with the expansion phase starting in 1998. Here we report on a retrospective evaluation designed to describe and analyze the process of taking IMCI to scale in Peru, conducted as one of five studies within the Multi-Country Evaluation of IMCI Effectiveness, Cost and Impact (MCE) coordinated by the World Health Organization. Trained surveyors visited each of Peru's 34 districts, interviewed district health staff and reviewed district records. Findings show that IMCI was not institutionalized in Peru: it was implemented parallel to existing programmes to address acute respiratory infections and diarrhoea, sharing budget lines and management staff. The number of health workers trained in IMCI case management increased until 1999 and then decreased in 2000 and 2001, with overall coverage levels among doctors and nurses calculated to be 10.3%. Efforts to implement the community component of IMCI began with the training of community health workers in 2000, but expected synergies between health facility and community interventions were not realized because districts where clinical training was most intense were not those where community IMCI training was strongest. We summarize the constraints to scaling up IMCI, and examine both the methodological and policy implications of the findings. Few monitoring data were available to document IMCI implementation in Peru, limiting the potential of retrospective evaluations to contribute to programme improvement. Even basic indicators recommended for national monitoring could not be calculated at either district or national levels. The findings document weaknesses in the policy and programme supports for IMCI that would cripple any intervention delivered through the health service delivery system. The Ministry of Health in Peru is now working to address these weaknesses; other countries working to achieve high and equitable coverage with essential child survival interventions can learn from their experience.

Child Health Services↗

PubMed2006

Are health interventions implemented where they are most needed? District uptake of the integrated management of childhood illness strategy in Brazil, Peru and the United Republic of Tanzania.

OBJECTIVE: To describe geographical patterns of implementation of the Integrated Management of Childhood Illness (IMCI) strategy in three countries and to assess whether the strategy was implemented in areas with the most pressing child health needs. METHODS: We conducted interviews with key informants at the national and district levels in Brazil, Peru and the United Republic of Tanzania, and an ecological study of factors associated with health worker training in IMCI. Explanatory factors included district population, distance from the capital, human development index, other socioeconomic indicators and baseline mortality rates in children younger than five years. FINDINGS: In line with recommendations by WHO, early implementation districts were characterized by proximity to the capital and suitable training sites, presence of motivated health managers and a functioning health system. In the expansion phase, IMCI tended to be adopted by other districts with similar characteristics. In Brazil, uptake by poor and small municipalities and those further away from the state capital was significantly lower. In Peru, there was no association with distance from Lima, and a non-significant trend for IMCI adoption by small and poor departments. In the United Republic of Tanzania, the only statistically significant finding was a lower uptake by remote districts. Implementation was not associated with baseline mortality levels in any country studied. CONCLUSION: Whereas clear and reasonable guidelines are provided for selection of early use districts, no criteria for promoting IMCI expansion had been issued, and areas of greatest need were not prioritized. Equity analyses based on the geographical deployment of new programmes and strategies can contribute to assessing whether they are reaching those who need them most.

Brazil↗

PubMed2006

Challenges to implementing and sustaining comprehensive mental health service programs.

The President's New Freedom Commission recently concluded that the nation's mental health service delivery system is ill equipped to meet the complex needs of persons with mental illness. A major contributor to this service quality crisis has been the longstanding divergence of research efforts and clinical programs. In this article, the authors begin by describing the unique needs of persons with serious and persisting psychiatric disorders and the evolution of the mental health service system that has attempted to meet these needs. They then discuss recent efforts to upgrade services by emphasizing the use of evidence-based practices (EBPs) and the research underlying their development. Next, they describe the difficulties of using traditional research methods to develop and test interventions for persons receiving services at public mental health agencies. Finally, they outline the challenges confronted when trying to disseminate these EBPs to the wider clinical community.

Advisory Committees↗

PubMed1996

Secondary prevention of excessive alcohol use: assessing the prospects of implementation.

BACKGROUND: Alcohol risk and harm reduction is a public health approach that goes beyond specialized treatments for alcoholism. The greatest potential for reducing alcohol risk and harm in a population depends on the extent to which health care practitioners use secondary prevention programmes. OBJECTIVE: We aim to assess the factors that affect the prospects of disseminating comprehensive, secondary prevention programmes into mainstream practice. METHOD: A decision balance was used to assess the prospects of practitioners implementing comprehensive programmes systematically. The stages-of-change model provides perspectives about behaviour change with regard to patients, practitioners and practice settings. RESULTS AND CONCLUSIONS: Programme implementation is extremely unlikely given the current organization of health care settings. To maintain the use of such programmes, we need to change the "unit of leverage" in the system: from the clinical encounter--that is, practitioners working with individual patients in a case-finding manner--to an organizational level--that is, the appropriate use of managerial and information systems supporting health care settings to identify at-risk patients systematically as they enter primary care and hospital settings. With appropriate infrastructure support, practitioners will be able to fulfil the potential for as well as maintain the use of comprehensive, secondary prevention programmes to reduce alcohol risk and harm in the population.

Alcoholism↗

PubMed2005

Concurrent and predictive validity of two scales to assess the fidelity of implementation of supported employment.

The ability of the Individual Placement and Support (IPS) and the Quality of Supported Employment Implementation Scale (QSEIS) fidelity scales to predict independently rated SE adherence and percentage of clients closed by the Office of Vocational Rehabilitation (OVR) was tested at 23 SE sites. QSEIS Total score (r = .47), Integration subscale (r = .53), and Support subscales (r = .61) correlated with SE adherence. Total QSEIS score also predicted OVR closure rate (r = .42). Correlations between IPS (sub)scale scores and the criterion measures were non-significant. The results support QSEIS validity and provide evidence that fidelity to the SE model is associated with better employment outcomes.

Community Mental Health Centers↗

PubMed2003

How the CATCH eat smart program helps implement the USDA regulations in school cafeterias.

This article describes the implementation of the U.S. Department of Agriculture's National School Lunch Program (NSLP) standards in school lunch menus in 56 intervention and 20 control schools from the Child and Adolescent Trial for Cardiovascular Health (CATCH) 5 years after the main trial, compared with 12 schools previously unexposed to CATCH. School food service personnel completed questionnaires to assess CATCH guideline implementation, demographic data, behavioral constructs, training, program material use, and participation in competing programs. Five days of menus and recipes were collected from school cafeteria staff, averaged, and compared to USDA School Meal Initiative (SMI) standards. Significant differences between intervention and unexposed schools were found for training and knowledge of CATCH and in mean percentage energy from fat and carbohydrates. Intervention schools most closely met USDA SMI recommendations for fat. Thus, the CATCH Eat Smart Program assisted school cafeterias in meeting USDA guidelines 5 years postimplementation.

Adolescent↗

PubMed2002

A framework for the dissemination and utilization of research for health-care policy and practice.

PURPOSE: The purpose of this paper is to construct a comprehensive framework of research dissemination and utilization that is useful for both health policy and clinical decision-making. ORGANIZING CONSTRUCT: The framework illustrates that the process of the adoption of research evidence into health-care decision-making is influenced by a variety of characteristics related to the individual, organization, environment and innovation. The framework also demonstrates the complex inter-relationships among these characteristics as progression through the five stages of innovation namely, knowledge, persuasion, decision, implementation and confirmation occurs. Finally, the framework integrates the concepts of research dissemination, evidence-based decision-making and research utilization within the diffusion of innovations theory. METHODS: During the discussion of each stage of the innovation adoption process, relevant literature from the management field (i.e., diffusion of innovations, organizational management and decision-making) and health-care sector (i.e., research dissemination and utilization and evidence-based practice) is summarized. Studies providing empirical data contributing to the development of the framework were assessed for methodological quality. CONCLUSIONS: The process of research dissemination and utilization is complex and determined by numerous intervening variables related to the innovation (research evidence), organization, environment and individual.

Clinical Nursing Research↗

PubMedDate not supplied

Solving the surgical waiting list problem? New Zealand's 'booking system'.

This article discusses the development and implementation of New Zealand's booking system for publicly funded non-urgent surgical and medical procedures. The 'booking system' emerged out of New Zealand's core services debate and the government's desire to remove waiting lists. It was targeted for implementation by mid-1998. However, the booking system remains in an unsatisfactory state and a variety of problems have plagued its introduction. These include a lack of national consistency in the priority access criteria, failure to pilot the system and a shortfall in the levels of funding available to treat the numbers of patients whose priority criteria 'scores' deem them clinically eligible for surgery. The article discusses endeavours to address these problems. In conclusion, based on the New Zealand experience, the article provides lessons for policy-makers interested in introducing surgical booking systems.

Appointments and Schedules↗

PubMed1995

Implementation of the homeless families program: 2. Characteristics, strengths, and needs of participant families.

The characteristics and needs of homeless families participating in a large-scale services-enriched housing program are examined. Although not a representative sample, participants constitute one of the largest subsets of homeless families in the literature. Moreover, the sample, which encompasses nine sites, is focused on families with multiple problems who have been recurrently homeless. Differing constellations of needs and implications for service delivery are explored.

Adolescent↗

PubMed2003

Tackling health inequalities in the United Kingdom: the progress and pitfalls of policy.

GOAL: Assess the progress and pitfalls of current United Kingdom (U.K.) policies to reduce health inequalities. OBJECTIVES: (1) Describe the context enabling health inequalities to get onto the policy agenda in the United Kingdom. (2) Categorize and assess selected current U.K. policies that may affect health inequalities. (3) Apply the "policy windows" model to understand the issues faced in formulating and implementing such policies. (4) Examine the emerging policy challenges in the U.K. and elsewhere. DATA SOURCES: Official documents, secondary analyses, and interviews with policymakers. STUDY DESIGN: Qualitative, policy analysis. DATA COLLECTION: 2001-2002. The methods were divided into two stages. The first identified policies which were connected with individual inquiry recommendations. The second involved case-studies of three policies areas which were thought to be crucial in tackling health inequalities. Both stages involved interviews with policymakers and documentary analysis. PRINCIPAL FINDINGS: (1) The current U.K. government stated a commitment to reducing health inequalities. (2) The government has begun to implement policies that address the wider determinants. (3) Some progress is evident but many indicators remain stubborn. (4) Difficulties remain in terms of coordinating policies across government and measuring progress. (5) The "policy windows" model explains the limited extent of progress and highlights current and possible future pitfalls. (6) The U.K.'s experience has lessons for other governments involved in tackling health inequalities. CONCLUSIONS: Health inequalities are on the agenda of U.K. government policy and steps have been made to address them. There are some signs of progress but much remains to be done including overcoming some of the perverse incentives at the national level, improving joint working, ensuring appropriate measures of performance/progress, and improving monitoring arrangements. A conceptual policy model aids understanding and points to ways of sustaining and extending the recent progress and overcoming pitfalls.

Health Plan Implementation↗

PubMed1999

An evaluation of WHA resolution 45.5: health human resource implications.

The World Health Assembly approved resolution WHA45.5 in 1992. This paper reports the findings of an evaluation of the implementation of this resolution using a survey technique. A total of 150 WHO Member States responded, for a 79% response rate. Findings suggest that the greatest strides worldwide have been made in education. While the data show that progress has been made at the country level, far more action is needed to strengthen nursing and midwifery if these cost-effective resources are to play a decisive role in improving the extent and quality of services, especially as delivered to people in the greatest need.

Cross-Sectional Studies↗

PubMed2004

[The "rehabilitation sciences" research funding programme: research findings -- implementation -- impact and perspectives].

In 1998, the German Federal Ministry of Education and Research (BMBF) and the German pension insurance scheme established a funding programme for research in rehabilitation. This "Rehabilitation Sciences" research funding programme comprises eight regional research networks for eight years in two periods (1998-2002, 2001-2005). In our paper we review the findings of the first funding period in five of the research fields: patient education, need for and access to rehabilitation, vocational training in medical rehabilitation to enhance return to work, comorbid mental disorders in patients with somatic diseases, and gender differences. Several activities aimed at transferring research findings into practice are outlined. Finally, the impact of the funding programme is summarized and perspectives for further funding are given.

Chronic Disease↗

PubMed2004

Managing under managed community care: the experiences of clients, providers and managers in Ontario's competitive home care sector.

In 1996, a newly elected government in the Province of Ontario, Canada, introduced a managed competition environment into the home care sector through the establishment of a competitive contracting process for home care services. Through 65 in-depth, semi-structured interviews conducted between November 1999 and January 2001, we trace the implementation of this competitive contracting policy within Ontario's newly established managed community care environment and assess the effects of competitive contracting against two sets of goals: (1). quality of care goals that consider continuity of care of paramount importance in the provision of home care; and (2). the managed competition goal of increased efficiency. In assessing the implementation of this policy against these goals, we highlight the conflicts that can arise in pursuing different policy goals in response to different formulations of the policy problem that underpin them. We map stakeholder experiences with the competitive contracting policy onto relevant contracting and managed competition literatures. When measured against the goals of quality of care and efficiency, the findings presented here offer a mixed review of the experiences to date with the competitive contracting process introduced in Ontario's home care sector and suggest improvements for managing future competitive contracting processes.

Attitude of Health Personnel↗

PubMed2000

Prevalence of suicide programs in schools and roadblocks to implementation.

We surveyed all school districts in Washington State for information on the prevalence of suicide programs and on major roadblocks to implementing programs. With 163 districts responding (62%), we found that the majority did not have suicide programs or policies and procedures. The largest perceived roadblock was insufficient staff and the greatest perceived need was more information. Although establishing policies and procedures is considered by many as a necessary first step to establishing suicide programs, we did not find schools choosing this option as often as others. This raises questions as to what are effective ways to have schools start suicide programs. We analyzed the data by school district size and by the title of the staff member making the report. We discuss the implications of these findings as well as the need for further efforts to develop appropriate programs for schools.

Adolescent↗

PubMedDate not supplied

The GDAHA hospital performance reports project: a successful community-based quality improvement initiative.

During the past decade there has been increasing distribution of hospital performance information but few examples of how this information is affecting the quality of health care delivery. This article describes the methods of implementation and factors influencing a successful community-based quality improvement initiative in Dayton, Ohio, involving a collaborative of five competing hospitals in partnership with the business community and local and state hospital associations. The initiative contributed to a 36% reduction in acute myocardial infarction mortality over a 3-year period by changing reperfusion patterns in patients with ST segment elevated myocardial infarction. Identification of an opportunity gap, root cause analysis, and development of process measures used to facilitate health care provider change are summarized. The driving and restraining forces that have shaped this initiative from a report card to a quality improvement program are outlined and a list of five contributors to success are presented. These factors can serve as a basis for how other communities can benefit from this collaborative model.

Cardiology Service, Hospital↗

PubMed2004

[Health care services for nomadic people. Lessons learned from research and implementation activities in Chad].

To overcome barriers of access to health care of nomadic people and to alleviate inequities in health, a transdisciplinary team has initiated research and intervention activities among three nomadic groups of Chad: Foulbé, Arabes and Gouranes. A regular and consistent communication among all actors involved (nomadic groups, researchers, planners and administrators of health and veterinary services, etc.) through repetitive meetings and workshops showed to be a crucial element for success. Differences between ethnic nomadic groups made it necessary to develop specific communication strategies adapted to each group. As to interventions to improve the vaccination coverage, mixed teams combining health and veterinary specialists were able to vaccinate an important number of children and women and showed to have a high potential in terms of organisational and logistic feasibility, acceptability as well as good cost-effectiveness. With regard to improving access to health care, Information--Education and Communication approaches adapted to the intervention context and linked to the provision of essential services and generic drugs showed to be crucial.

Adolescent↗

PubMed2004

Research utilization and the impact of health promotion policy.

OBJECTIVES: The conditions under which research utilization leads to policy impact are an important issue in health promotion. This analysis tests the assumption that utilization is positively associated with policy impact only if both political will (i.e., policy opportunities) and social strategies (in intervention and implementation) are present. METHODS: A survey of 719 policymakers involved in four policies was conducted in six European countries. Policy impact (output, i.e., program implementation, and outcome, i.e., effects on behavior) and its proposed determinants were analyzed. RESULTS: Regression analyses reveal limited cross-national differences in research utilization, but show comparably high use in policies with a pathogenic focus. Utilization is associated with impact only if political will is lacking; for outcome, this tends to depend on social strategies. Political will is the strongest determinant of impact. CONCLUSIONS: Research utilization is not supporting health promotion policy impact if political will is favorable, but if it is poor; political will itself is the crucial determinant of impact. The study contributes to the "research utilization"-field by showing that research utilization may partially compensate for lack of, rather than depend on, political will.

Cross-Cultural Comparison↗

PubMed2003

Community readiness to prevent intimate partner violence in Bexar County, Texas.

The purpose of this article is to describe the Community Readiness Model implemented by the San Antonio Safe Family Coalition in Bexar County, Texas, a coordinated community response to prevent intimate partner violence. The project used a participatory action process to (a) determine the city's and county's stage of readiness to prevent intimate partner violence; (b) identify differences in the city and county by dividing the area into sectors for the assessment; (c) engage the community in determining the accuracy and usefulness of the results of the assessment; (d) develop targeted strategies to move the city and county to a higher stage of readiness for prevention of intimate partner violence; and (e) evaluate the results of the project.

Attitude to Health↗