Organizational readiness for change Archives - Implementation Science at UW

✪ Exploring fidelity and its influence on effectiveness in an audit and feedback strategy implemented in a low-resource setting: an application of regression modeling

Abstract:

Background

Assessing implementation fidelity—the degree to which a program is implemented as intended—is essential to understand whether poor outcomes are due to implementation problems or the design of an intervention. Few studies in health research have documented the association between implementation fidelity and effectiveness. The Integrated District Evidence-to-Action (IDEAs) is a multicomponent audit and feedback strategy designed to improve the implementation of maternal and child clinical guidelines in Mozambique. In a previous study, we found mixed results of IDEAs effectiveness. The objective of the present study is to understand how implementation fidelity may have influenced the effectiveness of the strategy.

Methods

IDEAs was implemented in 154 health facilities across 12 districts in Manica and Sofala provinces in Mozambique between 2016 and 2020. We used the conceptual framework for implementation fidelity to guide descriptive analysis of IDEAs adherence. Regression modeling was used to study patterns of the direction of association between measures of fidelity and effectiveness for ten service delivery outcomes and five service readiness outcomes.

Results

We describe adherence on 15 measures of fidelity, of which 12 had high fidelity. Poor fidelity was found in conducting facility service readiness assessments and completing micro-interventions from action plans. Service delivery measures tended to be positively associated with participation and degree of micro-intervention completion and negatively associated with a higher number of action plans elaborated by participating teams. For the service readiness outcomes, delivery of essential care was positively associated with participation and micro-intervention completion, and staff availability was negatively associated with supervision.

Conclusion

Participation in audit and feedback meetings, the number of action plans elaborated, and the degree of completion of micro-interventions seem to be related to the effectiveness results. IDEAs should be adapted to reduce the number of action plans elaborated and promote better micro-intervention completion. Additionally, combining audit and feedback strategies with other strategies might enhance effectiveness in service outcomes. This study examines how to analyze the link between fidelity and effectiveness of a strategy to inform better design and recommend context-specific improvements.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Can audit and feedback improve health service readiness and delivery outcomes in a low-resource setting? Effectiveness results of the IDEAs strategy from central Mozambique

Abstract:

Limited evidence exists on audit and feedback (A&F) in low-resource contexts. We tested the Integrated District Evidence-to-Action (IDEAs), a multicomponent A&F strategy in Mozambique’s maternal and child health (MCH) services. IDEAs include A&F meetings, readiness assessments, and facility support. We report the effectiveness results. IDEAs were implemented in 2016–2020 across two provinces, 12 districts, and 154 primary health facilities in Mozambique. We assessed 1) ten service delivery outcomes across antenatal, maternity, postpartum, childcare, and reproductive health services and 2) five service readiness outcomes (medicines, infrastructure, equipment, care, and staffing availability). We used propensity score matching to minimize bias and a controlled interrupted time series with a negative binomial mixed effects model for service delivery analysis, presenting incidence rate ratios (IRR) with 95% confidence intervals (95% CI). For service readiness outcomes, we created composite scores for each domain and a difference-in-difference analysis using an ordinal mixed effects model, reporting odds ratios (OR) and 95% CI. Significant associations were found with first at-risk child appointments (IRR = 1.06 [1.04, 1.07]), first polymerase chain reaction tests for HIV-exposed children (IRR = 1.02 [1.01, 1.03]), new contraceptive users (IRR = 0.95 [0.94, 0.96]), women starting long-lasting contraceptives (IRR = 0.94 [0.93, 0.95]), availability of infrastructure (OR = 5.84 [1.32, 25.88]) and essential care (OR = 0.13 [0.03, 0.54]). No significant associations were found between IDEAs and six of 10 service delivery outcomes (women with a fourth dose of preventive malaria treatment; women protected with tetanus vaccine; women with four+ antenatal visits; deliveries with active management of the third stage of labor; first postpartum consultations and fully vaccinated children) and on medicine, equipment, and staffing availability. We observed mixed effectiveness in implementing IDEAs, with null and sub-optimal effects suggesting the need to refine and adapt strategy components to more effectively address clinical and readiness outcomes.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Adapting and testing measures of organizational context in primary care clinics in KwaZulu-Natal, South Africa

Abstract:

Background

Implementation science frameworks situate intervention implementation and sustainment within the context of the implementing organization and system. Aspects of organizational context such as leadership have been defined and measured largely within US health care settings characterized by decentralization and individual autonomy. The relevance of these constructs in other settings may be limited by differences like collectivist orientation, resource constraints, and hierarchical power structures. We aimed to adapt measures of organizational context in South African primary care clinics.

Methods

We convened a panel of South African experts in social science and HIV care delivery and presented implementation domains informed by existing frameworks and prior work in South Africa. Based on panel input, we selected contextual domains and adapted candidate items. We conducted cognitive interviews with 25 providers in KwaZulu-Natal Province to refine measures. We then conducted a cross-sectional survey of 16 clinics with 5–20 providers per clinic (N = 186). We assessed reliability using Cronbach’s alpha and calculated interrater agreement (awg) and intraclass correlation coefficient (ICC) at the clinic level. Within clinics with moderate agreement, we calculated correlation of clinic-level measures with each other and with hypothesized predictors – staff continuity and infrastructure – and a clinical outcome, patient retention on antiretroviral therapy.

Results

Panelists emphasized contextual factors; we therefore focused on elements of clinic leadership, stress, cohesion, and collective problem solving (critical consciousness). Cognitive interviews confirmed salience of the domains and improved item clarity. After excluding items related to leaders’ coordination abilities due to missingness and low agreement, all other scales demonstrated individual-level reliability and at least moderate interrater agreement in most facilities. ICC was low for most leadership measures and moderate for others. Measures tended to correlate within facility, and higher stress was significantly correlated with lower staff continuity. Organizational context was generally more positively rated in facilities that showed consistent agreement.

Conclusions

As theorized, organizational context is important in understanding program implementation within the South African health system. Most adapted measures show good reliability at individual and clinic levels. Additional revision of existing frameworks to suit this context and further testing in high and low performing clinics is warranted.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Implementation outcomes of the integrated district evidence to action (IDEAs) program to reduce neonatal mortality in central Mozambique: an application of the RE-AIM evaluation framework

Authors:

Aneth Dinis, Quinhas Fernandes, Bradley H Wagenaar, Sarah Gimbel, Bryan J Weiner, Grace John-Stewart, Ermyas Birru, Stephen Gloyd, Ruth Etzioni, Dorlim Uetela, Isaías Ramiro, Artur Gremu, Orvalho Augusto, Stélio Tembe, Jaime L Mário, Jalilo E Chinai, Alfredo F Covele, Cassimo M Sáide, Nélia Manaca & Kenneth Sherr

^{University of Washington affiliated authors are displayed in bold.}

✪ Open Access

Published: February 2024

Read the full text in the open access journal BMC Health Services Research

Abstract:

Background

Scarce evidence exists on audit and feedback implementation processes in low-resource health systems. The Integrated District Evidence to Action (IDEAs) is a multi-component audit and feedback strategy designed to improve the implementation of maternal and child guidelines in Mozambique. We report IDEAs implementation outcomes.

Methods

IDEAs was implemented in 154 health facilities across 12 districts in Manica and Sofala provinces between 2016 and 2020 and evaluated using a quasi-experimental design guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Reach is the proportion of pregnant women attending IDEAs facilities. Adoption is the proportion of facilities initiating audit and feedback meetings. Implementation is the fidelity to the strategy components, including readiness assessments, meetings (frequency, participation, action plan development), and targeted financial support and supervision. Maintenance is the sustainment at 12, 24, and 54 months.

Results

Across both provinces, 56% of facilities were exposed to IDEAs (target 57%). Sixty-nine and 73% of pregnant women attended those facilities’ first and fourth antenatal consultations (target 70%). All facilities adopted the intervention. 99% of the expected meetings occurred with an average interval of 5.9 out of 6 months. Participation of maternal and child managers was high, with 3076 attending meetings, of which 64% were from the facility, 29% from the district, and 7% from the province level. 97% of expected action plans were created, and 41 specific problems were identified. “Weak diagnosis or management of obstetric complications” was identified as the main problem, and “actions to reinforce norms and protocols” was the dominant subcategory of micro-interventions selected. Fidelity to semiannual readiness assessments was low (52% of expected facilities), and in completing micro-interventions (17% were completed). Ninety-six and 95% of facilities sustained the intervention at 12 and 24 months, respectively, and 71% had completed nine cycles at 54 months.

Conclusion

Maternal and child managers can lead audit and feedback processes in primary health care in Mozambique with high reach, adoption, and maintenance. The IDEAs strategy should be adapted to promote higher fidelity around implementing action plans and conducting readiness assessments. Adding effectiveness to these findings will help to inform strategy scale-up.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Evaluation of opportunities to implement community-wide mass drug administration for interrupting transmission of soil-transmitted helminths infections in India

Abstract:

Background

The World Health Organization Neglected Tropical Disease (NTD) guidelines recommend control of soil transmitted helminth (STH)-associated morbidity with targeted deworming of preschool and school-aged children who are disproportionately affected by STH-associated morbidity. However, this strategy leaves many adults untreated and reinfection within communities perpetuates transmission even when mass drug administration (MDA) coverage of children is high. Evidence suggests that it may be possible to interrupt STH transmission by expanding MDA to a community-wide MDA (cMDA).

Methods

This multi-methods study of organizational readiness survey, key informant interviews, and program mapping, were conducted with government stakeholders in three Indian states, Goa, Sikkim, and Odisha, to assess readiness of the states for transitioning from school-based MDA to cMDA and identify opportunities to leverage existing infrastructure from other NTD programs like lymphatic filariasis (LF) for STH cMDA.

Principal findings

Overall, all three states indicated a highly favorable policy environment, effective leadership structure, adequate material resources, demonstrated technical capacity, and adequate community infrastructure needed to launch a STH cMDA program. The findings indicated a high-level of health system readiness to implement provided human resources and financial resources to deliver cMDA is strengthened. Areas with a significant overlap between LF and STH MDA platforms, particularly at the community-level, may be best primed for transitioning. Immunization, maternal child health, and non-communicable disease control programs were the other programs for possible integration of cMDA. States indicated having effective leadership structures in place at the state-level, however, engaging local leaders and community groups were considered crucial for successful implementation of cMDA. In-migration was a perceived challenge for estimating drug requirement and preventing possible stockouts.

Conclusions

Findings from this study are intended to proactively support government decision making, prioritization, and program planning across heterogenous implementation contexts in India to speed the translation of research findings into practice.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Development of a Field Guide for Assessing Readiness to Implement Evidence-Based Cancer Screening Interventions in Primary Care Clinics

Abstract:

Evidence-based interventions, including provider assessment and feedback, provider reminders, patient reminders, and reduction of structural barriers, improve colorectal cancer screening rates. Assessing primary care clinics’ readiness to implement these interventions can help clinics use strengths, identify barriers, and plan for success. However, clinics may lack tools to assess readiness and use findings to plan for successful implementation. To address this need, we developed the Field Guide for Assessing Readiness to Implement Evidence-Based Cancer Screening Interventions (Field Guide) for the Centers for Disease Control and Prevention’s (CDC’s) Colorectal Cancer Control Program (CRCCP).

We conducted a literature review of evidence and existing tools to measure implementation readiness, reviewed readiness tools from selected CRCCP award recipients (n = 35), and conducted semi-structured interviews with key informants (n = 8). We sought feedback from CDC staff and recipients to inform the final document. The Field Guide, which is publicly available online, outlines 4 assessment phases: 1) convene team members and determine assessment activities, 2) design and administer the readiness assessment, 3) evaluate assessment data, and 4) develop an implementation plan. Assessment activities and tools are included to facilitate completion of each phase. The Field Guide integrates implementation science and practical experience into a relevant tool to bolster clinic capacity for implementation, increase potential for intervention sustainability, and improve colorectal cancer screening rates, with a focus on patients served in safety net clinic settings. Although this tool was developed for use in primary care clinics for cancer screening, the Field Guide may have broader application for clinics and their partners for other chronic diseases.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Measuring readiness for implementation: A systematic review of measures’ psychometric and pragmatic properties

Abstract:

Background

Systematic measure reviews can facilitate advances in implementation research and practice by locating reliable, valid, pragmatic measures; identifying promising measures needing refinement and testing; and highlighting measurement gaps. This review identifies and evaluates the psychometric and pragmatic properties of measures of readiness for implementation and its sub-constructs as delineated in the Consolidated Framework for Implementation Research: leadership engagement, available resources, and access to knowledge and information.

Methods

The systematic review methodology is described fully elsewhere. The review, which focused on measures used in mental or behavioral health, proceeded in three phases. Phase I, data collection, involved search string generation, title and abstract screening, full text review, construct assignment, and cited citation searches. Phase II, data extraction, involved coding relevant psychometric and pragmatic information. Phase III, data analysis, involved two trained specialists independently rating each measure using Psychometric and Pragmatic Evidence Rating Scales (PAPERS). Frequencies and central tendencies summarized information availability and PAPERS ratings.

Results

Searches identified 9 measures of readiness for implementation, 24 measures of leadership engagement, 17 measures of available resources, and 6 measures of access to knowledge and information. Information about internal consistency was available for most measures. Information about other psychometric properties was often not available. Ratings for internal consistency were “adequate” or “good.” Ratings for other psychometric properties were less than “adequate.” Information on pragmatic properties was most often available regarding cost, language readability, and brevity. Information was less often available regarding training burden and interpretation burden. Cost and language readability generally exhibited “good” or “excellent” ratings, interpretation burden generally exhibiting “minimal” ratings, and training burden and brevity exhibiting mixed ratings across measures.

Conclusion

Measures of readiness for implementation and its sub-constructs used in mental health and behavioral health care are unevenly distributed, exhibit unknown or low psychometric quality, and demonstrate mixed pragmatic properties. This review identified a few promising measures, but targeted efforts are needed to systematically develop and test measures that are useful for both research and practice.

Plain language abstract

Successful implementation of effective mental health or behavioral health treatments in service delivery settings depends in part on the readiness of the service providers and administrators to implement the treatment; the engagement of organizational leaders in the implementation effort; the resources available to support implementation, such as time, money, space, and training; and the accessibility of knowledge and information among service providers about the treatment and how it works. It is important that the methods for measuring these factors are dependable, accurate, and practical; otherwise, we cannot assess their presence or strength with confidence or know whether efforts to increase their presence or strength have worked. This systematic review of published studies sought to identify and evaluate the quality of questionnaires (referred to as measures) that assess readiness for implementation, leadership engagement, available resources, and access to knowledge and information. We identified 56 measures of these factors and rated their quality in terms of how dependable, accurate, and practical they are. Our findings indicate there is much work to be done to improve the quality of available measures; we offer several recommendations for doing so.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

Organizational readiness assessment in acute and long-term care has important implications for antibiotic stewardship for asymptomatic bacteriuria

✪ Readiness to Change Over Time: Change Commitment and Change Efficacy in a Workplace Health-Promotion Trial

Abstract:

Introduction

Organizational readiness to change may be a key determinant of implementation success and a mediator of the effectiveness of implementation interventions. If organizational readiness can be reliably and validly assessed at the outset of a change initiative, it could be used to assess the effectiveness of implementation-support activities by measuring changes in readiness factors over time.

Methods

We analyzed two waves of readiness-to-change survey data collected as part of a three-arm, randomized controlled trial to implement evidence-based health promotion practices in small worksites in low-wage industries. We measured five readiness factors: context (favorable broader conditions); change valence (valuing health promotion); information assessment (demands and resources to implement health promotion); change commitment (an intention to implement health promotion); and change efficacy (a belief in shared ability to implement health promotion). We expected commitment and efficacy to increase at intervention sites along with their self-reported effort to implement health promotion practices, termed wellness-program effort. We compared means between baseline and 15 months, and between intervention and control sites. We used linear regression to test whether intervention and control sites differed in their change-readiness scores over time.

Results

Only context and change commitment met reliability thresholds. Change commitment declined significantly for both control (−0.39) and interventions sites (−0.29) from baseline to 15 months, while context did not change for either. Only wellness program effort at 15 months, but not at baseline, differed significantly between control and intervention sites (1.20 controls, 2.02 intervention). Regression analyses resulted in two significant differences between intervention and control sites in changes from baseline to 15 months: (1) intervention sites exhibited significantly smaller change in context scores relative to control sites over time and (2) intervention sites exhibited significantly higher changes in wellness program effort relative to control sites.

Discussion

Contrary to our hypothesis, change commitment declined significantly at both Healthlinks and control sites, even as wellness-program effort increased significantly at HealthLinks sites. Regression to the mean may explain the decline in change commitment. Future research needs to assess whether baseline commitment is an independent predictor of wellness-program effort or an effect modifier of the HealthLinks intervention.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

Authors:

✪ Open Access

Read the full text in the open access journal Implementation Science Communications

Abstract:

Background

Methods

Results

Conclusion

Authors:

✪ Open Access

Read the full text in the open access journal PLOS Global Public Health

Abstract:

Authors:

✪ Open Access

Read the full text in the open access journal BMC Health Services Research

Abstract:

Background

Methods

Results

Conclusions

Authors:

✪ Open Access

Read the full text in the open access journal BMC Health Services Research

Abstract:

Background

Methods

Results

Conclusion

Authors:

✪ Open Access

Read the full text in the open access journal PLOS Neglected Tropical Diseases

Abstract:

Background

Methods

Principal findings

Conclusions

Authors:

✪ Open Access

Read the full text in the open access journal Preventing Chronic Disease: Public Health Research, Practice, and Policy

Abstract:

Authors:

✪ Open Access

Read the full text in the open access journal Implementation Research and Practice

Abstract:

Background

Methods

Results

Conclusion

Plain language abstract

Authors:

Subscription Required for Full Text Access

Read the full text in the subscription access American Journal of Infection Control

Authors:

✪ Open Access

Read the full text in the open access journal Frontiers in Public Health

Abstract:

Introduction

Methods

Results

Discussion