Implementation of the 'Optimising the Health Extension Program' Intervention in Ethiopia: A Process Evaluation Using Mixed Methods.
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SUBMITTER: Okwaraji YB
PROVIDER: S-EPMC7459764 | biostudies-literature | 2020 Aug
REPOSITORIES: biostudies-literature
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Implementation of the 'Optimising the Health Extension Program' Intervention in Ethiopia: A Process Evaluation Using Mixed Methods.
Okwaraji Yemisrach B YB Hill Zelee Z Defar Atkure A Berhanu Della D Wolassa Desta D Persson Lars Åke LÅ Gonfa Geremew G Schellenberg Joanna A JA
International journal of environmental research and public health 20200811 16
An intervention called 'Optimising the Health Extension Program', aiming to increase care-seeking for childhood illnesses in four regions of Ethiopia, was implemented between 2016 and 2018, and it included community engagement, capacity building, and district ownership and accountability. A pragmatic trial comparing 26 districts that received the intervention with 26 districts that did not found no evidence to suggest that the intervention increased utilisation of services. Here we used mixed me ...[more]
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Project description:BackgroundThe burden of obesity is high among US veterans, yet many face barriers to engaging in in-person, facility-based treatment programs. To improve access to weight-management services, the Veterans Health Administration (VHA) developed TeleMOVE, a home-based, 82-day curriculum that utilizes in-home messaging devices to promote weight loss in VHA patients facing barriers to accessing facility-based services.ObjectiveThe primary aim was to establish preliminary evidence for the program by comparing outcomes for TeleMOVE with standard, facility-based MOVE weight-management services (group, individual modalities) over the evaluation period based on the number of patients enrolled per site and the program's clinical effectiveness, as demonstrated by average weight lost per patient. The secondary aim was to understand factors influencing TeleMOVE implementation variability across demonstration sites to develop recommendations to improve national program dissemination.MethodsWe employed a formative mixed-methods design to evaluate the phased implementation of TeleMOVE at 9 demonstration sites and compare patient- and site-level measures of program uptake. Data were collected between October 1, 2009 and September 30, 2011. Patient-level program outcomes were extracted from VHA patient care databases to evaluate program enrollment rates and clinical outcomes. To assess preliminary clinical effectiveness, weight loss outcomes for veterans who enrolled in TeleMOVE were compared with outcomes for veterans enrolled in standard MOVE! at each demonstration site, as well as with national averages during the first 2 years of program implementation. For the secondary aim, we invited program stakeholders to participate in 2 rounds of semistructured interviews about aspects of TeleMOVE implementation processes, site-level contextual factors, and program delivery. Twenty-eight stakeholders participated in audio-recorded interviews.ResultsAlthough stakeholders at 3 sites declined to be interviewed, objective program uptake was high at 2 sites, delayed-high at 2 sites, and low at 5 sites. At 6 months post enrollment, the mean weight loss was comparable for TeleMOVE (n=417) and MOVE! (n=1543) participants at -5.2 lb (SD 14.4) and -5.1 lb (SD 12.2), respectively (P=.91). All sites reported high program complexity because TeleMOVE required more staff time per participant than MOVE! due to logistical and technical assistance issues related to the devices. High-uptake sites overcame implementation challenges by leveraging communication networks with stakeholders, adapting the program to patient needs whenever possible, setting programmatic goals and monitoring feedback of results, and taking time to reflect and evaluate on delivery to foster incremental delivery improvements, whereas low-uptake sites reported less leadership support and effective communication among stakeholders.ConclusionsThis implementation evaluation of a clinical telehealth program demonstrated the value of partnership-based research in which researchers not only provided operational leaders with feedback regarding the effectiveness of a new program but also relevant feedback into contextual factors related to program implementation to enable adaptations for national deployment efforts.
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Project description:BackgroundManagers and professionals in health and social care are required to implement evidence-based methods. Despite this, they generally lack training in implementation. In clinical settings, implementation is often a team effort, so it calls for team training. The aim of this study was to evaluate the effects of the Building Implementation Capacity (BIC) intervention that targets teams of professionals, including their managers.MethodsA non-randomized design was used, with two intervention cases (each consisting of two groups). The longitudinal, mixed-methods evaluation included pre-post and workshop-evaluation questionnaires, and interviews following Kirkpatrick's four-level evaluation framework. The intervention was delivered in five workshops, using a systematic implementation method with exercises and practical working materials. To improve transfer of training, the teams' managers were included. Practical experiences were combined with theoretical knowledge, social interactions, reflections, and peer support.ResultsOverall, the participants were satisfied with the intervention (first level), and all groups increased their self-rated implementation knowledge (second level). The qualitative results indicated that most participants applied what they had learned by enacting new implementation behaviors (third level). However, they only partially applied the implementation method, as they did not use the planned systematic approach. A few changes in organizational results occurred (fourth level).ConclusionsThe intervention had positive effects with regard to the first two levels of the evaluation model; that is, the participants were satisfied with the intervention and improved their knowledge and skills. Some positive changes also occurred on the third level (behaviors) and fourth level (organizational results), but these were not as clear as the results for the first two levels. This highlights the fact that further optimization is needed to improve transfer of training when building teams' implementation capacity. In addition to considering the design of such interventions, the organizational context and the participants' characteristics may also need to be considered to maximize the chances that the learned skills will be successfully transferred to behaviors.
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Project description:OBJECTIVES:During a cluster randomised trial, (the 3D study) of an intervention enacting recommended care for people with multimorbidity, including continuity of care and comprehensive biennial reviews, we examined implementation fidelity to interpret the trial outcome and inform future implementation decisions. DESIGN:Mixed-methods process evaluation using cross-trial data and a sample of practices, clinicians, administrators and patients. Interviews, focus groups and review observations were analysed thematically and integrated with quantitative data about implementation. Analysis was blind to trial outcomes and examined context, intervention adoption, reach and maintenance, and delivery of reviews to patients. SETTING:Thirty-three UK general practices in three areas. PARTICIPANTS:The trial included 1546 people with multimorbidity. 11 general practitioners, 14 nurses, 7 administrators and 38 patients from 9 of 16 intervention practices were sampled for an interview. RESULTS:Staff loss, practice size and different administrative strategies influenced implementation fidelity. Practices with whole administrative team involvement and good alignment between the intervention and usual care generally implemented better. Fewer reviews than intended were delivered (49% of patients receiving both intended reviews, 30% partially reviewed). In completed reviews >90% of intended components were delivered, but review observations and interviews with patients and clinicians found variation in style of component delivery, from 'tick-box' to patient-centred approaches. Implementation barriers included inadequate skills training to implement patient-centred care planning, but patients reported increased patient-centredness due to comprehensive reviews, extra time and being asked about their health concerns. CONCLUSIONS:Implementation failure contributed to lack of impact of the 3D intervention on the trial primary outcome (quality of life), but so did intervention failure since modifiable elements of intervention design were partially responsible. When a decisive distinction between implementation failure and intervention failure cannot be made, identifying potentially modifiable reasons for suboptimal implementation is important to enhance potential for impact and effectiveness of a redesigned intervention. TRIAL REGISTRATION NUMBER:ISRCTN06180958.
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Project description:Background: There is a lack of evidence concerning the effective implementation of strategies for stroke prevention and management, particularly in resource-limited settings. A primary-care-based integrated mobile health intervention (SINEMA intervention) has been implemented and evaluated via a 1-year-long cluster-randomized controlled trial. This study reports the findings from the trial implementation and process evaluation that investigate the implementation of the intervention and inform factors that may influence the wider implementation of the intervention in the future. Methods: We developed an evaluation framework by employing both the RE-AIM framework and the MRC process evaluation framework to describe the implementation indicators, related enablers and barriers, and illustrate some potential impact pathways that may influence the effectiveness of the intervention in the trial. Quantitative data were collected from surveys and extracted from digital health monitoring systems. In addition, we conducted quarterly in-depth interviews with stakeholders in order to understand barriers and enablers of program implementation and effectiveness. Quantitative data analysis and thematic qualitative data analysis were applied, and the findings were synthesized based on the evaluation framework. Results: The SINEMA intervention was successfully implemented in 25 rural villages, reached 637 patients with stroke in rural Northern China during the 12 months of the trial. Almost 90% of the participants received all follow-up visits per protocol, and about half of the participants received daily voice messages. The majority of the intervention components were adopted by village doctors with some adaptation made. The interaction between human-delivered and technology-enabled components reinforced the program implementation and effectiveness. However, characteristics of the participants, doctor-patient relationships, and the healthcare system context attributed to the variation of program implementation and effectiveness. Conclusion: A comprehensive evaluation of program implementation demonstrates that the SINEMA program was well implemented in rural China. Findings from this research provide additional information for program adaptation, which shed light on the future program scale-up. The study also demonstrates the feasibility of combining RE-AIM and MRC process evaluation frameworks in process and implementation evaluation in trials. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03185858.
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Project description:BackgroundCommunity-based educational programs can complement clinical strategies to increase cancer screenings and encourage healthier lifestyles to reduce cancer burden. However, implementation quality can influence program outcomes and is rarely formally evaluated in community settings. This mixed-methods study aimed to characterize implementation of a community-based cancer prevention program using the Consolidated Framework for Implementation Research (CFIR), determine if implementation was related to participant outcomes, and identify barriers and facilitators to implementation that could be addressed.MethodsThis study utilized quantitative participant evaluation data (n?=?115) and quantitative and qualitative data from semi-structured interviews with program instructors (N?=?13). At the participant level, demographic data (age, sex, insurance status) and behavior change intention were captured. Instructor data included implementation of program components and program attendance to create a 7-point implementation score of fidelity and reach variables. Degree of program implementation (high and low) was operationalized based on these variables (low: 0-4, high: 5-7). Relationships among degree of implementation, participant demographics, and participant outcomes (e.g., intent to be physically active or limit alcohol) were assessed using linear or ordinal logistic mixed effects models as appropriate. Interview data were transcribed and coded deductively for CFIR constructs, and constructs were then rated for magnitude and valence. Patterns between ratings of high and low implementation programs were used to determine constructs that manifested as barriers or facilitators.ResultsProgram implementation varied with scores ranging from 4 to 7. High implementation was related to greater improvements in intention to be physically active (p?<? 0.05), achieve a healthy weight (p?<? 0.05), and limit alcohol (p?<? 0.01). Eight constructs distinguished between high and low implementation programs. Design quality and packaging, compatibility, external change agents, access to knowledge and information, and experience were facilitators of implementation and formally appointed internal implementation leaders was a barrier to implementation.ConclusionsAs higher implementation was related to improved participant outcomes, program administrators should emphasize the importance of fidelity in training for program instructors. The CFIR can be used to identify barriers and/or facilitators to implementation in community interventions, but results may be unique from clinical contexts.
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Project description:BACKGROUND:Wearable technology interventions combined with digital behavior change resources provide opportunities to increase physical activity in adolescents. The implementation of such interventions in real-world settings is unknown. The Raising Awareness of Physical Activity (RAW-PA) study was a 12-week cluster randomized controlled trial targeting inactive adolescents attending schools in socioeconomically disadvantaged areas of Melbourne, Australia. The aim was to increase moderate- to vigorous-intensity physical activity using (1) a wrist-worn Fitbit Flex and app, (2) weekly challenges, (3) digital behavior change resources, and (4) email or text message alerts. OBJECTIVE:This paper presents adolescents' and teachers' perceptions of RAW-PA in relation to program acceptability, feasibility and perceived impact, adolescent engagement and adherence, and the potential for future scale-up. METHODS:A mixed methods evaluation of the RAW-PA study assessed acceptability, engagement, feasibility, adherence, and perceived impact. A total of 9 intervention schools and 144 intervention adolescents were recruited. Only adolescents and teachers (n=17) in the intervention group were included in the analysis. Adolescents completed web-based surveys at baseline and surveys and focus groups postintervention. Teachers participated in interviews postintervention. Facebook data tracked engagement with web-based resources. Descriptive statistics were reported by sex. Qualitative data were analyzed thematically. RESULTS:Survey data were collected from 142 adolescents at baseline (mean age 13.7 years, SD 0.4 years; 51% males) and 132 adolescents postintervention. A total of 15 focus groups (n=124) and 9 interviews (n=17) were conducted. RAW-PA had good acceptability among adolescents and teachers. Adolescents perceived the intervention content as easy to understand (100/120, 83.3%) and the Fitbit easy to use (112/120; 93.3%). Half of the adolescents perceived the text messages to be useful (61/120; 50.8%), whereas 47.5% (57/120) liked the weekly challenges and 38.3% (46/120) liked the Facebook videos. Facebook engagement declined over time; only 18.6% (22/118) of adolescents self-reported wearing the Fitbit Flex daily postintervention. Adolescents perceived the Fitbit Flex to increase their physical activity motivation (85/120, 70.8%) and awareness (93/119, 78.2%). The web-based delivery facilitated implementation of the intervention, although school-level policies restricting phone use were perceived as potential inhibitors to program roll-out. CONCLUSIONS:RAW-PA showed good acceptability among adolescents attending schools in socioeconomically disadvantaged areas and their teachers. Low levels of teacher burden enhanced their perceptions concerning the feasibility of intervention delivery. Although adolescents perceived that RAW-PA had short-term positive effects on their motivation to be physically active, adolescent adherence and engagement were low. Future research exploring the feasibility of different strategies to engage adolescents with wearable technology interventions and ways of maximizing system-level embeddedness of interventions in practice would greatly advance the field.
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Project description:ObjectivesParent carers of children with special educational needs or disability are at risk of poorer mental and physical health. In response to these needs, we codeveloped the 'Healthy Parent Carers' (HPC) programme. This study examined the views and experiences of participants in the HPC feasibility trial to inform programme refinement.Intervention, setting and participantsHPC is a peer-led group-based intervention (supported by online materials) for primary carers of disabled children, encouraging behaviours linked with health and well-being. It was delivered by two lead and six assistant peer facilitators in six community sites (one lead and one assistant per group) in South West England over six or 12 sessions. Control participants had online materials only. The trial involved 47 intervention and 45 control parent carers (97% female and 97% white) and eight facilitators (one male).DesignA preplanned mixed methods process evaluation using questionnaires and checklists (during and after the intervention), qualitative interviews with participants after intervention (n=18) and a focus group with facilitators after trial.ResultsHPC was highly acceptable to participants and facilitators and experiences were very positive. Participants reported that the programme increased awareness of what parent carers could and could not change and their self-efficacy to engage in health-promoting behaviours. The intended mechanisms of action (social identification and peer support) matched participants' expectations and experiences. Control participants found the online-only programme flexible but isolating, as there were no opportunities to share ideas and problem solve with peers, the key function of the programme. Areas for improvement were identified for programme content, facilitator training and delivery.ConclusionHPC was acceptable, well received and offers considerable potential to improve the health of parent carers. Under the pandemic, the challenge going forward is how best to maintain reach and fidelity to function while delivering a more virtual programme.Trial registration numberISRCTN151144652.
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Project description:BACKGROUND:The Community-Based Newborn Care (CBNC) program is a comprehensive strategy designed to improve the health of newborns during pregnancy, childbirth, and the postnatal period through health extension workers at community levels, although the implementation has not been evaluated yet. Therefore, this study aimed to evaluate the process of the CBNC program implementation in Geze Gofa district, south Ethiopia. METHODS:A case study evaluation design with a mixed method was employed from May 1 to 31, 2017. A total of 321 mothers who gave birth from September 01, 2016 to February 29, 2017, were interviewed. Similarly, 27 direct observations, six-month document reviews, and 14 key informant interviews were conducted. The quantitative data were entered into Epi-Data version 3.1 and exported to SPSS version 20 for analysis. In the multivariable logistic regression analysis, variables with <?0.05 p-values and Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were used to declare factors associated with maternal satisfaction. The qualitative data were transcribed, translated, coded, and analyzed using thematic analysis. The overall process of program implementation was measured based on pre-determined judgmental criteria. RESULTS:The overall level of the implementation process of the CBNC program was 72.7%, to which maternal satisfaction, availability of resources, and healthcare providers' compliance with the national guideline contributed 75.0, 81.0, and 68.0%, respectively. Essential drugs and medical equipment, like vitamin K, chlorohexidine ointment, neonatal resuscitation bags, and masks used in the program were out of stock. Very severe diseases were not treated according to the national guidelines, and the identification of neonatal sepsis cases was poor. Trading occupation (AOR: 0.16, 95% CI: 0.03-0.97) and low wealth status (AOR: 3.11, 95% CI: 1.16-8.36) were factors associated with maternal satisfaction. CONCLUSION:The process of CBNC program implementation was relatively good, although the compliance of healthcare providers with the national guideline and maternal satisfaction with the services was low. Some essential drugs and medical equipment were out of stock. Merchant and low wealth status affected maternal satisfaction. Therefore, healthcare offices should provide crucial medicines and equipment for better program implementation and improve the wealth status of mothers to enhance maternal satisfaction.
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Project description:Long periods of workplace sitting are associated with poor health outcomes. Interventions to reduce workplace sitting time have had variable impacts, the reasons for which require further investigation. In this paper, we report on a process evaluation aiming to determine the intervention fidelity of three "sit less at work" interventions and to explore barriers and enablers to implementation, using a mixed methods "before and after" intervention study design. Convenience samples of staff were recruited from three diverse organisations to participate in pre- and post-intervention online questionnaires, objective measures of sitting time (using activPAL3™ devices) and post-intervention focus groups. Intervention implementers and key personnel were also recruited to participate in post-intervention focus groups and interviews. The process evaluation found that none of the interventions were implemented as intended, with no consistent reductions in sitting time. Contextual and organisational cultural barriers included workload pressures and the social norms of sitting, competing priorities, lack of management buy-in, and perceptions of where the responsibility for behaviour change should come from. To ensure effective implementation of future initiatives, deeper organisational-level change, requiring buy-in from all levels of management and staff, may be needed to shift organisational culture and associated social norms.
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