Scale-up of prevention programmes: sustained state-wide use of programme delivery software is explained by normalised self-organised adoption and non-adoption

Abstract Background Population-level health promotion is often conceived as a tension between “top-down” and “bottom-up” strategy and action. We report behind-the-scenes insights from Australia’s largest ever investment in the “top-down” approach, the $45m state-wide scale-up of two childhood obesity programmes. We used Normalisation Process Theory (NPT) as a template to interpret the organisational embedding of the purpose-built software designed to facilitate the initiative. The use of the technology was mandatory for evaluation, i.e. for reporting the proportion of schools and childcare centres which complied with recommended health practices (the implementation targets). Additionally, the software was recommended as a device to guide the implementation process. We set out to study its use in practice. Methods Short-term, high-intensity ethnography with all 14 programme delivery teams across New South Wales was conducted, cross-sectionally, 4 years after scale-up began. The four key mechanisms of NPT (coherence/sensemaking, cognitive participation/engagement, collective action and reflexive monitoring) were used to describe the ways the technology had normalised (embedded). Results Some teams and practitioners embraced how the software offered a way of working systematically with sites to encourage uptake of recommended practices, while others rejected it as a form of “mechanisation”. Conscious choices had to be made at an individual and team level about the practice style offered by the technology—thus prompting personal sensemaking, re-organisation of work, awareness of choices by others and reflexivity about professional values. Local organisational arrangements allowed technology users to enter data and assist the work of non-users—collective action that legitimised opposite behaviours. Thus, the technology and the programme delivery style it represented were normalised by pathways of adoption and non-adoption. Normalised use and non-use were accepted and different choices made by local programme managers were respected. State-wide, implementation targets are being reported as met. Conclusion We observed a form of self-organisation where individual practitioners and teams are finding their own place in a new system, consistent with complexity-based understandings of fostering scale-up in health care. Self-organisation could be facilitated with further cross-team interaction to continuously renew and revise sensemaking processes and support diverse adoption choices across different contexts.

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The primary prevention of anxiety disorders

New Oxford Textbook of Psychiatry ◽

10.1093/med/9780198713005.003.0091 ◽

2020 ◽

pp. 948-960

Author(s):

Aliza Werner-Seidler ◽

Jennifer L. Hudson ◽

Helen Christensen

Keyword(s):

Anxiety Disorder ◽

Primary Prevention ◽

Scale Up ◽

Population Level ◽

Implementation Barriers ◽

Cognitive Behavioural ◽

Post Test ◽

Prevention Programmes ◽

Programme Content ◽

The Impact

This chapter describes the nature of primary prevention of anxiety and reports on evidence for its effectiveness. The chapter first defines prevention before reporting results of a systematic review of randomized controlled trials designed to prevent anxiety. A review of existing trials and associated effect sizes suggests that prevention programmes can be effective in preventing anxiety disorder incidence and symptoms in multiple settings (schools, workplaces, community) across the lifespan. The median effect size at post-test across all studies was 0.21, and 0.25 specifically for cognitive behavioural prevention programmes. Key elements common to prevention programmes are then discussed, including a consideration of programme content and personnel delivering the intervention. Key implementation barriers are raised, together with suggestions for how these might be overcome in order to scale up and offer prevention at a population level. The chapter concludes with a consideration of the impact these programmes could have on anxiety disorder incidence.

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Behavioral responses across a mosaic of ecosystem states restructure a sea otter–urchin trophic cascade

Proceedings of the National Academy of Sciences ◽

10.1073/pnas.2012493118 ◽

2021 ◽

Vol 118 (11) ◽

pp. e2012493118 ◽

Cited By ~ 2

Author(s):

Joshua G. Smith ◽

Joseph Tomoleoni ◽

Michelle Staedler ◽

Sophia Lyon ◽

Jessica Fujii ◽

...

Keyword(s):

Foraging Behavior ◽

Sea Urchin ◽

Spatial Organization ◽

Scale Up ◽

Population Level ◽

Kelp Forests ◽

Sea Otter ◽

Natural Ecosystems ◽

Top Down ◽

Relative Contribution

Consumer and predator foraging behavior can impart profound trait-mediated constraints on community regulation that scale up to influence the structure and stability of ecosystems. Here, we demonstrate how the behavioral response of an apex predator to changes in prey behavior and condition can dramatically alter the role and relative contribution of top-down forcing, depending on the spatial organization of ecosystem states. In 2014, a rapid and dramatic decline in the abundance of a mesopredator (Pycnopodia helianthoides) and primary producer (Macrocystis pyrifera) coincided with a fundamental change in purple sea urchin (Strongylocentrotus purpuratus) foraging behavior and condition, resulting in a spatial mosaic of kelp forests interspersed with patches of sea urchin barrens. We show that this mosaic of adjacent alternative ecosystem states led to an increase in the number of sea otters (Enhydra lutris nereis) specializing on urchin prey, a population-level increase in urchin consumption, and an increase in sea otter survivorship. We further show that the spatial distribution of sea otter foraging efforts for urchin prey was not directly linked to high prey density but rather was predicted by the distribution of energetically profitable prey. Therefore, we infer that spatially explicit sea otter foraging enhances the resistance of remnant forests to overgrazing but does not directly contribute to the resilience (recovery) of forests. These results highlight the role of consumer and predator trait-mediated responses to resource mosaics that are common throughout natural ecosystems and enhance understanding of reciprocal feedbacks between top-down and bottom-up forcing on the regional stability of ecosystems.

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Adaptation of a quality improvement approach to implement eScreening in VHA healthcare settings: innovative use of the Lean Six Sigma Rapid Process Improvement Workshop

Implementation Science Communications ◽

10.1186/s43058-021-00132-x ◽

2021 ◽

Vol 2 (1) ◽

Author(s):

James O. E. Pittman ◽

Borsika Rabin ◽

Erin Almklov ◽

Niloofar Afari ◽

Elizabeth Floto ◽

...

Keyword(s):

Quality Improvement ◽

Survey Data ◽

Implementation Strategy ◽

Scale Up ◽

Implementation Process ◽

Interview Data ◽

Self Report ◽

Veterans Health ◽

Health Administration ◽

Health Technologies

Abstract Background The Veterans Health Administration (VHA) developed a comprehensive mobile screening technology (eScreening) that provides customized and automated self-report health screening via mobile tablet for veterans seen in VHA settings. There is agreement about the value of health technology, but limited knowledge of how best to broadly implement and scale up health technologies. Quality improvement (QI) methods may offer solutions to overcome barriers related to broad scale implementation of technology in health systems. We aimed to develop a process guide for eScreening implementation in VHA clinics to automate self-report screening of mental health symptoms and psychosocial challenges. Methods This was a two-phase, mixed methods implementation project building on an adapted quality improvement method. In phase one, we adapted and conducted an RPIW to develop a generalizable process guide for eScreening implementation (eScreening Playbook). In phase two, we integrated the eScreening Playbook and RPIW with additional strategies of training and facilitation to create a multicomponent implementation strategy (MCIS) for eScreening. We then piloted the MCIS in two VHA sites. Quantitative eScreening pre-implementation survey data and qualitative implementation process “mini interviews” were collected from individuals at each of the two sites who participated in the implementation process. Survey data were characterized using descriptive statistics, and interview data were independently coded using a rapid qualitative analytic approach. Results Pilot data showed overall satisfaction and usefulness of our MCIS approach and identified some challenges, solutions, and potential adaptations across sites. Both sites used the components of the MCIS, but site 2 elected not to include the RPIW. Survey data revealed positive responses related to eScreening from staff at both sites. Interview data exposed implementation challenges related to the technology, support, and education at both sites. Workflow and staffing resource challenges were only reported by site 2. Conclusions Our use of RPIW and other QI methods to both develop a playbook and an implementation strategy for eScreening has created a testable implementation process to employ automated, patient-facing assessment. The efficient collection and communication of patient information have the potential to greatly improve access to and quality of healthcare.

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Phenotypic plasticity of labile traits in the wild

Current Zoology ◽

10.1093/czoolo/59.4.485 ◽

2013 ◽

Vol 59 (4) ◽

pp. 485-505 ◽

Cited By ~ 37

Author(s):

Jon E. Brommer

Keyword(s):

Life History ◽

Phenotypic Plasticity ◽

Statistical Approach ◽

Scale Up ◽

Population Level ◽

Wild Populations ◽

Quantitative Genetic ◽

In The Wild ◽

The Individual ◽

Quantitative Genetic Parameters

Abstract Individual-based studies allow quantification of phenotypic plasticity in behavioural, life-history and other labile traits. The study of phenotypic plasticity in the wild can shed new light on the ultimate objectives (1) whether plasticity itself can evolve or is constrained by its genetic architecture, and (2) whether plasticity is associated to other traits, including fitness (selection). I describe the main statistical approach for how repeated records of individuals and a description of the environment (E) allow quantification of variation in plasticity across individuals (IxE) and genotypes (GxE) in wild populations. Based on a literature review of life-history and behavioural studies on plasticity in the wild, I discuss the present state of the two objectives listed above. Few studies have quantified GxE of labile traits in wild populations, and it is likely that power to detect statistically significant GxE is lacking. Apart from the issue of whether it is heritable, plasticity tends to correlate with average trait expression (not fully supported by the few genetic estimates available) and may thus be evolutionary constrained in this way. Individual-specific estimates of plasticity tend to be related to other traits of the individual (including fitness), but these analyses may be anti-conservative because they predominantly concern stats-on-stats. Despite the increased interest in plasticity in wild populations, the putative lack of power to detect GxE in such populations hinders achieving general insights. I discuss possible steps to invigorate the field by moving away from simply testing for presence of GxE to analyses that ‘scale up’ to population level processes and by the development of new behavioural theory to identify quantitative genetic parameters which can be estimated.

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Mapping the Production and Mobilization Functions of Collective Action

Socius Sociological Research for a Dynamic World ◽

10.1177/2378023120977722 ◽

2020 ◽

Vol 6 ◽

pp. 237802312097772

Author(s):

Blaine G. Robbins ◽

Ross L. Matsueda ◽

Steven J. Pfaff

Keyword(s):

Collective Action ◽

Undergraduate Students ◽

Social Life ◽

Common Good ◽

Latent Class ◽

Critical Mass ◽

Population Level ◽

Individual Heterogeneity ◽

Average Production ◽

Intentions To Participate

Collective action is a fundamental feature of human social life. If public goods are to materialize, social norms are to emerge, and social protests are to succeed, individuals must act jointly to achieve their collective ends. But how can collective action evolve when individuals receive the benefits of a common good without contributing to its production? According to theories of the critical mass, the success of collective action hinges on the type of production function required for the provision of a common good. Production functions and mobilization functions, however, have proven difficult to observe empirically in large groups. Here, the authors report results from a factorial survey experiment administered to a disproportionate stratified random sample of undergraduate students ( n = 880) that required respondents to rate their perceptions of and intentions to participate in a hypothetical student protest. Results show that the population-average production and mobilization functions are decelerating, but individual heterogeneity is observed around the population averages. Moreover, the experiment demonstrates that latent class trajectories of production and mobilization functions, rather than population-level consensus or complete individual heterogeneity, exist in the population. The authors show that the majority of latent class trajectories are decelerating, while a minority are linear or relatively constant. The authors find that subjective interest in the common good and attitudes toward protest predict membership in latent class trajectories. Importantly, the authors provide evidence for the predictive validity of their estimates. The authors discuss the implications of these results for theories of the critical mass and for promoting collective action.

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Material efficiency: from top-down steering to tailor-made governance

Philosophical Transactions of The Royal Society A Mathematical Physical and Engineering Sciences ◽

10.1098/rsta.2011.0564 ◽

2013 ◽

Vol 371 (1986) ◽

pp. 20110564 ◽

Cited By ~ 7

Author(s):

Jacqueline Cramer

Keyword(s):

Public Administration ◽

Implementation Process ◽

System Change ◽

First Century ◽

Transition Management ◽

Top Down ◽

Material Efficiency ◽

The Government ◽

Role Of The Government

Material efficiency is one of the major challenges facing our society in the twenty-first century. Research can help to understand how we can make the transition towards a material-efficient society. This study focuses on the role of the government in such transition processes. Use is made of literature in the field of public administration and innovation literature, particularly transition management. On the basis of three Dutch examples (plastics, e-waste and bio-energy), the complex system change towards a material-efficient society will be reflected upon. These case studies underline the need for a tailor-made governance approach instead of a top-down government approach to enhance material efficiency in practice. The role of the government is not restricted to formulating policies and then leaving it up to other actors to implement these policies. Instead, it is a continuous interplay between the different actors during the whole implementation process. As such, the government's role is to steer the development in the desired direction and orchestrate the process from beginning to end. In order to govern with a better compass, scientifically underpinned guiding principles and indicators are needed. This is a challenge for researchers both in public administration and in transition management.

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Evaluation of the Implementation Process of the Mobile Health Platform ‘WelTel’ in Six Sites in East Africa and Canada Using the Modified Consolidated Framework for Implementation Research (mCFIR)

10.21203/rs.3.rs-127906/v1 ◽

2020 ◽

Author(s):

Samia El Joueidi ◽

Kevin Bardosh ◽

Richard Musoke ◽

Binyam Tilahun ◽

Maryam Abo Moslim ◽

...

Keyword(s):

Implementation Research ◽

Digital Health ◽

Descriptive Analysis ◽

Scale Up ◽

Implementation Process ◽

Evidence Based ◽

Structured Interviews ◽

User Friendliness ◽

Domain 3 ◽

And Performance

Abstract Background: Health systems globally are investing in integrating secure messaging platforms for virtual care in clinical practice. Implementation science is essential for adoption, scale-up, spread and maintenance of complex evidence-based solutions in clinics with evolving priorities. In response, the mHealth Research Group modified the existing Consolidated Framework for Implementation Research (mCFIR) to evaluate implementation of virtual health tools in clinical settings. WelTel® is an evidence-based digital health platform widely deployed in various geographical and health contexts. Objectives: To identify the facilitators and barriers for implementing WelTel and to assess the application of the mCFIR tool in facilitating focus groups in different geographical and health settings. Methodology: Both qualitative and semi-quantitative approaches were employed. Six mCFIR sessions were held in three countries with 51 key stakeholders surveyed. The mCFIR tool consists of 5 Domains and 25 Constructs and was built and distributed through Qualtrics XM. “Performance ” and “Importance” scores were valued on a scale of 0 to 10 (Mean + SD). Descriptive analysis was conducted using R computing software. NVivo 12 Pro software was used to analyze mCFIR responses and to generate themes from the participants’ input. Semi-structured interviews were conducted with the focus group facilitators to understand their experience using the mCFIR tool. Results: We observed a parallel trend in the scores for Importance and Performance. Of the five Domains, Domain 4 (End-user Characteristics) and Domain 3 (Inner Settings) scored highest in Importance (8.9 + 0.5 and 8.6 + 0.6, respectively) and Performance (7.6 + 0.7 and 7.2 + 1.3, respectively) for all sites. Domain 2 (Outer Setting) scored the lowest in both Importance and Performance for all sites (7.6 + 0.4 and 5.6 + 1.8). Areas of strengths included timely diagnosis, immediate response, cost-effectiveness, user-friendliness, and simplicity. Areas for improvement included training, phone accessibility, health authority’s engagement, and literacy. Conclusion: The mCFIR tool allowed for a comprehensive understanding of the barriers and facilitators to the implementation, reach, and scale-up of digital health tools. Participants emphasized the importance of creating partnerships with external organizations and health authorities in order to achieve sustainability and scalability.Trial Registration: NCT02603536 – November 11, 2015NCT01549457 – March 9, 2012

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Staff expectations for the implementation of an electronic health record system: A qualitative study using Normalisation Process Theory

10.21203/rs.2.12337/v3 ◽

2019 ◽

Author(s):

Carolyn Mccrorie ◽

Jonathan Benn ◽

Owen Johnson ◽

Arabella Scantlebury

Keyword(s):

Collective Action ◽

Electronic Health Record ◽

Patient Care ◽

Health Professionals ◽

Implementation Strategy ◽

Process Theory ◽

Normalisation Process Theory ◽

Successful Implementation ◽

Health Record ◽

Quality And Safety

Abstract Background Global evidence suggests a range of benefits for introducing electronic health record (EHR) systems to improve patient care. However, implementing EHR within healthcare organisations is complex and in the United Kingdom (UK), uptake has been slow. More research is needed to explore factors influencing successful implementation. This study explored staff expectations for change and outcome following procurement of a commercial EHR system by a large academic acute NHS hospital in the UK. Methods Qualitative interviews were conducted with 14 members of hospital staff who represented a variety of user groups across different specialities within the hospital. The four components of Normalisation Process Theory (Coherence, Cognitive participation, Collective action and Reflexive monitoring) provided a theoretical framework to interpret and report study findings. Results Health professionals had a common understanding for the rationale for EHR implementation (Coherence). There was variation in willingness to engage with and invest time into EHR (Cognitive participation) at an individual, professional and organisational level. Collective action (whether staff feel able to use the EHR) was influenced by context and perceived user-involvement in EHR design and planning of the implementation strategy. When appraising EHR (Reflexive monitoring), staff anticipated short and long-term benefits. Staff perceived that quality and safety of patient care would be improved with EHR implementation, but that these benefits may not be immediate. Some staff perceived that use of the system may negatively impact patient care. The findings indicate that preparedness for EHR use could mitigate perceived threats to the quality and safety of care. Conclusions Health professionals looked forward to reaping the benefits from EHR use. Variations in level of engagement suggest early components of the implementation strategy were effective, and that more work was needed to involve users in preparing them for use. A clearer understanding as to how staff groups and services differentially interact with the EHR as they go about their daily work was required. The findings may inform other hospitals and healthcare systems on actions that can be taken prior to EHR implementation to reduce concerns for quality and safety of patient care and improve the chance of successful implementation.

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Use, awareness and willingness to self-test for HIV: An analysis of cross-sectional population-based surveys in Malawi and Zimbabwe

10.21203/rs.3.rs-15570/v2 ◽

2020 ◽

Author(s):

Cheryl Case Johnson ◽

Melissa Neuman ◽

Peter MacPherson ◽

Augustine Choko ◽

Caitlin Quinn ◽

...

Keyword(s):

Sexual Risk ◽

Large Scale ◽

Scale Up ◽

Population Level ◽

Sociodemographic Factors ◽

Population Based ◽

African Countries ◽

Cross Sectional ◽

Self Test ◽

Result Analysis

Abstract Background Many southern African countries are nearing the global goal to diagnose 90% of people with HIV by 2020. In 2016, 84% and 86% of people with HIV knew their status in Malawi and Zimbabwe respectively. Despite this progress, gaps remain, particularly among men (≥25 years). We investigated awareness, use and willingness to HIV self-test (HIVST) prior to large scale implementation and explored sociodemographic associations. Methods We pooled responses from two of the first cross-sectional Demographic Health Surveys to include HIVST questions: Malawi and Zimbabwe in 2015-16. Sociodemographic factors and sexual risk behaviours associated with previously testing for HIV, and awareness, past use and future willingness to self-test were investigated using univariable and multivariable logistic regression, adjusting for the sample design and limiting analysis to participants with completed questionnaire and a valid HIV result. Analysis of willingness to self-test was restricted to Zimbabwean men, as Malawians and women were not asked this question. Results Of 31 385 individuals, the proportion never-tested was higher for men (31.2%) than women (16.5%), p<0.001. For men, having ever tested increased with age. Past use and awareness of HIVST was very low, 1.2% and 12.6% respectively. Awareness was lower among women than men (9.1% vs 15.3%, adjusted odds ratio (aOR)=1.55; 95% confidence interval [CI]: 1.37-1.75), and at younger ages, and lower education and literacy levels. Willingness to self-test among Zimbabwean men was high (84.5%), with having previously tested for HIV, high sexual risk, and being ≥25 years associated with greater willingness. Wealthier men had greater awareness of HIVST than poorer men (p<0.001). Men at higher HIV-related sexual risk, compared to men at lower HIV-related sexual risk, had the greatest willingness to self-test (aOR=3.74; 95%CI: 1.39-10.03, p<0.009).Conclusions In 2015-16 many Malawian and Zimbabwean men had never tested for HIV. Despite low awareness and minimal HIVST experience at that time, willingness to self-test was high among Zimbabwean men, especially in older men with moderate to high HIV-related sexual risk. These data provide a valuable baseline against which to investigate population-level uptake of HIVST as programmes scale-up. Programmes introducing, or planning to introduce HIVST, should consider including questions in population-based surveys.

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