Team- and individual-level motivation in complex primary care system change: A realist evaluation of the Salud Mesoamerica Initiative in El Salvador

Background: We study the role of individual and team-level motivation in explaining large-scale primary care performance improvements in El Salvador, one of the top-performing countries in the Salud Mesoamerica Initiative. Methods: Case study with outlier sampling of high-performing, community health teams in El Salvador. Design includes scoping review of literature, document review, non-participant observation, and qualitative analysis of in-depth interviews following a realist case study protocol. Results: The interplay between program interventions and organizational, community and policy contexts trigger multi-level motivational mechanisms that operate in complex, dynamic fashion. Interventions like performance measurement and team-based, in-kind incentives foster motivation among individual members of high-performing teams, which may be moderated by working conditions, supervision practices, and by the stress exerted by the interventions themselves. Individuals report a strong sense of public service motivation and an overarching sense of commitment to the community they serve. At the interpersonal level, the linkage between performance measurement and in-kind incentives triggers a sense of collective efficacy and increases team motivation and improvement behaviors. The convening of learning forums and performance dialogue increases the stakes for high-performing teams, helps them make sense of performance data, and leads to performance information utilization for healthcare improvements. Closeness to communities creates strong emotional linkages among team members that further increases collective efficacy and social identity. Such changes in individuals, team, and organizational behaviors can contribute to improved delivery of primary care services and explain the gains in performance demonstrated by the program. Conclusions: This case suggests that primary care systems that rely on multi-disciplinary teams for the provision of care can benefit from performance measurement and management interventions that leverage individual and team-level motivation. Realist evaluation can help prioritize policy-relevant research and enhance the design and evaluation of large-scale performance reforms in primary care systems in low- and middle-income settings.

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Characterizing performance improvement in primary care systems in Mesoamerica: A realist evaluation protocol

Gates Open Research ◽

10.12688/gatesopenres.12782.1 ◽

2018 ◽

Vol 2 ◽

pp. 1 ◽

Cited By ~ 5

Author(s):

Wolfgang Munar ◽

Syed S. Wahid ◽

Leslie Curry

Keyword(s):

Primary Care ◽

El Salvador ◽

Large Scale ◽

Grey Literature ◽

Realist Evaluation ◽

Program Theory ◽

Necessary Condition ◽

Observation Data ◽

Care Systems ◽

Preliminary Program

Background. Improving performance of primary care systems in low- and middle-income countries (LMICs) may be a necessary condition for achievement of universal health coverage in the age of Sustainable Development Goals. The Salud Mesoamerica Initiative (SMI), a large-scale, multi-country program that uses supply-side financial incentives directed at the central-level of governments, and continuous, external evaluation of public, health sector performance to induce improvements in primary care performance in eight LMICs. This study protocol seeks to explain whether and how these interventions generate program effects in El Salvador and Honduras. Methods. This study presents the protocol for a study that uses a realist evaluation approach to develop a preliminary program theory that hypothesizes the interactions between context, interventions and the mechanisms that trigger outcomes. The program theory was completed through a scoping review of relevant empirical, peer-reviewed and grey literature; a sense-making workshop with program stakeholders; and content analysis of key SMI documents. The study will use a multiple case-study design with embedded units with contrasting cases. We define as a case the two primary care systems of Honduras and El Salvador, each with different context characteristics. Data will be collected through in-depth interviews with program actors and stakeholders, documentary review, and non-participatory observation. Data analysis will use inductive and deductive approaches to identify causal patterns organized as ‘context, mechanism, outcome’ configurations. The findings will be triangulated with existing secondary, qualitative and quantitative data sources, and contrasted against relevant theoretical literature. The study will end with a refined program theory. Findings will be published following the guidelines generated by the Realist and Meta-narrative Evidence Syntheses study (RAMESES II). This study will be performed contemporaneously with SMI’s mid-term stage of implementation. Of the methods described, the preliminary program theory has been completed. Data collection, analysis and synthesis remain to be completed.

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Characterizing performance improvement in primary care systems in Mesoamerica: A realist evaluation protocol

Gates Open Research ◽

10.12688/gatesopenres.12782.2 ◽

2018 ◽

Vol 2 ◽

pp. 1 ◽

Cited By ~ 1

Author(s):

Wolfgang Munar ◽

Syed S. Wahid ◽

Leslie Curry

Keyword(s):

Primary Care ◽

Performance Measurement ◽

Study Design ◽

Care Delivery ◽

Realist Evaluation ◽

Case Study Design ◽

Evaluation Protocol ◽

Primary Care Delivery ◽

Salud Mesoamérica Initiative

Background. Evaluations of performance measurement and management interventions in public, primary care delivery systems of low- and middle-income countries are scarce. In such contexts, few studies to date have focused on characterizing how, why and under what contextual conditions do such complex, multifaceted arrangements lead to intended and unintended consequences for the healthcare workforce, the healthcare organizations involved, and the communities that are served. Methods. Case-study design with purposeful outlier sampling of high-performing primary care delivery systems in El Salvador and Honduras, as part of the Salud Mesoamerica Initiative. Case study design is suitable for characterizing individual, interpersonal and collective mechanisms of change in complex adaptive systems. The protocol design includes literature review, document review, non-participant observation, and qualitative analysis of in-depth interviews. Data analysis will use inductive and deductive approaches to identify causal patterns organized as ‘context-mechanism-outcome’ configurations. Findings will be triangulated with existing secondary data sources collected including country-specific performance measurement data, impact, and process evaluations conducted by the Salud Mesoamerica Initiative. Discussion. This realist evaluation protocol aims to characterize how, why and under what conditions do performance measurement and management arrangements contribute to the improvement of primary care system performance in two low-income countries.

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A scaling-up strategy supporting the expansion of integrated care: a study protocol

Journal of Integrated Care ◽

10.1108/jica-04-2018-0029 ◽

2019 ◽

Vol 27 (3) ◽

pp. 215-231 ◽

Cited By ~ 4

Author(s):

Liset Grooten ◽

Cristina-Adriana Alexandru ◽

Tamara Alhambra-Borrás ◽

Stuart Anderson ◽

Francesca Avolio ◽

...

Keyword(s):

Integrated Care ◽

Large Scale ◽

Scale Up ◽

Implementation Fidelity ◽

Scaling Up ◽

Realist Evaluation ◽

Content Type ◽

Project Outcomes ◽

Care Systems ◽

Funded Project

Purpose To ensure that more people will benefit from integrated care initiatives, scaling-up of successful initiatives is the way forward. However, new challenges present themselves as knowledge on how to achieve successful large-scale implementation is scarce. The EU-funded project SCIROCCO uses a step-based scaling-up strategy to explore what to scale-up, and how to scale-up integrated care initiatives by matching the complementary strengths and weaknesses of five European regions involved in integrated care. The purpose of this paper is to describe a multi-method evaluation protocol designed to understand what factors influence the implementation of the SCIROCCO strategy to support the scaling-up of integrated care. Design/methodology/approach The first part of the protocol focuses on the assessment of the implementation fidelity of the SCIROCCO step-based strategy. The objective is to gain insight in whether the step-based strategy is implemented as it was designed to explore what works and does not work when implementing the scaling-up strategy. The second part concerns a realist evaluation to examine what it is about the SCIROCCO’s strategy that works for whom, why, how and in which circumstances when scaling-up integrated care. Findings The intended study will provide valuable information on the implementation of the scaling-up strategy which will help to explain for what specific reasons the implementation succeeds and will facilitate further improvement of project outcomes. Originality/value The expected insights could be useful to guide the development, implementation and evaluation of future scaling-up strategies to advance the change towards more sustainable health and care systems.

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Quantification of the resilience of primary care networks by stress testing the health care system

Proceedings of the National Academy of Sciences ◽

10.1073/pnas.1904826116 ◽

2019 ◽

Vol 116 (48) ◽

pp. 23930-23935 ◽

Cited By ~ 3

Author(s):

Donald Ruggiero Lo Sardo ◽

Stefan Thurner ◽

Johannes Sorger ◽

Georg Duftschmid ◽

Gottfried Endel ◽

...

Keyword(s):

Primary Care ◽

Health Care ◽

Health Care System ◽

Large Scale ◽

Health Care Systems ◽

Primary Care Providers ◽

Care Providers ◽

Physician Density ◽

Care Systems ◽

Care System

There are practically no quantitative tools for understanding how much stress a health care system can absorb before it loses its ability to provide care. We propose to measure the resilience of health care systems with respect to changes in the density of primary care providers. We develop a computational model on a 1-to-1 scale for a countrywide primary care sector based on patient-sharing networks. Nodes represent all primary care providers in a country; links indicate patient flows between them. The removal of providers could cause a cascade of patient displacements, as patients have to find alternative providers. The model is calibrated with nationwide data from Austria that includes almost all primary care contacts over 2 y. We assign 2 properties to every provider: the “CareRank” measures the average number of displacements caused by a provider’s removal (systemic risk) as well as the fraction of patients a provider can absorb when others default (systemic benefit). Below a critical number of providers, large-scale cascades of patient displacements occur, and no more providers can be found in a given region. We quantify regional resilience as the maximum fraction of providers that can be removed before cascading events prevent coverage for all patients within a district. We find considerable regional heterogeneity in the critical transition point from resilient to nonresilient behavior. We demonstrate that health care resilience cannot be quantified by physician density alone but must take into account how networked systems respond and restructure in response to shocks. The approach can identify systemically relevant providers.

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Using linked data to evaluate enhanced primary care policies for chronic diseases using stroke as a case study

International Journal for Population Data Science ◽

10.23889/ijpds.v3i4.882 ◽

2018 ◽

Vol 3 (4) ◽

Author(s):

Nadine Andrew ◽

Joosup Kim ◽

Dominique Cadilhac ◽

Vijaya Sundararajan ◽

Amanda Thrift

Keyword(s):

Primary Care ◽

Chronic Diseases ◽

Large Scale ◽

Claims Data ◽

Data Linkage ◽

Australian Government ◽

Healthcare Provision ◽

Clinical Registry ◽

Care Policies

IntroductionThe global burden of chronic diseases is large and increasing. In response, governments are investing substantial funds in innovative models of primary care, characterised by multidisciplinary care and self-management support for people with chronic conditions. Currently, large scale population-based evaluations of the effectiveness of these policies are lacking. Objectives and ApproachWe aim to evaluate the effectiveness and cost-effectiveness of enhanced primary care policies for chronic diseases funded through Medicare Australia using stroke as a case study. Person-level linkages from the following will be used: Australian Stroke Clinical Registry (AuSCR) to define the cohort; Australian government-held Medicare claims data to identify receipt or not of enhanced primary care items; state government-held hospital data to define outcomes; and Australian government-held pharmaceutical and aged care claims data to define covariates. In Australia, unique identifiers are not used therefore, personal-identifiers will be submitted to data linkage units and content records merged using a Project-ID. ResultsIdentifiers from ~25,000 AuSCR registrants (2012-2016), from Victoria and Queensland will be submitted for linkage. The index event is the first event recorded in the AuSCR. Data applications to state health departments and the Australian Institute of Health and Welfare have commenced. To obtain detailed information on patient’s primary care experience 1,500 randomly selected AuSCR registrants are being sent surveys. Multivariable analyses using a competing risks Poisson regression model for multiple events and adjusted by a propensity score, will be used to test for differences in the rates of hospital presentations. We have power (a >0.05) to detect a ≥6% difference in the number of hospital contacts between those who did and did not receive enhanced primary care. An economic evaluation will also be undertaken. Conclusion/ImplicationsThis is the largest stroke data linkage study in Australia. The breadth of data will provide a comprehensive evaluation of the effectiveness of enhanced primary care policies within “real world” healthcare provision. Methods will advance the use of population data linkage in healthcare evaluation where unique identifiers are unavailable.

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The Unexpected Key to High Performing Primary Care Systems

Academy of Management Proceedings ◽

10.5465/ambpp.2018.17616abstract ◽

2018 ◽

Vol 2018 (1) ◽

pp. 17616

Author(s):

Erin Sullivan ◽

Sophia Arabadjis ◽

Jessica Alpert ◽

Andrew Ellner

Keyword(s):

Primary Care ◽

High Performing ◽

Care Systems

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The Genesis and Internal Dynamics of El Salvador's People's Revolutionary Army, 1970–1976

Behavioral and Brain Sciences ◽

10.1017/s0140525x13009850 ◽

2014 ◽

Vol 38 (01) ◽

pp. 102-129

Author(s):

ALBERTO MARTÍN ÁLVAREZ ◽

EUDALD CORTINA ORERO

Keyword(s):

Latin America ◽

El Salvador ◽

Early Years ◽

Left Wing ◽

Internal Dynamics ◽

Internal Coherence ◽

The 1960S

AbstractUsing interviews with former militants and previously unpublished documents, this article traces the genesis and internal dynamics of the Ejército Revolucionario del Pueblo (People's Revolutionary Army, ERP) in El Salvador during the early years of its existence (1970–6). This period was marked by the inability of the ERP to maintain internal coherence or any consensus on revolutionary strategy, which led to a series of splits and internal fights over control of the organisation. The evidence marshalled in this case study sheds new light on the origins of the armed Salvadorean Left and thus contributes to a wider understanding of the processes of formation and internal dynamics of armed left-wing groups that emerged from the 1960s onwards in Latin America.

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A Family With Autosomal-Dominant Progressive Sensorineural Hearing Loss

American Journal of Audiology ◽

10.1044/1059-0889.0501.23 ◽

1996 ◽

Vol 5 (1) ◽

pp. 23-32 ◽

Cited By ~ 3

Author(s):

Chris Halpin ◽

Barbara Herrmann ◽

Margaret Whearty

Keyword(s):

Speech Production ◽

Hearing Aids ◽

Role Models ◽

Speech Intelligibility ◽

Large Scale ◽

Speech Language Pathology ◽

The Family ◽

Patient Will ◽

Language Pathology

The family described in this article provides an unusual opportunity to relate findings from genetic, histological, electrophysiological, psychophysical, and rehabilitative investigation. Although the total number evaluated is large (49), the known, living affected population is smaller (14), and these are spread from age 20 to age 59. As a result, the findings described above are those of a large-scale case study. Clearly, more data will be available through longitudinal study of the individuals documented in the course of this investigation but, given the slow nature of the progression in this disease, such studies will be undertaken after an interval of several years. The general picture presented to the audiologist who must rehabilitate these cases is that of a progressive cochlear degeneration that affects only thresholds at first, and then rapidly diminishes speech intelligibility. The expected result is that, after normal language development, the patient may accept hearing aids well, encouraged by the support of the family. Performance and satisfaction with the hearing aids is good, until the onset of the speech intelligibility loss, at which time the patient will encounter serious difficulties and may reject hearing aids as unhelpful. As the histological and electrophysiological results indicate, however, the eighth nerve remains viable, especially in the younger affected members, and success with cochlear implantation may be expected. Audiologic counseling efforts are aided by the presence of role models and support from the other affected members of the family. Speech-language pathology services were not considered important by the members of this family since their speech production developed normally and has remained very good. Self-correction of speech was supported by hearing aids and cochlear implants (Case 5’s speech production was documented in Perkell, Lane, Svirsky, & Webster, 1992). These patients received genetic counseling and, due to the high penetrance of the disease, exhibited serious concerns regarding future generations and the hope of a cure.

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