ABSTRACT
BACKGROUND: Evidence-based interventions are more likely to be adopted if practitioners collaborate with researchers to develop an implementation strategy. This paper describes the steps to plan and execute a strategy, including the development of structure and supports needed for implementing proven health promotion interventions in primary and community care. RESULTS: Between 10 and 13 discussion and consensus sessions were performed in four highly-motivated primary health care centers involving 80% of the primary care staff and 21 community-based organizations. All four centers chose to address physical activity, diet, and smoking. They selected the 5 A's evidence-based clinical intervention to be adapted to the context of the health centers. The planned implementation strategy worked at multiple levels: bottom-up primary care organizational change, top-down support from managers, community involvement, and the development of innovative e-health information and communication tools. Shared decision making and practice facilitation were perceived as the most positive aspects of the collaborative modeling process, which took more time than expected, especially the development of the new e-health tools integrated into electronic health records. CONCLUSIONS: Collaborative modeling of an implementation strategy for the integration of health promotion in primary and community care was feasible in motivated centers. However, it was difficult, being hindered by the heavy workload in primary care and generating uncertainty inherent to a bottom-up decision making processes. Lessons from this experience could be useful in diverse settings and for other clinical interventions. Two companion papers report the evaluation of its feasibility and assess quantitatively and qualitatively the implementation process.
Subject(s)
Community Health Services/organization & administration , Health Promotion/organization & administration , Models, Organizational , Primary Health Care/organization & administration , Evidence-Based PracticeABSTRACT
BACKGROUND: Process evaluation is recommended to improve the understanding of underlying mechanisms related to clinicians, patients, context and intervention delivery that may impact on trial or program results, feasibility and transferability to practice. The aim of this study was to assess the feasibility of the Prescribe Healthy Life (PVS from the Spanish "Prescribe Vida Saludable") implementation strategy for enhancing the adoption and implementation of an evidence-based health promotion intervention in primary health care. METHODS: A descriptive study of 2-year implementation indicators for the PVS clinical intervention was conducted in four primary health care centers. A multifaceted collaborative modeling implementation strategy was developed to enhance the integration of a clinical intervention to promote healthy lifestyles into clinical practice. Process indicators were assessed for intervention reach, adoption, implementation, sustainability and their variability at center, practice, and patient levels. RESULTS: Mean rates of adoption by means of active collaboration among the three main professional categories (family physicians, nurses and administrative personnel) were 75% in all centers. Just over half of the patients that attended (n = 11650; 51.9%) were reached in terms of having their lifestyle habits assessed, while more than a third (33.7%; n = 7433) and almost 10% (n = 2175) received advice or a printed prescription for at least one lifestyle change, respectively. Only 3.7% of the target population received a repeat prescription. These process indicators significantly (p < 0.001) varied by center, lifestyle habit and patient characteristics. Sustainability of intervention components changed thorough the implementation period within centers. CONCLUSIONS: The implementation strategy used showed moderate-to-good performance on process indicators related to adoption, reach, and implementation of the evidence-based healthy lifestyle promotion intervention in the context of routine primary care. Sources of heterogeneity and instability in these indicators may improve our understanding of factors required to attain adequate program adoption and implementation through improved implementation strategies.
Subject(s)
Guidelines as Topic , Health Promotion/standards , Health Services Needs and Demand/standards , Primary Health Care/standards , Adolescent , Adult , Aged , Child , Delivery of Health Care, Integrated , Feasibility Studies , Female , Humans , Life Style , Male , Middle Aged , Patient Education as Topic , Spain , Young AdultABSTRACT
Introduccion Un estudio epidemiologico demostro en 1992 la existencia de deficiencia de yodo y bocio endemico en los escolares de la Comunidad Autonoma del Pais Vasco (CAPV).Objetivos1) Conocer el porcentaje de las viviendas de escolares en las que se consume sal yodada (SY); 2) estudiar el estado de nutricion del yodo en la poblacion escolar y comparar los datos obtenidos con los disponibles de estudios epidemiologicos anteriores. Metodos Estudio descriptivo transversal en 720 escolares seleccionados mediante muestreo aleatorio. Las determinaciones de concentracion urinaria de yodo (CUY) se realizaron mediante cromatografia liquida de alta resolucion (HPLC) (..) (AU)
Background: An epidemiologic survey showed in 1992 iodine deficiency and endemic goiter in schoolchildren from the Basque Country. Objectives: 1) To determine the percentage of homes of schoolchildren where iodized salt (IS)is used; 2) to assess iodine nutrition status in schoolchildren and to compare the data collected to those available from previous epidemiological studies. Design and Methods: A cross-sectional study in 720 randomly selected schoolchildren. Urinary iodine concentration (UIC) was measured using high-performance liquid chromatography(HPLC)with electrochemical detection. Results: IS was used at 53.0% of the homes (95% confidence interval [CI], 49.2-56.7%). Median UIC has increased by 226%, from 65 g/L in 1992 to 147 g/L (percentile [P], P25, 99 g/L;P75, 233 g/L) today. Both schoolchildren consuming IS and those using unfortified salt at their homes had UICs corresponding to adequate iodine intakes (165 and 132 g/L respectively). UICs experienced great seasonal fluctuations, being 55% higher during the November-February period than in June-September period (191 g/L vs 123 g/L; p < 0.001)Conclusions: Schoolchildren from the Basque Country have normalized their iodine nutrition status. The strong seasonal pattern of UICs suggests that consumption of milk and iodine-rich dairy products coming from cows feed iodized fodder is one of the most significant factors involved in the increase in iodine intake since 1992 (AU)
Subject(s)
Humans , Male , Female , Child , Goiter, Endemic/epidemiology , Iodine Deficiency , Iodine/urine , Nutritional Status , Dietary Supplements , Feeding BehaviorABSTRACT
BACKGROUND: An epidemiologic survey showed in 1992 iodine deficiency and endemic goiter in schoolchildren from the Basque Country. OBJECTIVES: (1) To determine the percentage of homes of schoolchildren where iodized salt (IS) is used; (2) to assess iodine nutrition status in schoolchildren and to compare the data collected to those available from previous epidemiological studies. DESIGN AND METHODS: A cross-sectional study in 720 randomly selected schoolchildren. Urinary iodine concentration (UIC) was measured using high-performance liquid chromatography(HPLC) with electrochemical detection. RESULTS: IS was used at 53.0% of the homes (95% confidence interval [CI], 49.2-56.7%). Median UIC has increased by 226%, from 65 µg/L in 1992 to 147 µg/L (percentile [P], P(25), 99 µg/L; P(75), 233 µg/L) today. Both schoolchildren consuming IS and those using unfortified salt at their homes had UICs corresponding to adequate iodine intakes (165 and 132 µg/L respectively). UICs experienced great seasonal fluctuations, being 55% higher during the November-February period than in June-September period (191 µg/L vs 123 µg/L; p<0.001) CONCLUSIONS: Schoolchildren from the Basque Country have normalized their iodine nutrition status. The strong seasonal pattern of UICs suggests that consumption of milk and iodine-rich dairy products coming from cows feed iodized fodder is one of the most significant factors involved in the increase in iodine intake since 1992.
