Improving personalised care, through the development of a service evaluation tool to assess, understand and monitor delivery.

Systematically implementing personalised care has far reaching benefits to individuals, communities and health and social care systems. If done well, personalised care can result in better health outcomes and experiences, more efficient use of health services and reduced health inequalities. Despite these known benefits, implementation of personalised care has been slow. Evaluation is an important step towards achieving the ambition of universally delivered personalised care. There are currently few comprehensive assessments or tools that are designed to understand the implementation of personalised care at a service or system level, or the cultural, practical and behavioural factors influencing this. The aim of this paper is to describe the development and testing of a system-wide evaluation tool. The tool offers a process through which healthcare systems can better understand the current delivery of personalised care and the factors influencing this. With a focus on implementation, the development of the tool was informed by the Consolidated Framework for Implementation Research, and its content is structured using behaviour change theory (COM-B Theory of Behaviour Change Model). The tool consists of four mirrored surveys, which were developed using an iterative exploratory design. This included a series of testing cycles, in which its structure and content were continually refined. To date, it has been used by 24 clinical services, involving 397 service users, 313 front-line practitioners, 73 service managers and 40 commissioners. These services have used the evaluation process to initiate quality improvement, targeted at one of the more aspects of personalised care. The use of the COM-B model increases the likelihood of those improvements being sustained, through identification of the core factors that enable or limit personalised care behaviours among healthcare staff. We have shown this process to be applicable in a wide range of settings, thus it potentially has broad applicability as a tool for cultural change and quality improvement. The next stage of this work will focus on implementation and evaluation, to fully understand if and how the tool can be used to drive improvements in personalised care delivery.

A 50-step walking test for analysis of recovery after decompressive surgery for thoracolumbar disc herniation in dogs.

BACKGROUND: Despite its importance, there is no agreed definition of recovery of ambulation in dogs with spinal cord injury. OBJECTIVES: To validate a new walking test in dogs recovering from thoracolumbar spinal cord injury. ANIMALS: Two hundred twenty-four dogs weighing <20 kg: 120 normally ambulatory dogs, plus 104 dogs undergoing decompressive surgery for acute thoracolumbar intervertebral disc herniation. METHODS: Prospective cohort studies. The distance each freely-ambulatory dog walked during 50 step cycles was regressed on ulna length. For each postsurgical dog, we recorded when the calculated 50-step distance was completed without falling, or their inability to complete this distance by 4 months or more after surgery. Bayesian analysis compared outcomes for presurgical neurologic categories; association of recovery with several preoperative variables was explored using logistic and time-to-event regression. RESULTS: For control dogs, 50-step distance (m) = 1.384 × ulnar length (cm) + 2.773. In postsurgical dogs, the 50-step test provided decisive evidence that deep pain-negative dogs were less likely to recover ambulation than dogs with intact pain perception (12/29 recovered vs 71/75; Bayes factor [BF] = 5.9 × 106 ) and, if they did recover, it took much longer (median 91 days vs median 14 days; BF = 1.5 × 103 ). Exploratory analysis suggested that presurgical neurologic status (subhazard ratio [SHR] = 0.022; P < .001) and duration of presurgical anesthesia (SHR = 0.740; P = .04) were associated with rapidity of recovery. CONCLUSIONS AND CLINICAL IMPORTANCE: This straightforward 50-step walking test provides robust data on ambulatory recovery well-suited to large scale pragmatic trials on treatment of thoracolumbar spinal cord injury in dogs.

Understanding help-seeking decisions in people with heart failure: a qualitative systematic review.

OBJECTIVE: To understand the process of help-seeking among heart failure patients from the perspectives of patients, caregivers and health professionals. DESIGN: Systematic review using qualitative meta-synthesis. METHODS: A systematic search (20th May 2011) was conducted to identify studies published in English as full papers ≥1995 reporting primary qualitative data with extractable heart failure-specific data or themes related to help-seeking in patients, caregivers or health professionals. Databases searched were: CINAHL, Medline, PsycInfo, Social Science Citation Index, Embase, Social policy/Practice, SocIndex, Ageline, Health Source Nursing, Scopus; additionally, we consulted with experts and manually searched references. RESULTS: 58 studies (990 patients; 274 female, 527 male, 189 sex not described; 229 caregivers, 79 health professionals) were included. Heart failure help-seeking was embedded in daily experiences of heart failure but ongoing symptoms were confusing, ambiguous and disruptive; little support was available from professionals to interpret the presence and significance of fluctuations in symptoms for help-seeking. Other significant barriers to help-seeking were: avoidance-based coping, fear of hospitals and misplaced reluctance to be burdensome. Help-seeking was facilitated by good involvement and frank communication between patients, caregivers and health professionals and the presence of a sense of elevated personal risk. CONCLUSION: Health services should harness primary care providers and support patients and caregivers to prioritize development of objective symptom monitoring skills, recognize and personally assimilate the elevated risks of heart failure and help-seeking delays and discourage avoidance-based coping and unwarranted concerns that downplay the significance of heart failure and urgency to address symptoms.

Healthy diet in Canadians of low socioeconomic status with coronary heart disease: Not just a matter of knowledge and choice.

People of low socioeconomic status (SES) are prone to premature coronary heart disease (CHD) and tend to have more risk factors and worse health and mortality. Yet, little is understood about the specific challenges faced by people of low SES with CHD in changing behavior around the consumption of dietary risk factors, such as salt, fat, and cholesterol, and adding heart-healthy foods, such as fruit, vegetables, lean meat, and fish. The aim of this study was to understand factors promoting and reducing willingness and capacity to consume a healthy diet in people of low SES with CHD. Qualitative research via semistructured interviewing and a critical realist theoretic framework was used, along with a questionnaire to provide context for the interviews. Food consumption and diet were not principally related to knowledge but were constrained by an ever-present scarcity of resources and the need to prioritize other daily living expenses perceived as being more important than diet. Having use of a vehicle also promoted access to dietary support from physicians and cardiac rehabilitation.

The potential of nursing to reduce the burden of heart failure in rural Canada: what strategies should nurses prioritize?

Chronic heart failure (CHF) is an increasingly common condition in high-income countries that has a large and negative impact on life quality and expectancy, and is associated with high financial costs. In Canada, CHF has an especially large impact on rural settings because of the higher proportion of older adults (aged >65 years) in these settings, and because care and outcomes tend to be more adverse in rural parts of the country compared to urban settings. Much can be done to reduce these burdens in terms of pharmacological, behavioural and health service strategies. However, rural patients tend to have worse care and outcomes than urban patients. Realizing the benefits of these strategies in Canada's rural settings requires consideration of underlying reasons for poor care and outcomes. We propose the main reasons for adverse outcomes are related to the nature of CHF and the combined influence of demographics, health services and the rural context. Nurses remain under-used in CHF management in Canada and can play a vital and influential role in reducing the burden of CHF in rural settings. To increase and improve nurses' roles, we recommend that nurses should support the development and adaptation of disease management programs in rural settings and promote the centrality of nursing in these programs. Nurses in or working with rural settings should seek to support and use tele-health technologies effectively and provide better support to lay caregivers. It will also be vital to increase the nursing capacity regarding specialist roles for CHF management.

Defining and operationalizing capacity for heart health promotion in Nova Scotia, Canada.

This paper presents an operational definition of capacity building for heart health promotion, instruments developed to measure heart health capacity, and baseline results of capacity for 20 organizations. Qualitative and quantitative research methods were used to collect data. Three instruments were developed to measure organizational capacity for heart health promotion: a survey of community agencies involved in heart health, a questionnaire of organizational practices supportive of heart health promotion, and an interview guide that focused on factors influencing heart health promotion. These instruments proved effective and informed the development of a comprehensive framework for heart health promotion.

Issues in measuring health promotion capacity in Canada: a multi-province perspective.

Significant international progress has been made researching and addressing the economic and social burden of cardiovascular disease, advanced particularly by international conferences and subsequent declarations, and the Canadian Heart Health Initiative (CHHI). The implementation focus of the CHHI on building capacity for heart health promotion is paralleled by efforts to measure capacity. Through the collective experience of Heart Health Programs in Nova Scotia, Saskatchewan, Alberta and British Columbia, critical issues in measuring health promotion capacity are identified and strategies for addressing them are presented. The provincial contexts for the programs vary, as do the conceptualizations of capacity and intervention strategies to build capacity. Yet, despite such differences across provinces, shared issues influencing measuring capacity number many. These include: multiple understandings of terms; evolving understanding of capacity; invisibility of capacity building; detecting change within a dynamic system; staff turnover; time course required for change; attribution for change in capacity; understanding a process through 'snap-shot' measurements; lack of existing 'gold standard' measurement tools; validity and credibility of instruments; evolving nature of measurement tools; gathering perspectives from multiple levels within organizations; dealing with conflicting perspectives; and managing and disseminating sensitive data. A number of strategies have been devised or adopted to address measurement issues, ranging from adopting participatory processes to the development of monitoring systems. Understanding and addressing issues in measuring capacity deserve attention as they may be potent influences in the dynamic interplay between research and intervention in the process of capacity building in the context of health promotion generally, and/or heart health specifically.

Facilitators and challenges to organizational capacity building in heart health promotion.

The authors describe the facilitators and challenges to a multi-sectoral initiative aiming at building organizational capacity for heart health promotion in Nova Scotia, Canada. The research process was guided by participatory action research. The study included 21 organizations from diverse sectors. Participant selection for the data collection was purposive. The authors collected data through organizational reflection logs and one-to-one semistructured interviews and used grounded theory techniques for the data analyses. Factors influencing organizational capacity for heart health promotion varied, depending on the project stage. Nonetheless, leadership, organizational readiness, congruence, research activities, technical supports, and partnerships were essential to capacity-building efforts. Approaches to organizational capacity building should be multi-leveled, because organizations are influenced by multiple social systems that are not all equally supportive of capacity.

Building capacity for heart health promotion: results of a 5-year experience in Nova Scotia, Canada.

PURPOSE: To present the outcomes of a capacity-building initiative for heart health promotion. DESIGN: Follow-up study combining quantitative and qualitative methods. SETTING: The Western Health Region of Nova Scotia, Canada. SUBJECTS: Twenty organizations, including provincial and municipal agencies and community groups engaged in health, education, and recreation activities. INTERVENTION: Two strategies were used for this study: partnership development and organizational development. Partnership development included the creation of multilevel partnerships in diverse sectors. Organizational development included the provision of technical support, action research, community activation, and organizational consultation. MEASURES: Quantitative data included number and type of partnerships, learning opportunities, community activation initiatives, and organizational changes. Qualitative data included information on the effectiveness of partnerships, organizational consultation, and organizational changes. RESULTS: Results included the development of 204 intersectoral partnerships, creation of a health promotion clearinghouse, 47 workshops attended by approximately 1400 participants, diverse research products, implementation of 18 community heart health promotion initiatives, and increased organizational capacity for heart health promotion via varied organizational changes, including policy changes, fund reallocations, and enhanced knowledge and practices. CONCLUSIONS: Partnership and organizational development were effective mechanisms for building capacity in heart health promotion. This intervention may have implications for large-scale, community-based, chronic-disease prevention projects.