From news to everyday use- the difficult art of implementation

karin.guldbrandsson@fhi.se

The fight against scurvy

We need evidence based methods for

implementing evidence based methods

Another example

Treatment of women who are in risk for premature child birth. The aim is to reduce difficulties in breathing for the newborn child.

1969 – the first studies on animals

1972 – the first studies on human beings

1979 – five RCTs, clear recommendations

1991 – used by 5-10% of all relevant clinics in the UK

1997 – used by 95% of all relevant clinics in the UK (Hanney 2005)

A litterature review

Method

• Two comprehensive litterature reviews (Fixsen et al

2005, Greenhalgh et al 2005)

Result

• A report from the Swedish National

Institute of Public Health aimed for

public health practicioners

Implementation - definitions

”A specified set of activities designed to put into practice an activity or program of known dimensions” (Fixsen 2005)

”Active and planned efforts to mainstream an innovation” (Greenhalgh 2005)

Definitions

Diffusion: the process in which an innovation is communicated through certain channels over time among the members of a social system (Rogers 2003)

Dissemination: a planned and active process intended to increase the rate and level of adoption above that which might have been achieved by diffusion alone (Greenhalgh 2005)

Method AND implementation

The method

• Define the method components

• Anticipated effects of the method

• Program fidelity

The implementation process

• Define the implementation components

• Anticipated effects of the method

BOTH the method AND the implementation must work!

There needs to be a need

Local needs are an important element for

successful implementation

”we are not satisfied with how bullying problems are

being handled at local schools”

When the needs are expressed explicitly, there

is more chance of successful implementation

”we need a new program to combat bullying in local schools”

Method criteria

The implementation will work better if the method:

• has relative benefits (Greenhalgh 2005, Rogers 2003, Dirksen 1996,

Aubert 2001)

• is in line with prevailing values, norms and working

methods (Greenhalgh 2005, Rogers 2003, Denis 2002, Glaser 1980,

Rohrbach 2006, Mihalic 2003, Aubert 2001, Ferlie 2001)

• is simple to use (Greenhalgh 2005, Rogers 2003, Meyer 1988, Denis 2002)

Method criteria

The implementation will work better if the method:

• is possible to test (Greenhalgh 2005, Rogers 2003, Yetton 1999)

• shows visible results quickly (Greenhalgh 2005, Meyer 1988, Denis

2002)

• is possible to adapt to local conditions (Greenhalgh 2005,

Rogers 2003, Glaser 1980)

• offer knowledge that can be generelised (Greenhalgh 2005,

Aubert 2001)

Implementation criteria

• A combination of measures (Gotham 2004, Fixsen 2005,

Rohrbach 2006, Grol 2000, Bero 1998, Ager 2001, Kelly 2000)

• Early involvement of the users (Greenhalgh 2005)

• Resources (Rohrbach 2006, Mihalic 2003, Robinson 2006,

Greenhalgh 2005, Rogers 2003, Fitzgerald 2002)

• Feedback (Fixsen 2005, Greenhalgh 2005)

Information and training is not enough! (Fixsen 2005, Azocar 2003, Davis 1995, Denton 2003, Rogers 2002)

Actors in the implementation process

Recipient Change agent Sender

The recipient

experiences a

need

The change agent

understands the

recipient’s need and

the sender’s method

and mediates

contact

The sender has

access to a

method that

meets the

recipient’s need

The work of a change agent

• Help the recipient to become aware of a problem

• Establish a trusting relationship with the recipient

• Help the recipient to analyse why the problem cannot be dealt with by existing methods

• Motivate the recipient to choose a specific method

• Provide practical support

• Support the institutionalisation of the new method

• Hand over completely to the recipient

The Community readiness model

• No awareness of the problem or the solution

• Denial of the problem or the sollution

• Planning

• Preparation

• Implementation

• Stabilising the implemented method

• Strengthening and expansion

A checklist for implementation – an example

There are locally defined needs □ Yes □ No

Needs:

The number of children with behaviour disorders in preschool has increased

The proposed method can meet these needs □ Yes □ No

Method:

A structured method for parental support (e.g. COPE, Komet, Familjeverkstan)

A checklist for implementation – an example

The method components are defined □ Yes □ No

The method consists of:

A written manual, skilled supervisors, video films, role plays, homework etc.

Anticipated effects:

Fewer children with behaviour disorders

A checklist for implementation - an example

The implementation components are defined □ Yes □ No

The implementation consists of:

Staff education, practical training, feedback, adaptation of the organisation etc.

Anticipated effects:

x number of the staff use the method after finished education

x number of parent support courses are given each year

A checklist for implementation – an exampleThe method is:

- relevant □ Yes □ No

- better than current methods □ Yes □ No

- effective (evidence-based) □ Yes □ No

- cost-efficient □ Yes □ No

A checklist for implementation – an example

The method is:

- consistent with prevailing values □ Yes □ No

- easy to use □ Yes □ No

- possible to test on a small scale □ Yes □ No

- possible to adapt to local conditions □ Yes □ No

A checklist for implementation – an example

Risks could be dealt with □ Yes □ No

The results can be quickly observed □ Yes □ No

Knowledge can be generalised □ Yes □ No

Users involved at an early stage □ Yes □ No

Everyone involved has enough skills□ Yes □ No

A checklist for implementation – an example

Systems for monitoring and feedback □ Yes □ No

Plans to hand over to the users □ Yes □ No

Resources (time, money and staff) □ Yes □ No

Adequate and long-term budget □ Yes □ No

www.fhi.se/childhealth