9 research outputs found
Learning from doing: the case for combining normalisation process theory and participatory learning and action research methodology for primary healthcare implementation research
Background: The implementation of research findings is not a straightforward matter. There are substantive and recognised gaps in the process of translating research findings into practice and policy. In order to overcome some of these translational difficulties, a number of strategies have been proposed for researchers. These include greater use of theoretical approaches in research focused on implementation, and use of a wider range of research methods appropriate to policy questions and the wider social context in which they are placed. However, questions remain about how to combine theory and method in implementation research. In this paper, we respond to these proposals.Discussion: Focussing on a contemporary social theory, Normalisation Process Theory, and a participatory research methodology, Participatory Learning and Action, we discuss the potential of their combined use for implementation research. We note ways in which Normalisation Process Theory and Participatory Learning and Action are congruent and may therefore be used as heuristic devices to explore, better understand and support implementation. We also provide examples of their use in our own research programme about community involvement in primary healthcare.Conclusions: Normalisation Process Theory alone has, to date, offered useful explanations for the success or otherwise of implementation projects post-implementation. We argue that Normalisation Process Theory can also be used to prospectively support implementation journeys. Furthermore, Normalisation Process Theory and Participatory Learning and Action can be used together so that interventions to support implementation work are devised and enacted with the expertise of key stakeholders. We propose that the specific combination of this theory and methodology possesses the potential, because of their combined heuristic force, to offer a more effective means of supporting implementation projects than either one might do on its own, and of providing deeper understandings of implementation contexts, rather than merely describing change
A qualitative systematic review of studies using the normalization process theory to research implementation processes
Background: There is a well-recognized need for greater use of theory to address research translational gaps.
Normalization Process Theory (NPT) provides a set of sociological tools to understand and explain the social
processes through which new or modified practices of thinking, enacting, and organizing work are implemented,
embedded, and integrated in healthcare and other organizational settings. This review of NPT offers readers the
opportunity to observe how, and in what areas, a particular theoretical approach to implementation is being used.
In this article we review the literature on NPT in order to understand what interventions NPT is being used to
analyze, how NPT is being operationalized, and the reported benefits, if any, of using NPT.
Methods: Using a framework analysis approach, we conducted a qualitative systematic review of peer-reviewed
literature using NPT. We searched 12 electronic databases and all citations linked to six key NPT development
papers. Grey literature/unpublished studies were not sought. Limitations of English language, healthcare setting and
year of publication 2006 to June 2012 were set.
Results: Twenty-nine articles met the inclusion criteria; in the main, NPT is being applied to qualitatively analyze a
diverse range of complex interventions, many beyond its original field of e-health and telehealth. The NPT
constructs have high stability across settings and, notwithstanding challenges in applying NPT in terms of
managing overlaps between constructs, there is evidence that it is a beneficial heuristic device to explain and guide
implementation processes.
Conclusions: NPT offers a generalizable framework that can be applied across contexts with opportunities for
incremental knowledge gain over time and an explicit framework for analysis, which can explain and potentially
shape implementation processes. This is the first review of NPT in use and it generates an impetus for further and
extended use of NPT. We recommend that in future NPT research, authors should explicate their rationale for
choosing NPT as their theoretical framework and, where possible, involve multiple stakeholders including service
users to enable analysis of implementation from a range of perspectives
Normalisation process theory: a framework for developing, evaluating and implementing complex interventions
Background: The past decade has seen considerable interest in the development and evaluation of complex
interventions to improve health. Such interventions can only have a significant impact on health and health care if
they are shown to be effective when tested, are capable of being widely implemented and can be normalised into
routine practice. To date, there is still a problematic gap between research and implementation. The Normalisation
Process Theory (NPT) addresses the factors needed for successful implementation and integration of interventions
into routine work (normalisation).
Discussion: In this paper, we suggest that the NPT can act as a sensitising tool, enabling researchers to think
through issues of implementation while designing a complex intervention and its evaluation. The need to ensure
trial procedures that are feasible and compatible with clinical practice is not limited to trials of complex
interventions, and NPT may improve trial design by highlighting potential problems with recruitment or data
collection, as well as ensuring the intervention has good implementation potential.
Summary: The NPT is a new theory which offers trialists a consistent framework that can be used to describe,
assess and enhance implementation potential. We encourage trialists to consider using it in their next trial
Exploring barriers to primary care for migrants in Greece in times of austerity: perspectives of service providers
Background: Migration in Europe is increasing at an unprecedented rate. There is an urgentneed to develop ‘migrant-sensitive healthcare systems’. However, there are many barriers to healthcare for migrants. Despite Greece’s recent, significant experiences of inward migration during a period of economic austerity, little is known about Greek primary care service providers’ experiences of delivering care to migrants.
Objectives: To identify service providers’ views on the barriers to migrant healthcare.
Methods: Qualitative study involving six participatory learning and action (PLA) focus group sessions with nine service providers. Data generation was informed by normalization process theory (NPT). Thematic analysis was applied to identify barriers to efficient migrant healthcare.
Results: Three main provider and system-related barriers emerged: (a) emphasis on major challenges in healthcare provision, (b) low perceived control and effectiveness to support migrant healthcare, and (c) attention to impoverished local population.
Conclusion: The study identified major provider and system-related barriers in the provision of primary healthcare to migrants. It is important for the healthcare system in Greece to provide appropriate supports for communication in cross-cultural consultations for its diversifying population
Engaging migrants and other stakeholders to improve communication in cross-cultural consultation in primary care: a theoretically informed participatory study
Objectives: Guidelines and training initiatives (G/TIs)
are available to support communication in crosscultural
consultations but are rarely implemented in
routine practice in primary care. As part of the
European Union RESTORE project, our objective was to
explore whether the available G/TIs make sense to
migrants and other key stakeholders and whether they
could collectively choose G/TIs and engage in their
implementation in primary care settings
Material practices for meaningful engagement: An analysis of participatory learning and action research techniques for data generation and analysis in a health search partnership
Background: The material practices which researchers use in research partnerships
may enable or constrain the nature of engagement with stakeholder groups.
Participatory learning and action (PLA) research approaches show promise, but there
has been no detailed analysis of stakeholders’ and researchers’ experiences of PLA
techniques for data generation and co-analysis.
Objectives: To explore stakeholders’ and researchers’ experiences of PLA techniques
for data generation and co-analysis.
Design: The EU RESTORE implementation science project employed a participatory
approach to investigate and support the implementation of guidelines and training initiatives
(GTIs) to enhance communication in cross-cultural
primary care consultations.
We developed a purposeful sample of 78 stakeholders (migrants, general practice
staff, community interpreters, service providers, service planners) from primary care
settings in Austria, England, Greece, Ireland and The Netherlands. We used speed
evaluations and participatory evaluations to explore their experiences of two PLA
techniques—Commentary Charts and Direct Ranking—which were intended to generate
data for co-analysis
by stakeholders about the GTIs under analysis. We evaluated
16 RESTORE researchers’ experiences using interviews. We conducted thematic and
content analysis of all evaluation data.
Results: PLA Commentary Charts and Direct Ranking techniques, with their visual,
verbal and tangible nature and inherent analytical capabilities, were found to be powerful
tools for involving stakeholders in a collaborative analysis of GTIs. Stakeholders.
had few negative experiences and numerous multifaceted positive experiences of
meaningful engagement, which resonated with researchers’ accounts.
Conclusion: PLA techniques and approaches are valuable as material practices in health
research partnerships
Research into implementation strategies to support patients of different origins and language background in a variety of European primary care settings (RESTORE): study protocol
Background: The implementation of guidelines and training initiatives to support communication in cross-cultural
primary care consultations is ad hoc across a range of international settings with negative consequences particularly
for migrants. This situation reflects a well-documented translational gap between evidence and practice and is part
of the wider problem of implementing guidelines and the broader range of professional educational and quality
interventions in routine practice. In this paper, we describe our use of a contemporary social theory, Normalization
Process Theory and participatory research methodology—Participatory Learning and Action—to investigate and
support implementation of such guidelines and training initiatives in routine practice.
Methods: This is a qualitative case study, using multiple primary care sites across Europe. Purposive and maximum
variation sampling approaches will be used to identify and recruit stakeholders—migrant service users, general
practitioners, primary care nurses, practice managers and administrative staff, interpreters, cultural mediators, service
planners, and policy makers. We are conducting a mapping exercise to identify relevant guidelines and training
initiatives. We will then initiate a PLA-brokered dialogue with stakeholders around Normalization Process Theory’s
four constructs—coherence, cognitive participation, collective action, and reflexive monitoring. Through this, we
will enable stakeholders in each setting to select a single guideline or training initiative for implementation in their
local setting. We will prospectively investigate and support the implementation journeys for the five selected
interventions. Data will be generated using a Participatory Learning and Action approach to interviews and focus
groups. Data analysis will follow the principles of thematic analysis, will occur in iterative cycles throughout the
project and will involve participatory co-analysis with key stakeholders to enhance the authenticity and veracity of
findings.
Discussion: This research employs a unique combination of Normalization Process Theory and Participatory
Learning and Action, which will provide a novel approach to the analysis of implementation journeys. The findings
will advance knowledge in the field of implementation science because we are using and testing theoretical and
methodological approaches so that we can critically appraise their scope to mediate barriers and improve the
implementation processes
Supporting the use of theory in crosscountry health services research: a participatory qualitative approach using normalisation process theory as an example
Objectives To describe and reflect on the process of
designing and delivering a training programme supporting
the use of theory, in this case Normalisation Process
Theory (NPT), in a multisite cross-country health services
research study.
Design Participatory research approach using qualitative
methods.
Setting Six European primary care settings involving
research teams from Austria, England, Greece, Ireland, The
Netherlands and Scotland.
Participants RESTORE research team consisting of 8
project applicants, all senior primary care academics,
and 10 researchers. Professional backgrounds included
general practitioners/family doctors, social/cultural
anthropologists, sociologists and health services/primary
care researchers.
Primary outcome measures Views of all research
team members (n=18) were assessed using qualitative
evaluation methods, analysed qualitatively by the trainers
after each session.
Results Most of the team had no experience of using
NPT and many had not applied theory to prospective,
qualitative research projects. Early training proved
didactic and overloaded participants with information.
Drawing on RESTORE’s methodological approach of
Participatory Learning and Action, workshops using role
play, experiential interactive exercises and light-hearted
examples not directly related to the study subject matter
were developed. Evaluation showed the study team
quickly grew in knowledge and confidence in applying
theory to fieldwork. Recommendations applicable to other
studies include: accepting that theory application is not a
linear process, that time is needed to address researcher
concerns with the process, and that experiential,
interactive learning is a key device in building conceptual
and practical knowledge. An unanticipated benefit was the
smooth transition to cross-country qualitative coding of
study data.
Conclusion A structured programme of training enhanced
and supported the prospective application of a theory,
NPT, to our work but raised challenges. These were not
unique to NPT but could arise with the application of any
theory, especially in large multisite, international projects.
The lessons learnt are applicable to other theoretically
informed studies
Occupation and risk of severe COVID-19: prospective cohort study of 120 075 UK Biobank participants
Objectives To investigate severe COVID-19 risk by occupational group.
Methods Baseline UK Biobank data (2006–10) for England were linked to SARS-CoV-2 test results from Public Health England (16 March to 26 July 2020). Included participants were employed or self-employed at baseline, alive and aged <65 years in 2020. Poisson regression models were adjusted sequentially for baseline demographic, socioeconomic, work-related, health, and lifestyle-related risk factors to assess risk ratios (RRs) for testing positive in hospital or death due to COVID-19 by three occupational classification schemes (including Standard Occupation Classification (SOC) 2000).
Results Of 120 075 participants, 271 had severe COVID-19. Relative to non-essential workers, healthcare workers (RR 7.43, 95% CI 5.52 to 10.00), social and education workers (RR 1.84, 95% CI 1.21 to 2.82) and other essential workers (RR 1.60, 95% CI 1.05 to 2.45) had a higher risk of severe COVID-19. Using more detailed groupings, medical support staff (RR 8.70, 95% CI 4.87 to 15.55), social care (RR 2.46, 95% CI 1.47 to 4.14) and transport workers (RR 2.20, 95% CI 1.21 to 4.00) had the highest risk within the broader groups. Compared with white non-essential workers, non-white non-essential workers had a higher risk (RR 3.27, 95% CI 1.90 to 5.62) and non-white essential workers had the highest risk (RR 8.34, 95% CI 5.17 to 13.47). Using SOC 2000 major groups, associate professional and technical occupations, personal service occupations and plant and machine operatives had a higher risk, compared with managers and senior officials.
Conclusions Essential workers have a higher risk of severe COVID-19. These findings underscore the need for national and organisational policies and practices that protect and support workers with an elevated risk of severe COVID-19