The influence of contextual factors on healthcare quality improvement initiatives:what works, for whom and in what setting? Protocol for a realist review

Background  Context shapes the effectiveness of knowledge implementation and influences health improvement. Successful healthcare quality improvement (QI) initiatives frequently fail to transfer to different settings, with local contextual factors often cited as the cause. Understanding and overcoming contextual barriers is therefore crucial to implementing effective improvement; yet context is still poorly understood. There is a paucity of information on the mechanisms underlyinghowandwhyQI projects succeed or fail in given settings. A realist review of empirical studies of healthcare QI initiatives will be undertaken to examine the influence and impact of contextual factors on quality improvement in healthcare settings and explore whether QI initiatives can work in all contexts.  Methods  The review will explore which contextual factors are important, and how, why, when and for whom they are important, within varied settings. The dynamic nature of context and change over time will be explored by examining which aspects of context impact at key points in the improvement trajectory. The review will also consider the influence of context on improvement outcomes (provider- and patient-level), spread and sustainability. The review process will follow five iterative steps: (1) clarify scope, (2) search for evidence, (3) appraise primary studies and extract data, (4) synthesise evidence and draw conclusions and (5) disseminate findings. The reviewers will consult with experts and stakeholders in the early stages to focus the review and develop a programme theory consisting of explanatory ‘context–mechanism–outcome’ configurations. Searches for primary evidence will be conducted iteratively. Data will be extracted and tested against the programme theory. A review advisory group will oversee the review process. Review findings will follow RAMESES guidelines and will be disseminated via a report, presentations and peer-reviewed publications.  Discussion  The review will update and consolidate evidence on the contextual conditions for effective improvement and distil new knowledge to inform the design and development of context-sensitive QI initiatives. This review ties in with the study of improvement programmes as vehicles of change and the development of an evidence base around healthcare improvement by addressing whether QI initiatives can work in all contexts.  Systematic review registration  PROSPERO CRD4201706213

Influence of external contextual factors on the implementation of health and social care interventions into practice within or across countries : a protocol for a 'best fit' framework synthesis

Background: The widespread implementation of interventions is often hindered by a decline and variability in effectiveness across implementation sites. It is anticipated that variations in the characteristics of the external context in different sites, such as the political and funding environment, socio-cultural context, physical environment or population demographics can influence implementation outcome. However, there is only a limited understanding about which and how external contextual factors influence implementation. We aim to develop a comprehensive framework conceptualising the influence of external contextual factors on implementation, particularly when spreading health and social care interventions within or across countries. Methods: The review will use the ‘best fit’ framework synthesis approach. In the first stage of the review, we will examine existing frameworks, models, concepts and theories on external contextual factors and their influence on implementation from a variety of sectors and disciplines including health and social care, education, environmental studies and international development fields. The resulting a priori meta-framework will be tested and refined in the second review stage by analysing evidence from empirical studies focusing on the implementation of health and social care interventions within or across countries. Searches will be conducted in bibliographic databases such as MEDLINE, ERIC, HMIC and IBSS, grey literature sources and on relevant websites. We will also search reference lists, relevant journals, perform citation searches and ask experts in the field. There is no restriction to study type, setting, intervention type or implementation strategy to enable obtaining a broad and in-depth knowledge from various sources of evidence. Discussion: The review will lead to a comprehensive framework for understanding the influence of external contextual factors on implementation, particularly when spreading health and social care interventions within or across countries. The framework is anticipated to help identify factors explaining the decline and variability in effectiveness of interventions and assessing the prospects of implementation effectiveness, when spreading interventions. We do not intend to only develop another stand-alone implementation framework but one that can be used in conjunction with existing frameworks. The framework can be honed and validated in future empirical research. Systematic review registration: PROSPERO CRD4201808448

Designing high-quality implementation research: development, application, feasibility and preliminary evaluation of the implementation science research development (ImpRes) tool and guide

Background:  Designing implementation research can be a complex and daunting task, especially for applied health researchers who have not received specialist training in implementation science. We developed the Implementation Science Research Development (ImpRes) tool and supplementary guide to address this challenge and provide researchers with a systematic approach to designing implementation research. Methods:  A multi-method and multi-stage approach was employed. An international, multidisciplinary expert panel engaged in an iterative brainstorming and consensus-building process to generate core domains of the ImpRes tool, representing core implementation science principles and concepts that researchers should consider when designing implementation research. Simultaneously, an iterative process of reviewing the literature and expert input informed the development and content of the tool. Once consensus had been reached, specialist expert input was sought on involving and engaging patients/service users; and economic evaluation. ImpRes was then applied to 15 implementation and improvement science projects across the National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London, a research organisation in London, UK. Researchers who applied the ImpRes tool completed an 11-item questionnaire evaluating its structure, content and usefulness. Results:  Consensus was reached on ten implementation science domains to be considered when designing implementation research. These include implementation theories, frameworks and models, determinants of implementation, implementation strategies, implementation outcomes and unintended consequences. Researchers who used the ImpRes tool found it useful for identifying project areas where implementation science is lacking (median 5/5, IQR 4–5) and for improving the quality of implementation research (median 4/5, IQR 4–5) and agreed that it contained the key components that should be considered when designing implementation research (median 4/5, IQR 4–4). Qualitative feedback from researchers who applied the ImpRes tool indicated that a supplementary guide was needed to facilitate use of the tool. Conclusions:  We have developed a feasible and acceptable tool, and supplementary guide, to facilitate consideration and incorporation of core principles and concepts of implementation science in applied health implementation research. Future research is needed to establish whether application of the tool and guide has an effect on the quality of implementation research

Adapting evidence-informed complex population health interventions for new contexts : a systematic review of guidance

Background Adapting interventions that have worked elsewhere can save resources associated with developing new interventions for each specific context. While a developing body of evidence shows benefits of adapted interventions compared with interventions transported without adaptation, there are also examples of interventions which have been extensively adapted, yet have not worked in the new context. Decisions on when, to what extent, and how to adapt interventions therefore are not straightforward, particularly when conceptualising intervention effects as contingent upon contextual interactions in complex systems. No guidance currently addresses these questions comprehensively. To inform development of an overarching guidance on adaptation of complex population health interventions, this systematic review synthesises the content of the existing guidance papers. Methods We searched for papers published between January 2000 and October 2018 in 7 bibliographic databases. We used citation tracking and contacted authors and experts to locate further papers. We double screened all the identified records. We extracted data into the following categories: descriptive information, key concepts and definitions, rationale for adaptation, aspects of adaptation, process of adaptation, evaluating and reporting adapted interventions. Data extraction was conducted independently by two reviewers, and retrieved data were synthesised thematically within pre-specified and emergent categories. Results We retrieved 6694 unique records. Thirty-eight papers were included in the review representing 35 sources of guidance. Most papers were developed in the USA in the context of implementing evidence-informed interventions among different population groups within the country, such as minority populations. We found much agreement on how the papers defined key concepts, aims, and procedures of adaptation, including involvement of key stakeholders, but also identified gaps in scope, conceptualisation, and operationalisation in several categories. Conclusions Our review found limitations that should be addressed in future guidance on adaptation. Specifically, future guidance needs to be reflective of adaptations in the context of transferring interventions across countries, including macro- (e.g. national-) level interventions, better theorise the role of intervention mechanisms and contextual interactions in the replicability of effects and accordingly conceptualise key concepts, such as fidelity to intervention functions, and finally, suggest evidence-informed strategies for adaptation re-evaluation and reporting

Embracing complexity and uncertainty to create impact: Exploring the processes and transformative potential of co-produced research through development of a social impact model

© 2018 The Author(s). The potential use, influence and impact of health research is seldom fully realised. This stubborn problem has caused burgeoning global interest in research aiming to address the implementation 'gap' and factors inhibiting the uptake of scientific evidence. Scholars and practitioners have questioned the nature of evidence used and required for healthcare, highlighting the complex ways in which knowledge is formed, shared and modified in practice and policy. This has led to rapid expansion, expertise and innovation in the field of knowledge mobilisation and funding for experimentation into the effectiveness of different knowledge mobilisation models. One approach gaining prominence involves stakeholders (e.g. researchers, practitioners, service users, policy-makers, managers and carers) in the co-production, and application, of knowledge for practice, policy and research (frequently termed integrated knowledge translation in Canada). Its popularity stems largely from its potential to address dilemmas inherent in the implementation of knowledge generated using more reductionist methods. However, despite increasing recognition, demands for co-produced research to illustrate its worth are becoming pressing while the means to do so remain challenging. This is due not only to the diversity of approaches to co-production and their application, but also to the ways through which different stakeholders conceptualise, measure, reward and use research. While research co-production can lead to demonstrable benefits such as policy or practice change, it may also have more diffuse and subtle impact on relationships, knowledge sharing, and in engendering culture shifts and research capacity-building. These relatively intangible outcomes are harder to measure and require new emphases and tools. This opinion paper uses six Canadian and United Kingdom case studies to explore the principles and practice of co-production and illustrate how it can influence interactions between research, policy and practice, and benefit diverse stakeholders. In doing so, we identify a continuum of co-production processes. We propose and illustrate the use of a new 'social model of impact' and framework to capture multi-layered and potentially transformative impacts of co-produced research. We make recommendations for future directions in research co-production and impact measurement

Associations between school-based peer networks and smoking according to socioeconomic status and tobacco control context:protocol for a mixed method systematic review

Background Smoking remains a major public health concern. School-based social networks influence uptake of smoking among peers. During the past two decades, the UK macro-systemic context within which schools are nested and interact with has changed, with anti-smoking norms having become set at a more macro-systemic level. Whilst the overall prevalence of smoking in the UK has decreased, inequality has prevailed. It is plausible that the influence of school-based social networks on smoking uptake may vary according to socioeconomic status. Therefore, this study aims to understand how social influence on smoking among adolescents has changed in line with variance within and between contexts according to time and geography. Methods The following databases will be searched: Medline, PsycINFO, Embase, Applied Social Sciences Index and Abstracts (ASSIA), British Education Index, Sociological abstracts, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Education Resources Information Center (ERIC) and Scopus. Additional searches will include reference checking of key papers, citation tracking, word of mouth and grey literature searches. The search strategies will incorporate terms relating to smoking, adolescents, schools, peers, network analysis and qualitative research. Titles and abstracts and full texts will be independently screened and assessed for quality by at least two researchers. Included studies will be assessed for quality, and data will be extracted for synthesis, including participant characteristics, setting and tobacco control context, study design and methods, analysis and results and conclusions. Quantitative findings will be narratively synthesised, whilst a lines of argument synthesis combined with refutational analysis will be employed to synthesise qualitative data. Both sets of findings will be charted on a timeline to add context to network findings and obtain an enhanced understanding of changes over time. Discussion This protocol is for a mixed methods synthesis of both social network findings, to investigate social structures and qualitative studies, to elicit contextual information. The review will synthesise changes in the context of social influence on adolescent smoking over time and geographically. As context is increasingly recognised as a key source of complexity, this enhanced understanding will help to inform future interventions targeting smoking through social influence. This will help to enhance their relevance to context, subsequent effectiveness and targeting of inequalities

Identifying contextual determinants of problems in tuberculosis care provision in South Africa: a theory-generating case study

Background: Despite progress towards End TB Strategy targets for reducing tuberculosis (TB) incidence and deaths by 2035, South Africa remains among the top ten high-burden tuberculosis countries globally. A large challenge lies in how policies to improve detection, diagnosis and treatment completion interact with social and structural drivers of TB. Detailed understanding and theoretical development of the contextual determinants of problems in TB care is required for developing effective interventions. This article reports findings from the pre-implementation phase of a study of TB care in South Africa, contributing to HeAlth System StrEngThening in Sub-Saharan Africa (ASSET)—a five-year research programme developing and evaluating health system strengthening interventions in sub-Saharan Africa. The study aimed to develop hypothetical propositions regarding contextual determinants of problems in TB care to inform intervention development to reduce TB deaths and incidence whilst ensuring the delivery of quality integrated, person-centred care. Methods Theory-building case study design using the Context and Implementation of Complex Interventions (CICI) framework to identify contextual determinants of problems in TB care. Between February and November 2019, we used mixed methods in six public-sector primary healthcare facilities and one public-sector hospital serving impoverished urban and rural communities in the Amajuba District of KwaZulu-Natal Province, South Africa. Qualitative data included stakeholder interviews, observations and documentary analysis. Quantitative data included routine data on sputum testing and TB deaths. Data were inductively analysed and mapped onto the seven CICI contextual domains. Results: Delayed diagnosis was caused by interactions between fragmented healthcare provision; limited resources; verticalised care; poor TB screening, sputum collection and record-keeping. One nurse responsible for TB care, with limited integration of TB with other conditions, and policy focused on treatment adherence contributed to staff stress and limited consideration of patients’ psychosocial needs. Patients were lost to follow up due to discontinuity of information, poverty, employment restrictions and limited support for treatment side-effects. Infection control measures appeared to be compromised by efforts to integrate care. Conclusions: Delayed diagnosis, limited psychosocial support for patients and staff, patients lost to follow-up and inadequate infection control are caused by an interaction between multiple interacting contextual determinants. TB policy needs to resolve tensions between treating TB as epidemic and individually-experienced social problem, supporting interventions which strengthen case detection, infection control and treatment, and also promote person-centred support for healthcare professionals and patients

Lehre qualitativer Forschung in Public Health und Medizin: Erfahrungen mit einem forschungsorientierten Seminar

Objectives: Qualitative health research can contribute to knowledge building in public health and medicine, but there is a lack of research-oriented training of qualitative methods at universities with public health programs and in medical schools. The aim of this paper is to describe our experiences in conceptualising, implementing and evaluating an elective on qualitative methods in the Master of Public Health (MPH) programme at the Medical Faculty of the Ludwig-Maximilians-University (LMU) Munich.Methods: A new research-oriented elective (3 Credit Points) was developed and delivered to MPH and medical students in summer 2016. This elective consisted of three blocks that were complemented by two practice sessions. The students worked in small groups. These groups developed a research question and a qualitative study design addressing the thematic focus of vaccinations. Each student conducted two semi-structured interviews with a semi-structured interview grid. Students transcribed the interviews, analysed them according to content analysis and presented the results collaboratively. Results: In that semester, 16 students successfully completed the elective. Groups of two to three students worked on their respective research questions, presented, and reflected on their research results. The participants evaluated the module as very good, particularly with regard to the structure and consistency of the blocks. To facilitate individualised mentoring and guidance, a high student-lecturer ratio is required. Timeframe and workload should pay tribute to the module's credit points.Conclusions: We successfully implemented a research-oriented elective providing a first-hand experience with qualitative health research methods. Students were able to learn about the theory and practical application of qualitative research in the field of medicine and public health.Ziele: Qualitative Forschung kann zur Wissensgenerierung in den Fächern Public Health und Medizin beitragen. Es fehlt jedoch vielerorts eine forschungsorientierte Vermittlung qualitativer Methoden, sowohl an Universitäten, die Public Health Programme anbieten, als auch an Medizinischen Fakultäten. Ziel dieses Artikels ist es, Erfahrungen bei der Konzeption, Durchführung und Evaluation eines Seminars zur Lehre qualitativer Methoden in diesen Fächern zu beschreiben. Das Seminar ist als Wahlpflichtmodul im Masterstudiengang Public Health an der Medizinischen Fakultät der Ludwig-Maximilians-Universität München (LMU) verankert.Methoden: Im Sommersemester 2016 wurde ein neues, forschungsorientiertes Seminar als Wahlpflichtmodul (3 ECTS-Anrechnungspunkte) entwickelt und für Public Health- und Medizin-Studierende angeboten. Dieses Wahlpflichtmodul bestand aus drei Blöcken, die durch zwei Praxisphasen ergänzt wurden. In den Praxisphasen arbeiteten Studierende in Kleingruppen, in denen sie eine Forschungsfrage und ein qualitatives Studiendesign zum Thema Impfen entwickelten. Jede*r Student*in führte anhand eines semi-strukturierten Interviewleitfadens zwei halb-offene Interviews. Die Studierenden transkribierten die Interviews, analysierten sie inhaltsanalytisch und präsentierten die Ergebnisse gemeinschaftlich. Ergebnisse: Insgesamt haben in diesem Semester 16 Studierende das Modul erfolgreich abgeschlossen. Gruppen von zwei bis drei Studierenden arbeiteten an ihren jeweiligen Forschungsfragen, präsentierten und reflektierten ihre Ergebnisse. Die Teilnehmer*innen evaluierten das Modul als 'sehr gut', besonders im Hinblick auf die Struktur und Konsistenz der Blöcke. Um in einem solchen Seminar eine studierendenzentrierte Betreuung und Anleitung zu ermöglichen, ist ein hoher Betreuungsschlüssel erforderlich. Die Anrechnungspunkte sollten dem zeitlichen Arbeitsaufwand entsprechen, weshalb sie im darauffolgenden Semester erhöht wurden. Zusammenfassung: Wir haben erfolgreich ein forschungsorientiertes Wahlpflichtseminar durchgeführt, in dem wir Studierenden eigene Erfahrungen mit qualitativen Forschungsmethoden im Gesundheitsbereich ermöglicht haben. Dadurch hatten Teilnehmende die Gelegenheit, sowohl etwas über die theoretische als auch die forschungspraktische Anwendung qualitativer Forschung auf dem Gebiet der Medizin und Public Health zu erlernen