Assessing community perspectives of the community based education and service model at Makerere University, Uganda: a qualitative evaluation

<p>Abstract</p> <p>Background</p> <p>Community partnerships are defined as groups working together with shared goals, responsibilities, and power to improve the community. There is growing evidence that these partnerships contribute to the success and sustainability of community-based education and service programs (COBES), facilitating change in community actions and attitudes. Makerere University College of Health Sciences (MakCHS) is forging itself as a transformational institution in Uganda and the region. The College is motivated to improve the health of Ugandans through innovative responsive teaching, provision of service, and community partnerships. Evaluating the COBES program from the community perspective can assist the College in refining an innovative and useful model that has potential to improve the health of Ugandans.</p> <p>Methods</p> <p>A stratified random sample of 11 COBES sites was selected to examine the community’s perception of the program. Key Informant Interviews of 11 site tutors and 33 community members were completed. The data was manually analyzed and themes developed.</p> <p>Results</p> <p>Communities stated the students consistently engaged with them with culturally appropriate behaviour. They rated the student’s communication as very good even though translators were frequently needed. Half the community stated they received some feedback from the students, but some communities interpreted any contact after the initial visit as feedback. Communities confirmed and appreciated that the students provided a number of interventions and saw positive changes in health and health seeking behaviours. The community reflected that some programs were more sustainable than others; the projects that needed money to implement were least sustainable. The major challenges from the community included community fatigue, and poor motivation of community leaders to continue to take students without compensation.</p> <p>Conclusions</p> <p>Communities hosting Makerere students valued the students’ interventions and the COBES model. They reported witnessing health benefits of fewer cases of disease, increased health seeking behavior and sustainable healthcare programs. The evidence suggests that efforts to standardize objectives, implement structural adjustments, and invest in development of the program would yield even more productive community interactions and a healthcare workforce with public health skills needed to work in rural communities.</p

Examining sustainability in a hospital setting: Case of smoking cessation

<p>Abstract</p> <p>Background</p> <p>The Ottawa Model of Smoking Cessation (OMSC) is a hospital-based smoking cessation program that is expanding across Canada. While the short-term effectiveness of hospital cessation programs has been documented, less is known about long-term sustainability. The purpose of this exploratory study was to understand how hospitals using the OMSC were addressing sustainability and determine if there were critical factors or issues that should be addressed as the program expanded.</p> <p>Methods</p> <p>Six hospitals that differed on OMSC program activities (identify and document smokers, advise quitting, provide medication, and offer follow-up) were intentionally selected, and two key informants per hospital were interviewed using a semi-structured interview guide. Key informants were asked to reflect on the initial decision to implement the OMSC, the current implementation process, and perceived sustainability of the program. Qualitative analysis of the interview transcripts was conducted and themes related to problem definition, stakeholder influence, and program features emerged.</p> <p>Results</p> <p>Sustainability was operationalized as higher performance of OMSC activities than at baseline. Factors identified in the literature as important for sustainability, such as program design, differences in implementation, organizational characteristics, and the community environment did not explain differences in program sustainability. Instead, key informants identified factors that reflected the interaction between how the health problem was defined by stakeholders, how priorities and concerns were addressed, features of the program itself, and fit within the hospital context and resources as being influential to the sustainability of the program.</p> <p>Conclusions</p> <p>Applying a sustainability model to a hospital smoking cessation program allowed for an examination of how decisions made during implementation may impact sustainability. Examining these factors during implementation may provide insight into issues affecting program sustainability, and foster development of a sustainability plan. Based on this study, we suggest that sustainability plans should focus on enhancing interactions between the health problem, program features, and stakeholder influence.</p

Sustainability of the whole-community project '10,000 Steps': a longitudinal study

<p>Abstract</p> <p>Background</p> <p>In the dissemination and implementation literature, there is a dearth of information on the sustainability of community-wide physical activity (PA) programs in general and of the '10,000 Steps' project in particular. This paper reports a longitudinal evaluation of organizational and individual sustainability indicators of '10,000 Steps'.</p> <p>Methods</p> <p>Among project adopters, department heads of 24 public services were surveyed 1.5 years after initially reported project implementation to assess continuation, institutionalization, sustained implementation of intervention components, and adaptations. Barriers and facilitators of project sustainability were explored. Citizens (<it>n </it>= 483) living near the adopting organizations were interviewed to measure maintenance of PA differences between citizens aware and unaware of '10,000 Steps'. Independent-samples <it>t</it>, Mann-Whitney <it>U</it>, and chi-square tests were used to compare organizations for representativeness and individual PA differences.</p> <p>Results</p> <p>Of all organizations, 50% continued '10,000 Steps' (mostly in cycles) and continuation was independent of organizational characteristics. Level of intervention institutionalization was low to moderate on evaluations of routinization and moderate for project saturation. The global implementation score (58%) remained stable and three of nine project components were continued by less than half of organizations (posters, street signs and variants, personalized contact). Considerable independent adaptations of the project were reported (e.g. campaign image). Citizens aware of '10,000 Steps' remained more active during leisure time than those unaware (227 ± 235 and 176 ± 198 min/week, respectively; <it>t </it>= -2.6; p < .05), and reported more household-related (464 ± 397 and 389 ± 346 min/week, respectively; <it>t </it>= -2.2; p < .05) and moderate-intensity-PA (664 ± 424 and 586 ± 408 min/week, respectively; <it>t </it>= -2.0; p < .05). Facilitators of project sustainability included an organizational leader supporting the project, availability of funding or external support, and ready-for-use materials with ample room for adaptation. Barriers included insufficient synchronization between regional and community policy levels and preference for other PA projects.</p> <p>Conclusions</p> <p>'10,000 Steps' could remain sustainable but design, organizational, and contextual barriers need consideration. Sustainability of '10,000 Steps' in organizations can occur in cycles rather than in ongoing projects. Future research should compare sustainability other whole-community PA projects with '10,000 Steps' to contrast sustainability of alternative models of whole-community PA projects. This would allow optimization of project elements and methods to support decisions of choice for practitioners.</p

Are vaccination programmes delivered by lay health workers cost-effective? A systematic review

<p>Abstract</p> <p>Background</p> <p>A recently updated Cochrane systematic review on the effects of lay or community health workers (LHWs) in primary and community health care concluded that LHW interventions could lead to promising benefits in the promotion of childhood vaccination uptake. However, understanding of the costs and cost-effectiveness of involving LHWs in vaccination programmes remains poor. This paper reviews the costs and cost-effectiveness of vaccination programme interventions involving LHWs.</p> <p>Methods</p> <p>Articles were retrieved if the title, keywords or abstract included terms related to 'lay health workers', 'vaccination' and 'economics'. Reference lists of studies assessed for inclusion were also searched and attempts were made to contact authors of all studies included in the Cochrane review. Studies were included after assessing eligibility of the full-text article. The included studies were then reviewed against a set of background and technical characteristics.</p> <p>Results</p> <p>Of the 2616 records identified, only three studies fully met the inclusion criteria, while an additional 11 were retained as they included some cost data. Methodologically, the studies were strong but did not adequately address affordability and sustainability and were also highly heterogeneous in terms of settings and LHW outcomes, limiting their comparability. There were insufficient data to allow any conclusions to be drawn regarding the cost-effectiveness of LHW interventions to promote vaccination uptake. Studies focused largely on health outcomes and did illustrate to some extent how the institutional characteristics of communities, such as governance and sources of financial support, influence sustainability.</p> <p>Conclusion</p> <p>The included studies suggest that conventional economic evaluations, particularly cost-effectiveness analyses, generally focus too narrowly on health outcomes, especially in the context of vaccination promotion and delivery at the primary health care level by LHWs. Further studies on the costs and cost-effectiveness of vaccination programmes involving LHWs should be conducted, and these studies should adopt a broader and more holistic approach.</p

Barriers to the sustainability of an intervention designed to improve patient engagement within NHS mental health rehabilitation units: a qualitative study nested within a randomised controlled trial.

BACKGROUND: We undertook a cluster randomised controlled trial to assess the effectiveness of a staff training intervention to improve patient engagement in activities in inpatient mental health rehabilitation units. Concurrently, we undertook a qualitative study to investigate the experiences of staff within the intervention units and the contextual issues that may have influenced the effectiveness of the intervention. METHOD: We conducted focus groups with staff working in the inpatient units that received the intervention, sampled using a maximum variation strategy. RESULTS: The intervention was accepted by staff. However, the skills gained, and changes to the unit's processes and structures that were agreed with the intervention team were not sustained after they left. The main reasons for this were a) external factors (economic recession, resource limitations); b) organisation level factors (lack of senior staff support; competing priorities); c) limitations of the intervention itself (length of intensive training period; reinforcement of skills). CONCLUSION: This study illustrates some of the inter-related factors which operate at different levels within and outside of NHS organisations that may impact on the success of complex interventions. These factors need to be considered when designing interventions to ensure adequate buy-in from senior staff. TRIAL REGISTRATION: Current Controlled Trials ISRCTN25898179 (Registered 23 April 2010)

The barriers and facilitators influencing the sustainability of hospital-based interventions: a systematic review

Acknowledgements University of Stirling for providing financial support for open access costs Funding This review was funded by the Chief Scientist Office, grant number GCA/17/26. JC, PC and EAD are employed by the Nursing, Midwifery and Allied Health Professions Research Unit, which is funded by the Chief Scientist Office in Scotland.Peer reviewedPublisher PD

Protocol for the ROSE sustainment (ROSES) study, a sequential multiple assignment randomized trial to determine the minimum necessary intervention to maintain a postpartum depression prevention program in prenatal clinics serving low-income women

Background: More research on sustainment of interventions is needed, especially return on investment (ROI) studies to determine cost-benefit trade-offs for effort required to sustain and how much is gained when effective programs are sustained. The ROSE sustainment (ROSES) study uses a sequential multiple assignment randomized (SMART) design to evaluate the effectiveness and cost-effectiveness of a stepwise approach to sustainment of the ROSE postpartum depression prevention program in 90 outpatient clinics providing prenatal care to pregnant women on public assistance. Postpartum depression (PPD) is common and can have lasting consequences. Outpatient clinics offering prenatal care are an opportune place to provide PPD prevention because most women visit while pregnant. The ROSE (Reach Out, Stay Strong, Essentials for mothers of newborns) program is a group educational intervention to prevent PPD, delivered during pregnancy. ROSE has been found to reduce cases of PPD in community prenatal settings serving low-income pregnant women. Methods: All 90 prenatal clinics will receive enhanced implementation as usual (EIAU; initial training + tools for sustainment). At the first time at which a clinic is determined to be at risk for failure to sustain (i.e., at 3, 6, 9, 12, and 15 months), that clinic will be randomized to receive either (1) no additional implementation support (i.e., EIAU only), or (2) low-intensity coaching and feedback (LICF). If clinics receiving LICF are still at risk at subsequent assessments, they will be randomized to either (1) EIAU + LICF only, or (2) high-intensity coaching and feedback (HICF). Additional follow-up interviews will occur at 18, 24, and 30 months, but no implementation intervention will occur after 18 months. Outcomes include (1) percent sustainment of core program elements at each time point, (2) health impact (PPD rates over time at each clinic) and reach, and (3) ROI (costs and cost-effectiveness) of each sustainment step. Hypothesized mechanisms include sustainment of capacity to deliver core elements and engagement/ownership. Discussion: This study is the first randomized trial evaluating the ROI of a stepped approach to sustainment, a critical unanswered question in implementation science. It will also advance knowledge of implementation mechanisms and clinical care for an at-risk population