| 1. |
- Carlfjord, Siw, 1959-
(author)
-
The Challenge of Changing Practice : Applying Theory in the Implementation of an Innovation in Swedish Primary Health Care
- 2012
-
Doctoral thesis (other academic/artistic)abstract
- Background: The translation of new knowledge, such as research findings, new tools or methods into health care practice has gained increased interest in recent years. Important factors that determine implementation outcome have been identified, and models and checklists to be followed in planning as well as in carrying out an implementation process have been produced. However, there are still knowledge gaps regarding what approach should be used in which setting and for which problems. Primary health care (PHC) in Sweden is an area where there is a paucity of research regarding implementation of new methods into practice. The aim of the thesis was to apply theory in the study of the implementation of an innovation in Swedish PHC, and identify factors that influenced outcome.Methods: The study was performed using a quasi-experimental design, and included six PHC units, two from each one of three county councils in the southeast part of Sweden. A computer-based lifestyle intervention tool (CLT) developed to facilitate addressing lifestyle issues, was introduced at the units. Two different strategies were used for the introduction, both aiming to facilitate the process: a theory-based explicit strategy and an implicit strategy requiring a minimum of effort. Data collection was performed at baseline, and after six, nine and 24 months. Questionnaires were distributed to staff and managers, and data was also collected from the CLT database and county council registers. Implementation outcome was defined as the proportion of eligible patients being referred to the CLT, and was also measured in terms of Reach, Effectiveness, Adoption, Implementation and Maintenance according to the RE-AIM framework. Interviews were performed in order to explore experiences of the implementation process as perceived by staff and managers.Results: A positive organizational climate seemed to promote implementation. Organizational changes or staff shortages coinciding with the implementation process had a negative influence on outcome. The explicit implementation strategy seemed to be more effective than the implicit strategy in the short term, but the differences levelled out over time. The adopters’ perceptions of the implementation seemed to be influenced by the existing professional sub-cultures. Successful implementation was associated with positive expectations, perceptions of the innovation being compatible with existing routines and perceptions of relative advantage.Conclusions: The general conclusion is that when theory was applied in the implementation of a lifestyle intervention tool in Swedish PHC, factors related to the adopters and to the innovation seemed to be more important over time than the strategy used. Staff expectations, perceptions of the innovation’s relative advantage and potential compatibility with existing routines were found to be positively associated with implementation outcome, and other major organizational changes concurrent with implementation seemed to affect the outcome in a negative way. Values, beliefs and behaviour associated with the existing sub-cultures in PHC appeared to influence how the implementation of an innovation was perceived by managers and the different professionals.
|
|
| 2. |
- Arrelöv, Britt, 1953-
(author)
-
Towards Understanding of Determinants of Physicians’ Sick-listing Practice and their Interrelations : A Population-based Epidemiological Study
- 2003
-
Doctoral thesis (other academic/artistic)abstract
- Physicians are supposed to act as sick-listing experts and they possess a role as gate-keepers to the social insurance system. Earlier studies have demonstrated variation between physicians and physician categories regarding sick-listing practice. In addition to the patient's disease and its severity, a number of other factors may be expected to influence sick-listing practice. Most earlier studies have focused on the patient's disease and his or her work place as cause for sickness absence.The aims of this study were to analyse variation of sick-listing practice between physician categories and the influence of physician characteristics on sick-listing practice, the influence of structure, organisation and remuneration of health care on physician sick-listing practice, the influence of local structural factors in the community, and the influence of a legislative change on physician sick-listing practice.The study was conducted as a cross-sectional epidemiological study of 57563 doctors’ certificates for sickness absence, received by 28 local social insurance offices in eight Swedish counties, during four months in 1995 and two months in 1996.Patient age, sex, and diagnostic group, issuing physician category, presence of a hospital in the municipality, municipality population size and county were all significantly and independently correlated to number of net days of sick-listing. Physician characteristics, such as age, sex and degree of specialisation were all associated with number of net days of sick-listing. Physicians working in general practice issued significantly shorter periods of sick-listing than the other physician categories. Reimbursement of general practice and participation in financial co-operation with social insurance were significantly correlated to length of sickness episode issued by general practitioners. A legislative change performed during the study period was associated with small effects in sick-listing practice.In conclusion, a number of factors other than disease and disease severity and other patient and physician linked factors were found to influence the variation of sick-listing practice. It appears that the closer the influencing factor was to the place were the decision was taken, i.e., the patient-physician consultation, the higher the impact on the decision appeared to be.
|
|
