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Long-term impact of a real-world coordinated lifestyle promotion initiative in primary care: a quasi-experimental cross-sectional study
Linköping University, Faculty of Health Sciences. Linköping University, Department of Medical and Health Sciences, Division of Community Medicine.
Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in West Östergötland, Department of Medical Specialist in Motala.
2014 (English)In: BMC Family Practice, ISSN 1471-2296, Vol. 15, no 201Article in journal (Refereed) Published
Abstract [en]

Background: Integration of lifestyle promotion in routine primary care has been suboptimal. Coordinated care models (e.g. screening, brief advice and referral to in-house specialized staff) could facilitate lifestyle promotion practice; they have been shown to increase the quality of services and reduce costs in other areas of care. This study evaluates the long-term impact of a coordinated lifestyle promotion intervention with a multidisciplinary team approach in a primary care setting. Methods: A quasi-experimental, cross-sectional design was used to compare three intervention centres using a coordinated care model and three control centres using a traditional model of lifestyle promotion care. Outcomes were inspired by using the RE-AIM framework: reach, the proportion of patients receiving lifestyle promotion; effectiveness, self-reported attitudes and competency among staff; adoption, proportion of staff reporting daily practice of lifestyle promotion and referral; and implementation, of the coordinated care model. The impact was investigated after 3 and 5 years. Data collection involved a patient questionnaire (intervention, n = 433-497; control, n = 455-497), a staff questionnaire (intervention, n = 77-76; control, n = 43-56) and structured interviews with managers (n = 8). The X-2 test or Fisher exact test with adjustment for clustering by centre was used for the analysis. Problem-driven content analysis was used to analyse the interview data. Results: The findings were consistent over time. Intervention centres did not show higher rates for reach of patients or adoption among staff at the 3- or 5-year follow-up. Some conceptual differences between intervention and control staff remained over time in that the intervention staff were more positive on two of eight effectiveness outcomes (one attitude and one competency item) compared with control staff. The Lifestyle team protocol, which included structural opportunities for coordinated care, was implemented at all intervention centres. Lifestyle teams were perceived to have an important role at the centres in driving the lifestyle promotion work forward and being a forum for knowledge exchange. However, resources to refer patients to specialized staff were used inconsistently. Conclusions: The Lifestyle teams may have offered opportunities for lifestyle promotion practice and contributed to enabling conditions at centre level but had limited impact on lifestyle promotion practices.

Place, publisher, year, edition, pages
BioMed Central , 2014. Vol. 15, no 201
Keyword [en]
Healthy lifestyle promotion; Primary care; Implementation; Coordinated care; RE-AIM framework; Maintenance
National Category
Family Medicine
URN: urn:nbn:se:liu:diva-114597DOI: 10.1186/s12875-014-0201-xISI: 000349124100001PubMedID: 25512086OAI: diva2:791428

Funding Agencies|Ostergotland County Council; Linkoping University

Available from: 2015-02-27 Created: 2015-02-26 Last updated: 2015-09-22
In thesis
1. Implementation of coordinated healthy lifestyle promotion in primary care: Process and outcomes
Open this publication in new window or tab >>Implementation of coordinated healthy lifestyle promotion in primary care: Process and outcomes
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Implementation of healthy lifestyle promotion in routine primary has been suboptimal. There is emerging evidence that coordinating care can improve the efficiency and quality of care. However, more research is needed on the implementation of coordinated care in healthy lifestyle promotion, the role of patients in implementation and the long-term outcomes of implementation efforts.

Overall aim: To investigate the implementation of coordinated healthy lifestyle promotion in primary care in terms of process and outcomes, from the perspectives of both staff and patients.

Methods: In 2008, Östergötland county council commissioned primary care centres to implement a coordinated care initiative, lifestyle teams, to improve healthy lifestyle promotion routines. A lifestyle team protocol stipulated centres to: (1) create multi-professional teams, (2) appoint team managers, (3) hold team meetings, and (4) create in-house referral routines for at-risk patients. Paper I investigated the implementation process of three lifestyle teams during a two year period using a mixed method, convergent parallel design. A proposed theory of implementation process was used to analyse data from manager interviews, documents and questionnaires. Paper II explored patients’ role in implementation using grounded theory. Interview data from patients with varied experience of promotion was used. Paper III investigated implementation outcomes using a quasi-experimental, cross-sectional design that compared three intervention centres (lifestyle teams) with three control centres (no teams). Data were collected by staff and patient questionnaires and manager interviews at 3 and 5 years after commissioning. The RE-AIM framework was modified and used to define outcome variables: Reach of patients, Effectiveness (attitudes and competency among staff), Adoption among staff, Implementation fidelity to the lifestyle team protocol, and Maintenance of the results at 5-year follow-up.

Results: Paper I: The implementation process was complex including multiple innovation components and groups of adopters. The conditions for implementation, e.g. resources varied between staff and team members which challenged the embedding of the teams and new routines. The lifestyle teams were continuously redefined by team members to accommodate contextual factors, features of the protocol and patients. The lifestyle team protocol presented an infrastructure for practice at the centres. Paper II: A grounded theory about being healthy with three interconnected subcategories emerged from data: (1) conditions, (2) managing, and (3) interactions regarding being healthy. Being healthy represented a process of approaching a health ideal which occurred simultaneously with, and could contradict, a process of maximizing well-being. A typology of four patient types (resigned, receivers, co-workers, and leaders) illustrated how processes before, during and after healthy lifestyle promotion were interconnected. Paper III: Reach: significantly more patients at control centres received promotion compared to intervention centres at 3-year (48% and 41% respectively) and 5-year followups (44% and 36% respectively). Effectiveness: At 3-year follow-up, after controlling for clustering by centres, intervention staff were significantly more positive concerning perceived need for lifestyle teams; that healthy lifestyle promotion was prioritized at their centre and that there was adequate competency at individual and centre level regarding lifestyle promotion. At 5-year follow-up, significant differences remained regarding prioritization of lifestyle promotion at centre level. The majority of both intervention and control staff were positive towards lifestyle promotion. Adoption: No significant differences were found between control and intervention centres at 3 years (59% and 47% respectively) or at 5 years (45% and 36% respectively). Implementation fidelity: all components of the lifestyle team protocol had been implemented at all the intervention centres and at none of the control centres.

Conclusions: The implementation process was challenged by a complex interaction between groups of staff, innovation components and contextual factors. Although coordinated care are used for other conditions in primary care, the findings suggest that it is difficult to adopt similar routines for healthy lifestyle promotion. Findings suggest that the lifestyle team protocol did not fully consider social components of coordinated care or the varied conditions for change exhibited by adopters. Patients can be seen as coproducing implementation of healthy lifestyle promotion.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2015. 92 p.
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1464
National Category
Nursing Public Health, Global Health, Social Medicine and Epidemiology Health Care Service and Management, Health Policy and Services and Health Economy
urn:nbn:se:liu:diva-121492 (URN)10.3384/diss.diva-121492 (DOI)978-91-7519-043-3 (print) (ISBN)
Public defence
2015-10-15, Belladonna, Hus 511-001, Campus US, Linköping, 09:00 (Swedish)
Available from: 2015-09-22 Created: 2015-09-22 Last updated: 2015-09-22Bibliographically approved

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