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Implementation fidelity trajectories of a health promotion program in multidisciplinary settings: managing tensions in rehabilitation care

BACKGROUND: Although the importance of evaluating implementation fidelity is acknowledged, little is known about heterogeneity in fidelity over time. This study aims to generate insight into the heterogeneity in implementation fidelity trajectories of a health promotion program in multidisciplinary...

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Autores principales: Hoekstra, Femke, van Offenbeek, Marjolein A. G., Dekker, Rienk, Hettinga, Florentina J., Hoekstra, Trynke, van der Woude, Lucas H. V., van der Schans, Cees P.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BioMed Central 2017
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5709964/
https://www.ncbi.nlm.nih.gov/pubmed/29191230
http://dx.doi.org/10.1186/s13012-017-0667-8
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author Hoekstra, Femke
van Offenbeek, Marjolein A. G.
Dekker, Rienk
Hettinga, Florentina J.
Hoekstra, Trynke
van der Woude, Lucas H. V.
van der Schans, Cees P.
author_facet Hoekstra, Femke
van Offenbeek, Marjolein A. G.
Dekker, Rienk
Hettinga, Florentina J.
Hoekstra, Trynke
van der Woude, Lucas H. V.
van der Schans, Cees P.
author_sort Hoekstra, Femke
collection PubMed
description BACKGROUND: Although the importance of evaluating implementation fidelity is acknowledged, little is known about heterogeneity in fidelity over time. This study aims to generate insight into the heterogeneity in implementation fidelity trajectories of a health promotion program in multidisciplinary settings and the relationship with changes in patients’ health behavior. METHODS: This study used longitudinal data from the nationwide implementation of an evidence-informed physical activity promotion program in Dutch rehabilitation care. Fidelity scores were calculated based on annual surveys filled in by involved professionals (n = ± 70). Higher fidelity scores indicate a more complete implementation of the program’s core components. A hierarchical cluster analysis was conducted on the implementation fidelity scores of 17 organizations at three different time points. Quantitative and qualitative data were used to explore organizational and professional differences between identified trajectories. Regression analyses were conducted to determine differences in patient outcomes. RESULTS: Three trajectories were identified as the following: ‘stable high fidelity’ (n = 9), ‘moderate and improving fidelity’ (n = 6), and ‘unstable fidelity’ (n = 2). The stable high fidelity organizations were generally smaller, started earlier, and implemented the program in a more structured way compared to moderate and improving fidelity organizations. At the implementation period’s start and end, support from physicians and physiotherapists, professionals’ appreciation, and program compatibility were rated more positively by professionals working in stable high fidelity organizations as compared to the moderate and improving fidelity organizations (p < .05). Qualitative data showed that the stable high fidelity organizations had often an explicit vision and strategy about the implementation of the program. Intriguingly, the trajectories were not associated with patients’ self-reported physical activity outcomes (adjusted model β = − 651.6, t(613) = − 1032, p = .303). CONCLUSIONS: Differences in organizational-level implementation fidelity trajectories did not result in outcome differences at patient-level. This suggests that an effective implementation fidelity trajectory is contingent on the local organization’s conditions. More specifically, achieving stable high implementation fidelity required the management of tensions: realizing a localized change vision, while safeguarding the program’s standardized core components and engaging the scarce physicians throughout the process. When scaling up evidence-informed health promotion programs, we propose to tailor the management of implementation tensions to local organizations’ starting position, size, and circumstances. TRIAL REGISTRATION: The Netherlands National Trial Register NTR3961. Registered 18 April 2013. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi: 10.1186/s13012-017-0667-8) contains supplementary material, which is available to authorized users.
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spelling pubmed-57099642017-12-06 Implementation fidelity trajectories of a health promotion program in multidisciplinary settings: managing tensions in rehabilitation care Hoekstra, Femke van Offenbeek, Marjolein A. G. Dekker, Rienk Hettinga, Florentina J. Hoekstra, Trynke van der Woude, Lucas H. V. van der Schans, Cees P. Implement Sci Research BACKGROUND: Although the importance of evaluating implementation fidelity is acknowledged, little is known about heterogeneity in fidelity over time. This study aims to generate insight into the heterogeneity in implementation fidelity trajectories of a health promotion program in multidisciplinary settings and the relationship with changes in patients’ health behavior. METHODS: This study used longitudinal data from the nationwide implementation of an evidence-informed physical activity promotion program in Dutch rehabilitation care. Fidelity scores were calculated based on annual surveys filled in by involved professionals (n = ± 70). Higher fidelity scores indicate a more complete implementation of the program’s core components. A hierarchical cluster analysis was conducted on the implementation fidelity scores of 17 organizations at three different time points. Quantitative and qualitative data were used to explore organizational and professional differences between identified trajectories. Regression analyses were conducted to determine differences in patient outcomes. RESULTS: Three trajectories were identified as the following: ‘stable high fidelity’ (n = 9), ‘moderate and improving fidelity’ (n = 6), and ‘unstable fidelity’ (n = 2). The stable high fidelity organizations were generally smaller, started earlier, and implemented the program in a more structured way compared to moderate and improving fidelity organizations. At the implementation period’s start and end, support from physicians and physiotherapists, professionals’ appreciation, and program compatibility were rated more positively by professionals working in stable high fidelity organizations as compared to the moderate and improving fidelity organizations (p < .05). Qualitative data showed that the stable high fidelity organizations had often an explicit vision and strategy about the implementation of the program. Intriguingly, the trajectories were not associated with patients’ self-reported physical activity outcomes (adjusted model β = − 651.6, t(613) = − 1032, p = .303). CONCLUSIONS: Differences in organizational-level implementation fidelity trajectories did not result in outcome differences at patient-level. This suggests that an effective implementation fidelity trajectory is contingent on the local organization’s conditions. More specifically, achieving stable high implementation fidelity required the management of tensions: realizing a localized change vision, while safeguarding the program’s standardized core components and engaging the scarce physicians throughout the process. When scaling up evidence-informed health promotion programs, we propose to tailor the management of implementation tensions to local organizations’ starting position, size, and circumstances. TRIAL REGISTRATION: The Netherlands National Trial Register NTR3961. Registered 18 April 2013. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi: 10.1186/s13012-017-0667-8) contains supplementary material, which is available to authorized users. BioMed Central 2017-12-01 /pmc/articles/PMC5709964/ /pubmed/29191230 http://dx.doi.org/10.1186/s13012-017-0667-8 Text en © The Author(s). 2017 Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
spellingShingle Research
Hoekstra, Femke
van Offenbeek, Marjolein A. G.
Dekker, Rienk
Hettinga, Florentina J.
Hoekstra, Trynke
van der Woude, Lucas H. V.
van der Schans, Cees P.
Implementation fidelity trajectories of a health promotion program in multidisciplinary settings: managing tensions in rehabilitation care
title Implementation fidelity trajectories of a health promotion program in multidisciplinary settings: managing tensions in rehabilitation care
title_full Implementation fidelity trajectories of a health promotion program in multidisciplinary settings: managing tensions in rehabilitation care
title_fullStr Implementation fidelity trajectories of a health promotion program in multidisciplinary settings: managing tensions in rehabilitation care
title_full_unstemmed Implementation fidelity trajectories of a health promotion program in multidisciplinary settings: managing tensions in rehabilitation care
title_short Implementation fidelity trajectories of a health promotion program in multidisciplinary settings: managing tensions in rehabilitation care
title_sort implementation fidelity trajectories of a health promotion program in multidisciplinary settings: managing tensions in rehabilitation care
topic Research
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5709964/
https://www.ncbi.nlm.nih.gov/pubmed/29191230
http://dx.doi.org/10.1186/s13012-017-0667-8
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