Process evaluation of a knowledge translation intervention using facilitation of local stakeholder groups to improve neonatal survival in the Quang Ninh province, Vietnam

BACKGROUND: Annually, 2.8 million neonatal deaths occur worldwide, despite the fact that three-quarters of them could be prevented if available evidence-based interventions were used. Facilitation of community groups has been recognized as a promising method to translate knowledge into practice. In northern Vietnam, the Neonatal Health - Knowledge Into Practice trial evaluated facilitation of community groups (2008-2011) and succeeded in reducing the neonatal mortality rate (adjusted odds ratio, 0.51; 95 % confidence interval 0.30-0.89). The aim of this paper is to report on the process (implementation and mechanism of impact) of this intervention. METHODS: Process data were excerpted from diary information from meetings with facilitators and intervention groups, and from supervisor records of monthly meetings with facilitators. Data were analyzed using descriptive statistics. An evaluation including attributes and skills of facilitators (e.g., group management, communication, and commitment) was performed at the end of the intervention using a six-item instrument. Odds ratios were analyzed, adjusted for cluster randomization using general linear mixed models. RESULTS: To ensure eight active facilitators over 3 years, 11 Women's Union representatives were recruited and trained. Of the 44 intervention groups, composed of health staff and commune stakeholders, 43 completed their activities until the end of the study. In total, 95 % (n = 1508) of the intended monthly meetings with an intervention group and a facilitator were conducted. The overall attendance of intervention group members was 86 %. The groups identified 32 unique problems and implemented 39 unique actions. The identified problems targeted health issues concerning both women and neonates. Actions implemented were mainly communication activities. Communes supported by a group with a facilitator who was rated high on attributes and skills (n = 27) had lower odds of neonatal mortality (odds ratio, 0.37; 95 % confidence interval, 0.19-0.73) than control communes (n = 46). CONCLUSIONS: This evaluation identified several factors that might have influenced the outcomes of the trial: continuity of intervention groups' work, adequate attributes and skills of facilitators, and targeting problems along a continuum of care. Such factors are important to consider in scaling-up efforts.

Den offentliga sektorns komplexa adaptiva system : En kvalitativ studie om medarbetarpolicys i praktiken

Intresset för hur HR och ledning kan påverka medarbetarnas beteendemönster och den sociala strukturen inom organisationer har gett upphov till denna undersökning. Med utgångspunkt i teorier om komplexa adaptiva system som perspektiv har jag försökt fånga medarbetarnas förutsättningar att nå organisationers vision och därmed förverkliga medarbetarpolicyn i praktiken. Tillsammans med kontaktpersoner från den undersökta kommunen har jag gjort en djupdykning i en offentlig organisation i syfte att förklara byråkratins inverkan på beteendemönstret hos medarbetarna och hur de tillsammans skapar en social struktur vilken speglar organisationens vision. Syftet med studien är att undersöka hur det adaptiva systemet fungerar i en byråkratisk organisation och vad det betyder för medarbetarnas möjligheter att förverkliga organisationens vision och medarbetarpolicy. Undersökningen har genomförts på en socialförvaltning i en kommun i mellan Sverige och med en kvalitativ metod och semistrukturerade intervjuer har sex respondenter deltagit i undersökningen. Samtliga respondenter har olika befattningar inom organisationen och bidrar därmed med olika perspektiv på samma fenomen. Undersökningens resultat visar att den offentliga verksamhetens byråkratiska organisationsstruktur bidrar till att det bildas olika adaptiva system inom organisationen, där medarbetarnas beteendemönster bildar en social struktur som leder till att visionen och medarbetarpolicyn inte förverkligas. Undersökningen visar även att de adaptiva systemen inom organisationen inte påverkar varandra, då de inte interagerar med varandra inom organisationen. Det som ligger till grund för hur medarbetarnas beteendemönster etableras inom organisationen är kraven från omvärlden, hög arbetsbelastning och avsaknaden av stabilitet i den organisatoriska och sociala arbetsmiljön och inte vad tidigare forskning visat; att det skulle vara hög regelstyrning som ligger till grund för beteendemönstret inom den offentliga sektorn. Slutsatsen är att för att medarbetarna ska kunna förverkliga organisationens vision och medarbetarpolicy kräver det att HR, ledning och medarbetare alla ingår i samma adaptiva system. För att det ska vara möjligt behöver HR upprätta strategier för hur samtliga inom organisationen ska interagera med varandra i det dagliga arbetet. Ledningen och medarbetarna behöver även ha goda möjligheter att kommunicera med varandra regelbundet i en större omfattning än vad de gör idag. Konkreta åtgärder för hur det lämpligen bör genomföras presenteras under diskussionen.

Communication in Smoking Cessation and Self-management : a study at Nurse-led COPD-clinics in Primary Health Care

ABSTRACTThe general aim of this thesis was to investigate behavioral change communication at nurse-led chronic obstructive pulmonary disease (COPD) clinics in primary health care, focusing on communication in self-management and smoking cessation for patients with COPD.Designs: Observational, prospective observational and experimental designs were used.Methods: To explore and describe the structure and content of self-management education and smoking cessation communication, consultations between patients (n=30) and nurses (n=7) were videotaped and analyzed with three instruments: Consulting Map (CM), the Motivational Interviewing Treatment Integrity (MITI) scale and the Client Language Assessment in Motivational Interviewing (CLAMI). To examine the effects of structured self-management education, patients with COPD (n=52) were randomized in an intervention and a control group. Patients’ quality of life (QoL), knowledge about COPD and smoking cessation were examined with a questionnaire on knowledge about COPD and smoking habits and with St. George’s Respiratory Questionnaire, addressing QoL. Results: The findings from the videotaped consultations showed that communication about the reasons for consultation mainly concerned medical and physical problems and (to a certain extent) patients´ perceptions. Two consultations ended with shared understanding, but none of the patients received an individual treatment-plan. In the smoking cessation communication the nurses did only to a small extent evoke patients’ reasons for change, fostered collaboration and supported patients’ autonomy. The nurses provided a lot of information (42%), asked closed (21%) rather than open questions (3%), made simpler (14%) rather than complex (2%) reflections and used MI non-adherent (16%) rather than MI-adherent (5%) behavior. Most of the patients’ utterances in the communication were neutral either toward or away from smoking cessation (59%), utterances about reason (desire, ability and need) were 40%, taking steps 1% and commitment to stop smoking 0%. The number of patients who stopped smoking, and patients’ knowledge about the disease and their QoL, was increased by structured self-management education and smoking cessation in collaboration between the patient, nurse and physician and, when necessary, a physiotherapist, a dietician, an occupational therapist and/or a medical social worker.Conclusion The communication at nurse-led COPD clinics rarely involved the patients in shared understanding and responsibility and concerned patients’ fears, worries and problems only to a limited extent. The results also showed that nurses had difficulties in attaining proficiency in behavioral change communication. Structured self-management education showed positive effects on patients’ perceived QoL, on the number of patients who quit smoking and on patients’ knowledge about COPD.