RESUMEN
BACKGROUND: "Context" is a mediating construct that significantly influences the initiation and maintenance of program implementation, but it has seldom been studied in process evaluation. This case study describes the contextual factors that encourage or impede the implementation processes of a research-tested program at a Federally Qualified Community Health Center. METHOD: We conducted 14 key informant interviews with providers, nurses, medical assistants, and clinic staff in leadership and management positions during the 24 months of active implementation. Interview data were analyzed using Atlas.ti software. A written log documenting exposure, adherence, and coverage of the implementation was used to describe implementation fidelity. RESULTS: Findings indicated that program implementation needs to align with the organization's mission and values. Sensemaking caused individuals to understand the importance of the new process and increased their motivation to follow assigned procedures. Revisions of the implementation process allowed the program to fit better with the clinic's existing workflow. However, permitting flexibility in the delivery of an intervention may result in inconsistent implementation fidelity. In this study, threats to implementation included unanticipated changes in the clinic environment, such as budget cuts to resources and staff turnover as a consequence of the current economic downturn. CONCLUSIONS: Momentum leading to sustainable implementation requires a continuous team effort and a stable environment; consequently, a successful implementation requires a structure that supports problem solving, communication, and evaluation.
Asunto(s)
Actitud del Personal de Salud , Neoplasias Colorrectales/diagnóstico , Educación en Salud/métodos , Personal de Salud/psicología , Anciano , Asiático , Centros Comunitarios de Salud , Femenino , Humanos , Entrevistas como Asunto , Masculino , Persona de Mediana Edad , Estudios de Casos Organizacionales , Vietnam/etnologíaRESUMEN
BACKGROUND: Understanding and enhancing change capabilities, including Practice Adaptive Reserve (PAR), of Community Health Centers (CHCs) may mitigate cancer-related health disparities. MATERIALS AND METHODS: Using stratified random sampling, we recruited 232 staff from seven CHCs serving Asian Pacific Islander communities to complete a self-administered survey. We performed multilevel regression analyses to examine PAR composite scores by CHC, position type, and number of years worked at their clinic. RESULTS: The mean PAR score was 0.7 (s.d. 0.14). Higher scores were associated with a greater perceived likelihood that clinic staff would participate in an evidence-based intervention (EBI). Constructs such as communication, clinic flow, sensemaking, change valence, and resource availability were positively associated with EBI implementation or trended toward significance. CONCLUSIONS: PAR scores are positively associated with perceived likelihood of clinic staff participation in cancer screening EBI. Future research is needed to determine PAR levels most conducive to implementing change and to developing interventions that enhance Adaptive Reserve.
Asunto(s)
Pueblo Asiatico/estadística & datos numéricos , Centros Comunitarios de Salud/organización & administración , Práctica Clínica Basada en la Evidencia , Promoción de la Salud , Nativos de Hawái y Otras Islas del Pacífico/estadística & datos numéricos , Neoplasias/prevención & control , Adulto , Atención a la Salud , Detección Precoz del Cáncer , Femenino , Estudios de Seguimiento , Accesibilidad a los Servicios de Salud , Humanos , Masculino , Persona de Mediana Edad , Neoplasias/etnología , Pronóstico , Adulto JovenRESUMEN
Hearing protection devices (HPD) remain a primary method of prevention of noise-induced hearing loss despite their well-known limitations. A three-pronged intervention to increase HPD use was conducted among construction workers and included a baseline hearing loss prevention training, follow-up 'toolbox' (TB) reinforcement trainings, and use of a personal noise level indicator (NLI). A total of 176 subjects on eight sites completed three assessments. Prior to intervention, HPDs were used an average of 34.5% of the time and increased significantly, up about 12.1% after intervention and 7.5% two months after interventions were completed. The increase in HPD use was greatest among the group receiving both TB and NLI interventions; up about 25% from baseline, and this group was about two times more likely to use HPDs than the BL (baseline) training only group. This study demonstrates the mild impact of a well-constructed HPD use training and provides support for the additional use of a personal NLI to increase use of HPDs among construction workers. The most effective procedures for using such instruments require further exploration.
Asunto(s)
Dispositivos de Protección de los Oídos/estadística & datos numéricos , Arquitectura y Construcción de Instituciones de Salud , Promoción de la Salud , Pérdida Auditiva Provocada por Ruido/prevención & control , Ruido en el Ambiente de Trabajo/efectos adversos , Enfermedades Profesionales/prevención & control , Servicios de Salud del Trabajador , Servicios Preventivos de Salud , Adulto , Audiometría , Diseño de Equipo , Conductas Relacionadas con la Salud , Educación en Salud , Conocimientos, Actitudes y Práctica en Salud , Pérdida Auditiva Provocada por Ruido/diagnóstico , Pérdida Auditiva Provocada por Ruido/etiología , Humanos , Modelos Lineales , Modelos Logísticos , Masculino , Persona de Mediana Edad , Enfermedades Profesionales/diagnóstico , Enfermedades Profesionales/etiología , Oportunidad Relativa , Refuerzo en Psicología , Factores de Tiempo , Washingtón , Recursos HumanosRESUMEN
OBJECTIVES: Although noise-induced hearing loss is completely preventable, it remains highly prevalent among construction workers. Hearing protection devices (HPDs) are commonly relied upon for exposure reduction in construction, but their use is complicated by intermittent and highly variable noise, inadequate industry support for hearing conservation, and lax regulatory enforcement. METHODS: As part of an intervention study designed to promote HPD use in the construction industry, we enrolled a cohort of 268 construction workers from a variety of trades at eight sites and evaluated their use of HPDs at baseline. We measured HPD use with two instruments, a questionnaire survey and a validated combination of activity logs with simultaneous dosimetry measurements. With these measurements, we evaluated potential predictors of HPD use based on components of Pender's revised health promotion model (HPM) and safety climate factors. RESULTS: Observed full-shift equivalent noise levels were above recommended limits, with a mean of 89.8 +/- 4.9 dBA, and workers spent an average of 32.4 +/- 18.6% of time in each shift above 85 dBA. We observed a bimodal distribution of HPD use from the activity card/dosimetry measures, with nearly 80% of workers reporting either almost never or almost always using HPDs. Fair agreement (kappa = 0.38) was found between the survey and activity card/dosimetry HPD use measures. Logistic regression models identified site, trade, education level, years in construction, percent of shift in high noise, and five HPM components as important predictors of HPD use at the individual level. Site safety climate factors were also predictors at the group level. CONCLUSIONS: Full-shift equivalent noise levels on the construction sites assessed were well above the level at which HPDs are required, but usage rates were quite low. Understanding and predicting HPD use differs by methods used to assess use (survey versus activity card/dosimetry). Site, trade, and the belief that wearing HPD is not time consuming were the only predictors of HPD use common to both measures on an individual level. At the group level, perceived support for site safety and HPD use proved to be predictive of HPD use.