![]() | Feature: Healthy Living Move for Health | No.49 January 2007 |
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Abstract
This paper explains why innovation processes, such as the introduction
of newly developed physical activity programs, often fail in the implementation
phase. Why is it important to carry out research in this area and how
may we do this? The implementation challenge is illustrated using examples
of the introduction of physical activity programs for older people.
Attention is paid to the definition of some widely used concepts and what
is known in general about the implementation challenge. Introduction
Most research on physical activity is in the area of effectiveness:
are there favourable results from a program on health variables? Are
the results in the experimental group better than in the control group?
In the best case, all the available research articles are put together
in a scholarly review or a meta-analysis of the effects on personal
(health) variables.
However, in most cases the question still remains of what facilitates or impedes the introduction of a new intervention program in practice. This is called the “implementation challenge”. It is not enough to observe health effects in a laboratory situation (as is mostly the case in randomised controlled trials) - programs also have to show their effect in real life situations and to prove their implementation ability in the organisations that will serve the programs to the public. It is known from experience in introduction of innovative programs (1) that, without a systematically guidance of the introduction by program managers, only 7% is used as intended (see figure 1). Figure 1: Illustration of the “Implementation Challenge”. Use as intended of innovations
after one year (Adjusted from Paulussen, 1994) ![]() In this paper it will be explained why innovation
processes often fail, why it is important to carry out research in this
area and how we may do this, and what we can learn of earlier experiences
in the introduction of innovative physical activity programs. The definition of some widely used concepts will be given. After that, the pathway from basic research to implementation is viewed from the perspective of the researcher and from the perspective of the practitioner, illustrated with examples of my own research. Finally, some basic principles of the diffusion theory of Rogers are given and the RE-AIM framework of Glasgow is introduced to support research on innovation processes. Concepts and definitions
Margot Fleuren and her colleagues (2) reviewed the determinants of innovations
within health care organisations. They carried out a review of the literature
and a Delphi procedure among 44 implementation experts. As stated before,
only around 7% of the innovative programs were used as intended. Several
determinants facilitated or impeded their introduction. Fleuren et al.
(2004) identified 50 determinants of the innovation process. They were
categorised as:
To avoid confusion about terminology, the most widely
used concepts are defined below, using the definitions by King et al.
(3):
Dissemination = the purposive process by which knowledge, including knowledge about an innovation or program, is transferred (especially transfer between researchers and practitioners). Adoption = the decision-making step when an individual or organisation initially accepts an innovation or program, and commences the process of putting it to use. Implementation = conducting a program or set of activities as planned. This means that the program manager of the organisation or the individual tries to adhere to the innovation as intended. Maintenance = the continued use or implementation of a program. How the organisation or individual does its best to continue the use. Diffusion = the spread or transfer of knowledge, including knowledge about an innovation or program; a passive process. Note the difference between this and dissemination. Dissemination is a purposive process, while diffusion is something that happens spontaneously. Linkage = the system or patterns of connection between groups (especially researchers and practitioners). The processes from dissemination to maintenance
is mostly referred to as the “implementation process”, but
may be better generalised as the “innovation process”. Linkage
is important during all the various stages of this process, and researchers,
program developers and program managers, as well as practitioners, should
continuously put effort into this inter-group communication. Depending on the perspective of researcher or practitioner, how the innovation process looks like, will vary. We may even distinguish a third perspective: the program manager and policy maker. This third party may be interested in monitoring the whole process. Innovation from the perspective of the researcher
Nutbeam and his colleagues (4) developed a research model to guide the
innovation process (see figure 2).
Figure 2: The researchers’perspective: the model of Nutbeam et al (1990) ![]() (Adapted from Nutbeam et al., J Epi Comm Health 1990; 44: 83-89) After basic research and theory have been studied,
the experimental phase can start (mostly with randomised controlled trials).
If this research is successful, then a demonstration study can be planned
with relatively more emphasis placed on process evaluation. If this phase
is successful, then dissemination studies can be planned. The model ends
with the continuing management of implementation (if the innovation was
successful of course). These stages in the Nutbeam model will be discussed
in more detail, using the TNO Ageing Well and Healthily program (a physical
activity program for older adults) as an example (see textbox 1).
Basic Research and Theory
Because nobody wants to re-invent the wheel, one
needs to search the literature for information on the type of innovation
you want to develop and to implement. You also always need to collect
information about determinants of behaviour. A number of theoretical models
about determinants of individual behaviour have been developed. An integrative
model that is frequently used is the so-called ASS model, where A stands
for attitude, S for social norms and S for self-efficacy (5). Attitude,
social norms and self-efficacy together determine the individual behavioural
intention. It is important to realise that this part of the model has
a rather good ability to predict the outcome of individual behavioural
intention. It is more difficult, however, to predict actual behaviour.
The prediction of actual individual behaviour can be improved by taking
information about perceived barriers and about specific skills into account.
In the field of exercise behaviour the model of Triandis (6), ‘habits’
are also added as an important predictor of actual behaviour. A problem
that is often neglected is the relapse of behaviour (7)[1]
. Of course the desired outcome is always the maintenance of a certain
“beneficial” individual behaviour. With knowledge from several
determinants studies, we were able to design an innovative intervention
(Ageing Well and Healthily), with group health education and a low intensity
exercise program as the two ingredients to help individual older inactive
people to adopt a healthier lifestyle.
Experimental studies
The next step in the Nutbeam research model is to carry out experimental
studies.
The intervention can be tested in a small randomised controlled study. At this stage, outcome evaluation is the most important feature. For example, in a study of exercise programs, one could choose to measure blood pressure variables, some physiological measures, and blood variables such as cholesterol and glucose. In the Ageing Well and Healthily study this is exactly what was done (8). Respondents were divided in an experimental group and a control group. Various physiological variables were measured at baseline, before the intervention was started. The study participants were also interviewed at home, using standardised health and quality of life measures.
According to the model of Nutbeam, one should also perform process evaluation
at this stage. This can be done while the intervention is being carried
out. Process evaluation measures the satisfaction of the individual
participants with the intervention, and variables such as the participation
level and location and travel problems. Using short questionnaires,
completed after each session by both participants as well as the group
leaders, can carry out process evaluation. In this way, it was discovered
that the peer educators of the Ageing Well and Healthily program needed
more time for their part of the sessions. Because this type of research
is usually relatively expensive because of the intensive outcome evaluation,
it is preferable to do this in small groups only.
Researchers should not forget that a program could be tested perfectly
well in a laboratory setting; however, the question remains whether
the same results will be obtained when the intervention is carried out
in the ‘real’ world. Demonstration study
In the case of Ageing Well and Healthily, the intervention was found
to have beneficial effects in the experimental phase and so we continued
with a demonstration study. According to the model of Nutbeam, in this
phase, relatively little attention is given to outcome evaluation and
more attention is paid to process evaluation.
The researcher still plays an important role. We first had to decide
where we wanted to perform our demonstration studies. In our case, we
chose a few big towns, some middle-sized towns and some relatively small
villages. We then approached people in organisations to see whether
they would be willing to collaborate with us. Collaboration with TNO
was usually considered attractive because we arranged a lot of things,
such as a symposium at the start and the end of the project, protocols
and money for the organisation of the local programs. We also provided
materials, trained peer-educators and trained exercise leaders.
In this type of study, the randomised-controlled approach is not the
most appropriate design. We elected a Community Intervention Trial (8,9).
It takes a lot of effort to conduct health interventions in a broad
area, in the field, and still keep the study under full control of the
researchers. As a researcher, you have to be very creative in finding
ways to control the study design. We used a time-delay method where
one big town, two middle-size towns and one small village served as
controls for four other towns and villages of the same size. At the
end of the study we were able to control for the most important outcome
variables. For the process evaluation we made use of a specially trained
interviewer who functioned independently and could ask questions to
participants, educators, exercise leaders and program organisers. Dissemination and Implementation study
As a researcher, after the demonstration phase you hope that your intervention
was successful enough to warrant dissemination and implementation through
national introduction. In the case of Ageing Well and Healthily, it
was two years after the start of the experimental study before we could
start the broader introduction of the program. In this stage, collaboration
with national partners in the field is necessary. As a researcher, you
no longer decide where programs should be carried out. Your task is
to disseminate the knowledge and just wait and see what happens (maybe
policy makers and program managers can be assisted to monitor this innovation
process, but this requires another kind of researcher).
There are various ways to disseminate information and knowledge about
your intervention, for example, by books, and training sessions. In
our case, we established a co-ordination centre at TNO in Leiden. We
published articles in journals for local professionals. In this context,
it was important to present the information in an understandable, practical
way, and this was not necessarily the same way we would present the
information in an article for a research journal. Once is not enough,
you have to be very tenacious. In order to do the right things you may
use the model of Fleuren et al. (2) to determine the most suitable determinants
of innovation. You should think of making flyers, posters, videos; all
possible ways to make people aware of your program. In the case of Ageing
Well and Healthily, we collaborated with the Dutch Red Cross organisation,
with the association for More Exercise for Seniors, and with the national
association of Municipal Health Services. We made posters, videos and
flyers to support the collaborating parties in dissemination of Ageing
Well and Healthily.
It was possible to monitor dissemination ie where programs were carried
out, by whom, with how many participants, were they satisfied, did they
change their behaviour, was it easy to disseminate, if not, why not,
what can be done to make things better, do organisers, educators, and
exercise trainers alter the intervention, if yes, why and in what way?
In the case of Ageing Well and Healthily, dissemination of the program
took longer than we had anticipated (9). This was due to problems with
the costs of training of the peer-educators and the long time that was
needed for local organisations to include Ageing Well and Healthily
in their yearly budgets for health interventions in this field. After
a few years, we noticed that dissemination and implementation were both
slowing down. One of the problems was the ‘not-invented-here syndrome’;
organisations were reluctant to implement an innovative intervention
that was not developed in their own organisations. This was very disappointing
because at the start of the project we also used the so-called “linkage
model” of Orlandi et al (10) to ensure that key-organisations
for implementation were involved from the beginning. Innovation from the perspective of the practitioner
The practitioner often works in a consensus-based manner: “if
I do this, it will work?”. Why should he or she change his or
her habits? What will the advantage be? What does it mean for the daily
organisation of the work? It can be very disappointing for researchers
if practitioners ignore their beautifully designed innovative interventions.
In the next figure the linkage model of Orlandi et al. (1990) is described.
Figure 3: The linkage model for Researchers and Practitioners (Orlandi et al, 1990)
![]() According to the linkage model, researchers and
practitioners should exchange knowledge on a regular basis. They should
know each other personally and know about each other’s policies,
practices and innovations. For example, in the case of Ageing Well and
Healthily, we cooperated from the start of the whole process with the
director of More Exercise for Seniors, the organisation of exercise leaders.
To effectively link the two systems, we used tools such as symposia, articles
in non-scientific media, videos, brochures and special training sessions
(trained exercise leaders could earn a certificate). Not only should the
researcher provide the practitioners with information but the practitioners
should also provide the researcher with information and feedback. Researchers
should read the journals and leaflets of the practitioner’s organisation
and listen to the requests for research to be carried out on a certain
topic. In the example of Ageing Well and Healthily, it turned out that
exercise leaders of More Exercise for Seniors found it very difficult
to cooperate with a senior health educator. Organisation of the intervention
was perceived as too difficult and too time-consuming. The exercise leaders
were not able to integrate the program into their daily routines. The
researchers were perceived as too demanding on them. Diffusion of innovations
To illustrate the process of adoption of an innovation by practitioners,
the model developed by Rogers (11) is introduced. In his (retrospective)
diffusion model (see Figure 4) you can consider ‘practitioners’
as the exercise leaders of exercise programs.
Figure 4: Diffusion of innovations: the model of Rogers (2003)
![]() At the start of the implementation, the relevant
organisations worked with the innovators and early adopters. These are
people who are willing to change. After a while, the early majority will
adopt the innovation. The most difficult part, however, is to convince
the late majority to adopt the innovative intervention. If you can do
this, it will speed up the dissemination and implementation of your intervention.
The implementing organisation should be prepared that it can take years,
before the full implementation of the innovation is achieved and the so-called
‘laggards’ are reached. And if so, it may be questioned if
the interventions are still delivered as intended! In the case of the
Ageing Well and Healthily program, we have heard that the interventions
have been implemented in more places than we originally knew of. Organisations
copied the materials and trained the educators and exercise leaders on
their own. The exercise leaders that were reluctant to cooperate with
health educators found solutions, such as delivering the health education
part by themselves. Of course, the model of Roger is a theoretical model,
and nobody want to be labelled as a ‘laggard’. Most laggards
have in fact good reasons to be reluctant and will find their solutions
to deal with their problems as just described. By now, we have the biggest
problem at the tail end: people who have changed the innovative interventions
so that these are NOT used as intended!
At TNO we made use of this knowledge and changed the Ageing Well and
Healthily program in the desired direction. We are currently busy making
all the health education materials easily available using the Internet,
to prevent wrong materials being used. We also started training of exercise
leaders in delivering health education to older people. Hopefully, this
will ease the use of the intervention. As researchers however, we have
a problem now: does this adapted intervention still work? To answer
this question, researchers may use a framework for monitoring the innovation
process called the RE-AIM framework. Monitoring dissemination and implementation using
the RE-AIM framework
A relatively new development in the area of innovation research is the
RE-AIM framework of Glasgow et all (12). They identified the following
indicators, which should be monitored to get an indication of the innovation
process.
These are: Reach, Effectiveness, Adoption, Implementation and Maintenance (see figure 5). Figure 5: Description of the RE-AIM framework for
monitoring of dissemination and implementation of health educational interventions
(Glasgow et al, 1999; see website www.re-aim.org)
![]() We are currently using these indicators in our
monitoring research regarding the implementation of two innovative physical
activity programs for people with osteoarthritis of the hip or knee (13).
Both programs are in a re-invention process by the Royal Dutch College
of Physiotherapists that will implement these programs among physiotherapists
in the Netherlands. We hope to get the answers of this research after
a few years of implementation in the field. Discussion
There is still a long way to go before effective health promotion and
innovative physical activity programs are well implemented in the community
or health care organisations. It requires substantial financial resources
to guide these processes. The whole process starts with the identification
of a problem by researchers, practitioners and program managers. Systematic
introduction and careful monitoring of the whole innovation process
is recommended, in order to identify pitfalls and challenges. Two kinds
of researchers are needed: the ones that use the models of Nutbeam and
Orlandi to develop and evaluate innovative programs, and researchers
who are specialised in guiding and monitoring the whole innovation process
after a program is found to be effective in terms of health variables.
The model of Fleuren et al. could be a helpful tool to identify determinants
of this innovation process and the RE-AIM framework is useful for monitoring,
if an effective innovation has be designed and is ready for implementation.
Future research in this area may use the theoretical and practical tools
and insights described here, in order to face the “implementation
challenge”. Acknowledgement
Dr. Margot Fleuren is gratefully acknowledged for the critical reading
of the first draft of this article.
This paper is an adapted version of: Hopman-Rock M. The effective introduction of programs for adapted physical activity for older people: what do we know and what can we learn? In: Bergland A, Langhammer B, red. Adapted physical activity and ageing: an interdisciplinary European challenge. Oslo: Oslo University College, Faculty of Health Sciences, 2006:p. 26-41. [1] mind the difference between individual maintenance
of behaviour and maintenance in the context of the innovation process. References
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13. de Jong, O.R.W., Hopman-Rock, M., Tak, E.C.P.M.
& Klazinga, N.S. (2004). The Results of an Implementation Study of
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Adults with Osteoarthritis (OA) of the Knee and Hip. Health Educ Res;19(3):316-25. Contact
Marijke Hopman-Rock PhD, MSc, MA
TNO Quality of Life, Department of Physical Activity and Health, Leiden, the Netherlands; BodyatWork Research Center Physical Activity, Work and Health, TNO VU University Medical Center Amsterdam, the Netherlands Marijke.Hopman@tno.nl ![]() http://www.icsspe.org/portal/index.php?w=1&z=5 |