Background
Key terms | Explanation of key terms |
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Implementation | A specified set of steps and activities designed to put into practice a specific intervention, program or method of known dimensions [22] |
Implementation research | Systematic and scientific studies that focuses on understanding and improving the processes involved in the implementation of interventions, programs, or methods in real-world settings. It investigates the barriers and facilitators to successful implementation, explores how to adopt interventions to different contexts, and identifies strategies to enhance uptake and sustainability of evidence-based practices. The goal of implementation research is to promote effective translation of research findings into actions that lead to positive outcomes in for example healthcare practice [22, 28, 30] |
Implementation intervention | A specific action or approach designed to facilitate and support the successful implementation of an innovation/method/practice. It is designed to change behaviours at organisational, practitioner, or patient level, and aims to address the barriers and challenges that may arise during the implementation process and improve adoption and integration of the proposed changes into the targeted setting. Implementation interventions can take various forms, such as training and capacity building, stakeholder engagement activities, using evidence-based implementation strategies etcetera. The selection of appropriate implementation intervention depends on the context, the nature of the innovation/method/practice to be implemented and the specific challenges that need to be addressed [22, 24, 25] |
Implementation process | |
Implementation strategies | Discrete activities or techniques used to enhance the successful adoption, integration, and sustainability of an innovation/method/practice in a specific setting or context. These strategies are designed to overcome barriers, enhance the implementation process and promote the uptake of evidence-based practices. Implementation strategies can be diverse and tailored to the unique needs of the situation. The selection of appropriate implementation strategies depends on several factors, including the nature of the innovation/method/practice, the context, the available resources, and potential barriers to implementation [26, 28, 33] |
Implementation activities | |
Process evaluation | Method to assess the implementation and execution of an intervention. That is, it focuses on assessment of the process of an intervention instead of the effect of an intervention. It involves examining the procedures, activities, and resources used to deliver the intervention and how well they align with the intended objectives. A process evaluation helps to identify strengths, weaknesses and areas for improvements, which contributes to a better understanding of how and why an intervention is effective or requires adjustments [31, 32, 34] |
Materials and methods
Study design
Context and participants
Procedure
The clinical intervention – PAP-S
Implementation intervention
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External facilitation [30], one of the researchers (first author) acted as an external facilitator, activating the implementation process at each PHC centre and moderating the meetings and seminars that were held as part of the implementation intervention.
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Leadership engagement [44], support and internal facilitation provided by the managers at each PHC centre.
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Local champions [45], support and internal facilitation provided by healthcare professionals at each PHC centre who were appointed as local PAP-S coordinators: two nurses and one physiotherapist at PHC-C1, one nurse, one physician and one physiotherapist at PHC-C2, and one nurse, one physician, one physiotherapist and one cognitive behavioural therapy (CBT) counsellor at PHC-C3.
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Tailoring to local conditions [46], producing local work routines tailored to each of the PHC centres’ conditions/context.
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Educational outreach [47], an ‘inspirational lecture’ concerning the health benefits of physical activity and an ‘educational lecture’ concerning the PAP-S method.
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Audit and feedback [48], the manager regularly providing statistics to the staff at each PHC centre on the number of PAP-S prescriptions.
Data collection and analyses
Process evaluation of the implementation intervention
Participants’ background characteristics, attitudes towards physical activity promotion, and PAP-S and experiences of the implementation intervention
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How was the implementation process perceived regarding delivery, acceptability, adherence and suitability in relation to context?
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Which components of the implementation intervention facilitated, respectively impeded using the PAP-S method?
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How was the use of the PAP-S method affected during and after the implementation intervention?
Outcome on PAP-S prescriptions
Establishing rigour in data collection and the qualitative analyses
Results
Characteristics of participants and context
PHC centre 1 (n = 41) | PHC centre 2 (n = 17)a | PHC centre 3 (n = 18) | |
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n (%) | n (%) | n (%) | |
Gender | |||
Female / Male | 36 (87.8) / 5 (12.2) | 11 (64.7) / 6 (35.3) | 15 (83.3) / 3 (16.7) |
Profession | |||
Nurse | 19 (46.3) | 6 (35.3) | 5 (27.8) |
Occupational therapist | 3 (7.3) | 0 (0.0) | 0 (0.0) |
PHC centre manager | 1 (2.4) | 2 (11.8) | 1 (5.6) |
Physician | 8 (19.5) | 4 (23.5) | 5 (27.8) |
Physiotherapist | 7 (17.1) | 1 (5.9) | 2 (11.1) |
Psychologist/CBT-therapist | 3 (7.3) | 0 (0.0) | 1 (5.6) |
Other (nurse aides) | 0 (0.0) | 2 (11.8) | 2 (11.1) |
Missing information | 0 (0.0) | 2 (11.8) | 2 (11.1) |
Years of working in the profession | |||
Less than 1 year | 2 (4.9) | 2 (11.8) | 1 (5.6) |
1–3 years | 3 (7.3) | 1 (5.9) | 3 (16.7) |
More than 3 years | 36 (87.8) | 12 (70.6) | 12 (66.7) |
Missing information | 0 (0.0) | 2 (11.8) | 2 (11.1) |
Years of working at the PHC centre | |||
Less than 1 year | 9 (22.0) | 4 (23.5) | 3 (16.7) |
1–3 years | 6 (14.6) | 0 (0.0) | 5 (27.8) |
More than 3 years | 26 (63.4) | 11 (64.7) | 8 (44.4) |
Missing information | 0 (0.0) | 2 (11.8) | 2 (11.1) |
How important is it that healthcare in general promote physical activity in patient consultations? (1–4) | |||
"Not at all important" | 0 (0.0) | 0 (0.0) | 0 (0.0) |
"Not especially important" | 0 (0.0) | 0 (0.0) | 0 (0.0) |
"Rather important" | 8 (19.5) | 5 (29.4) | 0 (0.0) |
"Very important" | 33 (80.5) | 10 (58.8) | 16 (88.9) |
Missing information | 0 (0.0) | 2 (11.8) | 2 (11.1) |
How important is it that you, in your profession practice, promote physical activity in patient consultations? (1–4) | |||
"Not at all important" | 0 (0.0) | 0 (0.0) | 0 (0.0) |
"Not especially important" | 0 (0.0) | 0 (0.0) | 0 (0.0) |
"Rather important" | 15 (36.6) | 6 (35.3) | 5 (27.8) |
"Very important" | 26 (63.4) | 9 (52.9) | 11 (61.1) |
Missing information | 0 (0.0) | 2 (11.8) | 2 (11.1) |
To what extent do you provide physical activity health promotion consultations in your current professional practice? (1–4) | |||
"To a very limited extent or not at all" | 2 (4.9) | 2 (11.8) | 2 (11.1) |
"To a rather small extent" | 12 (29.3) | 4 (23.5) | 3 (16.7) |
"To a rather large extent" | 16 (39.0) | 5 (29.4) | 6 (33.3) |
"To a very large extent" | 11 (26.8) | 3 (17.6) | 5 (27.8) |
Missing information | 0 (0.0) | 3 (17.6) | 2 (11.1) |
The Swedish Physical Activity on Prescription PAP-S, is a method in healthcare for promoting physical activity | |||
Are you familiar with the PAP-S method? (1–4) | |||
"No, I am not familiar with the PAP-S method" | 2 (2.9) | 0 (0.0) | 0 (0.0) |
"Yes, I have heard about the PAP-S method" | 10 (24.4) | 2 (11.8) | 4 (22.2) |
"Yes, I have some general knowledge about the PAP-S method, but not about its specific components" | 26 (63.4) | 8 (47.1) | 11 (61.1) |
"Yes, I am well familiar with the PAP-S method and its specific components" | 3 (7.3) | 4 (23.5) | 1 (5.6) |
Missing information | 0 (0.0) | 3 (17.6) | 2 (11.1) |
To what extent do you use the PAP-S method to promote physical activity in your professional practice? (1–4) | |||
"To a very limited extent or not at all" | 23 (56.1) | 6 (35.3) | 9 (50.0) |
"To a small extent" | 15 (36.6) | 6 (35.3) | 4 (22.2) |
"To a rather large extent" | 2 (4.9) | 0 (0.0) | 1 (5.6) |
"To a very large extent" | 0 (0.0) | 0 (0.0) | 0 (0.0) |
"I do not have patient consultations in my current position" | 1 (2.4) | 2 (11.8) | 2 (11.1) |
Missing information | 5 (6.6) | 3 (17.6) | 2 (11.1) |
Compared to your current situation, to what extent would you like to use the PAP-S method? (1–5) | |||
"To a much lesser extent than today or not at all" | 0 (0.0) | 0 (0.0) | 0 (0.0) |
"To a little lesser extent than today" | 0 (0.0) | 0 (0.0) | 0 (0.0) |
"To the same extent as today" | 3 (7.3) | 2 (11.8) | 3 (16.7) |
"To a little larger extent than today" | 23 (56.1) | 8 (47.1) | 7 (38.9) |
"To a much larger extent than today" | 13 (31.7) | 2 (11.8) | 4 (22.2) |
Missing information | 2 (4.9) | 5 (29.4) | 4 (22.2) |
Median (IQR) | Median (IQR) | Median (IQR) | |
How confident do you feel about your ability to promote physical activity in patient consultations? (0–10) | |||
0 = "not at all confident", 10 = "very confident" (Missing information n = 5, 6.6%) | 7 (5.5–8) | 6 (3.75–9) | 7 (4.25–8) |
How confident do you feel about your ability to use the PAP-S method to promote physical activity in patient consultations? (0–10) | |||
0 = "not at all confident", 10 = "very confident" (Missing information n = 11, 14.5%) | 3 (1–7) | 4.5 (2.25–8.5) | 4.5 (0.75–7) |
Process evaluation of the implementation intervention
Implementation intervention delivery
Changes in context and participants’ attitudes and behaviour
Participants’ experiences of the implementation process
Implementation strategies
Baseline | 9-month follow-up | Chi-squarec | 15-month follow-up | Chi-squarec | |||
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(n = 76) | (n = 76) | df | p-value | (n = 76) | df | p-value | |
To what extent do you use the PAP-S method to promote physical activity in your professional practice? | 9 | .001 | 9 | < .001 | |||
"To a very limited extent or not at all" n(%) | 38 (50.0) | 23 (30.3) | 18 (23.7) | ||||
"To a small extent" n(%) | 25 (32.9) | 18 (23.7) | 23 (30.3) | ||||
"To a rather large extent" n(%) | 3 (3.9) | 12 (15.8) | 8 (10.5) | ||||
"To a very large extent" n(%) | 0 (0.0) | 0 (0.0) | 1 (1.3) | ||||
"I do not have patient consultations in my current position" n(%) | 5 (6.6) | 3 (3.9) | 2 (2.6) | ||||
Missing informationa n(%) | 5 (6.6) | 20 (26.3) | 24 (31.6) | ||||
When you make a physical activity prescription, what of the following components are included: | |||||||
A person-centred counselling talk on health promoting physical activity, for example by use of Motivational Interviewing (1–4) | 6 | .004 | 6 | .021 | |||
"Never" n(%) | 5 (6.6) | 3 (3.9) | 2 (2.6) | ||||
"Seldom" n(%) | 8 (10.5) | 7 (9.2) | 2 (2.6) | ||||
"Often" n(%) | 11 (14.5) | 11 (14.5) | 12 (15.8) | ||||
"Always" n(%) | 14 (18.4) | 17 (22.4) | 17 (22.4) | ||||
Missing informationa n(%) | 38 (50.0) | 38 (50.0) | 43 (56.6) | ||||
Evidence-based diagnosis-specific physical activity advices based on FYSSb (1–4) | 9 | .104 | 6 | .002 | |||
"Never" n(%) | 5 (6.6) | 8 (10.5) | 2 (2.6) | ||||
"Seldom" n(%) | 13 (17.1) | 12 (15.8) | 7 (9.2) | ||||
"Often" n(%) | 14 (18.4) | 12 (15.8) | 16 (21.1) | ||||
"Always" n(%) | 4 (5.3) | 6 (7.9) | 7 (9.2) | ||||
Missing informationa n(%) | 40 (52.6) | 38 (50.0) | 44 (57.9) | ||||
A written prescription in the PAP-S form (1–4) | 9 | .017 | 6 | .087 | |||
"Never" n(%) | 3 (3.9) | 4 (5.3) | 0 (0.0) | ||||
"Seldom" n(%) | 11 (14.5) | 9 (11.8) | 8 (10.5) | ||||
"Often" n(%) | 7 (9.2) | 8 (10.5) | 5 (6.6) | ||||
"Always" n(%) | 18 (23.7) | 18 (23.7) | 21 (27.6) | ||||
Missing informationa n(%) | 37 (48.7) | 37 (48.7) | 42 (55.3) | ||||
A routine for pre-planned and scheduled follow-up of the PAP-S prescription (1–4) | 9 | < .001 | 4 | .002 | |||
"Never" | 6 (7.9) | 8 (10.5) | 2 (2.6) | ||||
"Seldom" | 11 (14.5) | 5 (6.6) | 6 (7.9) | ||||
"Often" | 10 (13.2) | 10 (13.2) | 9 (11.8) | ||||
"Always" | 11 (14.5) | 15 (19.7) | 16 (21.1) | ||||
Missing informationa n(%) | 38 (50.0) | 38 (50.0) | 43 (56.6) | ||||
Referral of the PAP-S prescription to a specialised function within the PHC centre or the healthcare organisation, e.g. a physiotherapist (1–4) | 6 | .119 | 9 | .012 | |||
"Never" n(%) | 7 (9.2) | 11 (14.5) | 8 (10.5) | ||||
"Seldom" n(%) | 10 (13.2) | 11 (14.5) | 8 (10.5) | ||||
"Often" n(%) | 19 (25.0) | 12 (15.8) | 14 (18.4) | ||||
"Always" n(%) | 1 (1.3) | 4 (5.3) | 3 (3.9) | ||||
Missing informationa n(%) | 39 (51.3) | 38 (50.0) | 43 (56.6) | ||||
Referring patients to whom I have prescribed PAP-S, to an activity organiser outside healthcare (1–4) | 4 | .234 | 9 | .001 | |||
"Never" n(%) | 4 (5.3) | 6 (7.9) | 5 (6.6) | ||||
"Seldom" n(%) | 13 (17.1) | 16 (21.1) | 10 (13.2) | ||||
"Often" n(%) | 20 (26.3) | 16 (21.1) | 15 (19.7) | ||||
"Always" n(%) | 1 (1.3) | 1 (1.3) | 4 (5.3) | ||||
Missing informationa n(%) | 38 (50.0) | 37 (48.7) | 42 (55.3) |