Background
Educational tools for patients are constantly created, disseminated and implemented across healthcare settings, with the ultimate aim of improving health outcomes. Dissemination involves planned efforts to spread experimentation with or adoption of the tool, while implementation refers to efforts to integrate it into usual care. Healthcare education tools come in many formats and can be disseminated using different strategies. According to systematic reviews, evidence comparing the effectiveness of dissemination strategies is mostly equivocal [
1‐
3]. However, passive dissemination, such as handing out or mailing printed materials, is less effective than active dissemination strategies and does not show an effect on patient outcomes [
2].
Multi-component dissemination strategies show more powerful effects than any single strategy alone [
2‐
4]. There is some evidence that characteristics of certain dissemination strategies may enhance ease of use, such as the inclusion of how-to materials, tailored toolkits, or skill training for providers involved in dissemination [
4].
Greenhalgh et al. [
5] proposed three broad system antecedents for innovation, i.e. characteristics of a facility that facilitate the successful dissemination of educational tools. These system antecedents include (1) institutions that are large and mature enough to incorporate changes, since smaller, newer institutions focus on more basic growth and have fewer resources; (2) preexisting knowledge base within the institution, to better integrate new materials; and (3) a receptive context for change, including appropriate leadership within an organization. They also identified factors that enhance implementation once a system is ready for dissemination, including assigning decision-making to frontline medical teams and having good internal communication, thereby allowing providers to communicate dissemination strategies with one another.
This paper details the dissemination and implementation of an educational tool called the STAR Well-Kit (SWK), a DVD designed to introduce U.S. Veterans to Complementary and Alternative Medicine (CAM) practices. The VA Office of Patient Centered Care & Cultural Transformation funded the development of the SWK to promote CAM modalities as a more patient-centered approach reflecting Veteran interest in these services [
6]. Given the geographic dispersion of VA healthcare facilities and the limited on-site expertise available at many VA healthcare facilities at the time, the SWK focused on modalities which can be practiced independently, such as yoga, meditation, and breathing. The goals of the SWK were to raise awareness by educating Veterans about the benefits of CAM practices using Veteran testimonials and to allow them to try several brief demonstration practices. The DVD consisted of 85 min of content divided into four major segments and included closed captioning. The major segments included an introduction to CAM for Veterans, interviews with Veterans on their CAM experience, brief CAM practices to try along with the DVD (specifically, soft belly breathing, guided meditation, qigong, chair yoga, and hatha yoga), and views from the provider community regarding the benefits of CAM for Veterans. With increased awareness, Veterans could then seek additional CAM opportunities, whether through multimedia recordings or classes within their VA or community.
In line with the best-practices above, SWK dissemination involved multi-component strategies, and was distributed with “tip sheets” for both Veterans and their providers. Once the SWK and its accompanying materials were designed, the question remained as to optimal implementation techniques given the institutional structure of the VA, the needs of particular Veterans and providers, and the fact that CAM is a relatively novel and nontraditional approach to improving wellness. To determine best practices for dissemination and implementation of the SWK, we considered many factors, including the available resources of the VA, the availability and involvement (or lack thereof) of providers, and the variability of VA facilities’ existing CAM-related infrastructure.
This paper describes the dissemination and implementation of the SWK, including successful strategies and lessons learned. The value of understanding SWK dissemination and implementation process is not exclusive to this project. Rather, it highlights important lessons and strategies that may be applied to the broad dissemination and implementation of many healthcare-related educational tools.
Methods
The SWK was disseminated and implemented over two phases. The first, dissemination phase, focused on spreading experimentation with the SWK and assessing the best settings and methods for adoption. The second, implementation phase was an effort to integrate the SWK into usual care on a broader scale. Methods for the two phases are described separately.
Dissemination phase
During the initial phase, 725 Veterans were given SWK packets containing an instruction letter, pre- and post-viewing surveys with return envelopes, and a focus group invitation. All dissemination took place within the catchment area of the Veterans Affairs-New Jersey Health Care System (VA-NJHCS), which covers northern and central New Jersey. The ambulatory service settings were chosen with a goal of ensuring participant diversity in terms of age, deployment experience, and mental and physical health. Beyond being a Veteran, there were no inclusion or exclusion criteria for participants receiving the SWK, as participation was anonymous. However, providers, peers and team members who distributed the SWK were encouraged to discuss the need for access to a DVD player or computer with DVD drive.
Four dissemination methods were used: (1) Active Dissemination: A research team member explained the study in waiting rooms in one of three clinic settings: primary care, mental health, and clinics for recently separated Iraq or Afghanistan Veterans (“post-deployment clinics”). The researcher distributed packets and explained the contents to interested Veterans. (2) Passive Dissemination: Along with an explanatory poster, unattended copies of the SWK packet (usually ten at a time) were left in waiting rooms in the three selected clinic types for Veterans to take at their own behest. Interested Veterans were expected to follow the instructions in the cover letter. A member of the research team monitored packets to see how many had been taken. (3) Healthcare Provider-Mediated Dissemination: We asked healthcare providers of many types from the three selected clinic types to provide the packet to patients in the context of their routine clinical visit. Providers who volunteered were advised to use their discretion to decide how and to whom to present it. (4) Peer-mediated Dissemination: A community-based peer support and outreach group staffed by Veterans offered the packet to Veteran clients they interacted with by phone, in person, or at group outreach events. Funding was provided for this group to be involved in the dissemination. Peer-counselors were given talking points for disseminating packets.
Five Veteran focus groups were conducted by research team members, with 43 Veterans participating. Participants had all received a SWK packet and called or returned a mailing stating their interest in joining a focus group. The purpose of the focus groups was to assess Veteran awareness, knowledge and perceptions of CAM, to pilot test the SWK content, and obtain feedback on the various SWK dissemination techniques used, as well as other possible strategies. Some limited information on the packaging of the DVDs was also addressed. Finally, Veterans were asked to discuss possible next steps of using the DVD and any barriers. Two trained moderators led the groups and each session was recorded. At the end of each group, the moderator and at least one observer/research assistant discussed top line observations and noted minor additions to the discussion guide for subsequent groups. Waivers of informed consent were approved by the VA-NJHCS IRB given the anonymous and low-risk nature of the research. The focus group audio recordings were transcribed and de-identified by assigning a numeric ID to each participant in the focus groups. Using the grounded theory approach, “discovery of theory from data--systematically obtained and analyzed,” [
7] the research team developed a code book and 2–3 researchers independently coded each group using the software “NVivo 8.” Differences in coding were reconciled to attain consensus.
The coded text was then reviewed in an iterative fashion from which themes emerged. Once themes were developed the researchers went back through the coded text to find quotes that supported or best illustrated the theme.
During the initial phase, providers who agreed to disseminate SWK packets were asked to return a questionnaire with their impressions of the SWK and their experiences disseminating it. They were also asked to volunteer for semi-structured interviews to further assess their approaches to dissemination. Forty-seven providers agreed to disseminate, 14 returned surveys, and eight participated in semi-structured interviews. NJHCS IRB waived the informed consent of provider interviews.
Data from this project is potentially available from the corresponding author subject to VA’s policies and regulations on privacy and information security.
Implementation phase
This phase involved dissemination throughout the VA healthcare system and collecting program evaluation data to assess effectiveness. Data from Veteran focus groups suggested that engaging providers in SWK dissemination would be beneficial. The low initial response from volunteer providers prompted the focus on “champion” providers in the implementation phase. Champion providers were physicians, psychologists, social workers, nurses and physician assistants who had existing knowledge of CAM and its nascent role in VA healthcare. These providers were targeted as more likely to implement the SWK successfully. They were identified from across the national VA system based on involvement in VA Office of Patient Centered Care and Cultural Transformation (OPCC & CT) programs, or involvement with the War Related Illness and Injury Study Center (WRIISC).
Champions were emailed information about the SWK and asked if they were interested in disseminating DVDs. Interested providers watched DVDs and completed semi-structured interviews assessing their views of the DVD, whether they would like to disseminate copies, and if so, how and to whom. Interviews were recorded and key segments transcribed. Fifteen hundred of the DVDs (28 %) were mailed with program evaluation surveys on views of CAM for Veterans to complete, with attached return envelopes. Interested providers received DVDs to disseminate and a “dissemination suggestions tip sheet” with information on optimizing dissemination, based on feedback from the initial phase. Six weeks after DVDs were mailed, providers gave follow-up information by phone or email. Follow-up questions assessed whether dissemination was going according to original plan, whether it had changed and why, what barriers they had encountered, and what feedback or conversations they had with Veterans about the SWK. Engaged providers were offered additional DVDs to distribute. Some providers requested additional DVDs to share with their colleagues, which we provided.
Analysis
The current paper focuses on qualitative information from providers and Veterans during both phases of the project. In addition, quantitative results were calculated from the tracking systems used by the research team and are interspersed in the results to provide additional context. During the dissemination phase, we used the grounded theory approach, involving “discovery of theory from data” [
6]. We developed coding schemes to code transcripts, from which themes emerged. Two researchers independently coded transcriptions, and differences were reconciled to attain inter-coder reliability. During the implementation phase, data collected for program evaluation purposes were analyzed using the basic coding scheme from the dissemination phase. Subsequently, the research team triangulated the dissemination and implementation phase data to identify and organize themes that emerged from Veteran focus groups, provider semi-structured interviews, and other communications with providers.
Discussion
Many lessons from the SWK project support the existing literature about factors that support or hinder effective dissemination and implementation. Passive dissemination is common and lower cost. However, as previous evidence has shown [
2], it does not lead to a wide-scale uptake. The threshold initiative for patients to take the SWK from the waiting room was low, but use of the tool and follow-up were also presumed low in this situation.
Reaching patients through their providers is a more effective means of implementing a large scale, sustainable education dissemination program. However, handing tools to providers with little commitment or knowledge of the subject matter may not fare much better than passive dissemination. Some providers had trouble finding time or the appropriate context to discuss the SWK within a clinical visit, and some had little previous knowledge of CAM, or connection to colleagues with this expertise.
The implementation phase addressed many known determinants of successful dissemination. In terms of system antecedents to innovation [
5], the VA is large and mature enough to incorporate new tools and ideas. Many selected sites also had institutional CAM support. The SWK was most successful in settings with both champion providers and existing infrastructure to support CAM, which is likely related to the institutions’ leadership. By targeting champions, we sought out providers with preexisting CAM knowledge. This was effective because the provider community was engaged with the message, and the educational tool fit into the broader local context. Champion providers were more likely to communicate to Veterans that they were on board with CAM, and available for follow-up questions or for assistance integrating CAM into overall healthcare.
Other factors can improve dissemination after system antecedents are in place [
5], including allowing providers to dictate the dissemination method. Our results show the value of this practice. Providers need to be engaged with education, organizational supports, and peer communication to increase awareness and value of educational tools. However, they also need to adapt dissemination to fit the confines of their particular duties and time commitments, addressing needs of the population they serve.
Results of this project also illustrated that good internal communication improves dissemination efforts [
5]. Not all providers can begin as “champion” providers in a given area. SWK use spread through provider-initiated dissemination to colleagues, including to providers who did not specialize in CAM. Having the SWK distributed by known colleagues with broader training may increase provider interest in using the SWK first as a learning tool and then as a teaching tool for their patients. When introducing any new health education tool, optimal success may require culture change and infrastructure developments as well as opportunities for collaboration among healthcare providers.
While our experience may inform any educational healthcare tool, some features may be unique to CAM-related interventions and the VA setting. Primary care doctors have expressed interest in having more information on CAM [
8], which continues to spread within medical contexts [
9,
10]. In terms of the SWK project, VA CAM offerings have been expanding over the past decade [
6], which likely has increased Veteran and VA provider interest. One published paper discussed lessons learned in disseminating CAM curricular initiatives within a medical education setting [
11]. While the setting differs from ours, the authors’ experiences implementing CAM education support our recommendations and experiences. For example, they note that some faculty were resistant due to lack of time and not prioritizing CAM. However, they ultimately described successful CAM integration into the curriculum using many of the same tactics as the SWK project, including nurturing the organization’s leadership on the matter, increasing educational opportunities, and making CAM a part of their infrastructure by embedding it in other educational activities. Another study examined the integration of stand-alone CAM clinics into their broader communities and healthcare settings [
12] and emphasized the importance of “visionary” champions within the centers as well as strong internal networking and communication.
Limitations
Because the SWK was a clinical implementation project, we lacked empirical data from Veterans who received the SWK, especially during the implementation phase. Evidence of successful and unsuccessful dissemination strategies is based on the rate of survey return or on qualitative feedback from semi-structured interviews with providers. We obtained only limited data from Veterans about their actual use and adaptation of the tool. Evaluation of a dissemination and implementation strategy and its potential impact is best conducted by direct patient experience and observation. However, to maintain patient anonymity and allow for provider freedom in dissemination, and due to the national scale of the implementation project and the imperative to disseminate the SWK as quickly as possible, the information we present is based largely on provider experience and feedback.
Conclusions and practice implications
Many of the lessons learned from the SWK project can be applied to the dissemination of any new educational tool within a healthcare setting. The results of the SWK project reiterate the importance of utilizing best practices for introducing educational tools within the healthcare context and the need for thoughtful, multi-faceted dissemination strategies. Systematic evaluation of future CAM education and implementation efforts should build on this report and expand our knowledge of best practices.
Acknowledgements
We would like to acknowledge the work of Anna Rusiewicz, Ph.D. in developing the STAR Well-Kit that was disseminated during our study.