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Table 2 Mapping the findings of Indigenous Australian health implementation reviews to the PARiHS framework elements

From: The effectiveness of implementation in Indigenous Australian healthcare: an overview of literature reviews

 

PARiHS – conditions needed for successful implementation

Indigenous Australian implementation – what was included

Indigenous Australian implementation – what was missing

PARiHS – what was missing

1) What is the level and nature of the evidence that underpins implementation

• Research and published guidelines

• Clinical experiences and perceptions

• Patient experiences, needs, and preferences

• Local practice information

• Characteristics of the targeted EBP:

• Relative advantage

• Observability

• Compatibility

• Complexity

• Trialability

• Design quality and packaging

• Costs

Many health services and programs being implemented were not underpinned by rigorous evaluation of their effects. However it seemed that more evidence-based programs were being implemented than the proportion reported in the literature – i.e., implementers were aware of the evidence and implemented evidence-based programs. Research quality of implementation studies was poor or moderate.

Reviews mentioned clinical and patient experience as a source of evidence, but did not elaborate what local data was available or accessed, nor how this knowledge was embedded in practice.

Reviews highlighted the value of Aboriginal control of the research process.

Reviews highlighted the value of local Indigenous knowledge in developing and implementing services and programs.

2) What are the contexts into which the evidence is placed and how does implementation work within diverse health contexts

• Leadership support

• Culture

• Evaluation capabilities

• Receptivity to the targeted innovation/change

Reviews recognised the need for clearly defined management structures and procedures. Commitments to employment of local Indigenous health workers as leaders supported implementation.

The extent to which managers (or other leaders) supported implementation was not made explicit.

To improve the equity and effectiveness of service provision, support for the implementation of services or programs in areas of greatest need was seen to be warranted

Barriers to implementation were reported, e.g., staff recruitment and retention, staff development, the availability and designation of implementation leaders and absence of implementation or communication plans.

The extent to which key stakeholders collaborate, value open dialogue, support implementation and see it as appropriate to their role was not reported.

Short-term funding exacerbated problems in service implementation whilst modest additional resources produced change and enhanced outcomes.

The extent to which targeted sites had resources (expertise and systems) to access baseline and other evaluative data, or evaluated implementation, was not reported.

Community control enhanced credibility and enabled community engagement, cultural activities and commitment to service or program longevity.

The extent to which communication channels, formal networks, internal facilitation resources and authority, and the fit of implementation with organisational priorities was not reported.

Effective partnerships, and collaboration and networking between government and research agencies, health-care providers and Indigenous primary healthcare services increased the likelihood of implementation success.

3) What are the methods for facilitating implementation and what facilitation strategies work?

Role of facilitator:

Three key types of facilitation were found: participatory, grass roots and hierarchical. The need for tailoring implementation across sites was recognised. Implementation was facilitated by external and internal change agents, and enhanced through Indigenous leadership, governance and support for implementation.

The type of facilitation role needed for each type of implementation (e.g., external or system level facilitator) was not explicated; nor was the availability of individual facilitators with appropriate attributes, skills and expertise.

The importance of sustaining service or program implementation was reported, however most of the included studies focused on singular incidents of implementation through pilot initiatives. The cost effectiveness of implementation was mentioned in only one review.

• Purpose, external and/or internal role

• Expectations and activities

• Skills and attributes of facilitator

Other implementation interventions suggested per site diagnostic assessment or relevant sources (e.g., prior research/literature and supplementary theories) and used by the Facilitator and others

Active facilitation worked better than passive dissemination methods. Reviews cited implementation of more than one facilitation strategy, but mix was not optimal.

• Related to E

• Related to C

• Other

4) What works in successfully implementing health services and programs for Indigenous Australians?

Implementation plan and its realisation

Reviews reported a need to plan implementation, yet planning was considered primarily when plans were abandoned due to unexpected contingencies. Formative evaluation to refine implementation plans was reported.

The perceptions of Indigenous stakeholders in terms of the usefulness of such changes was not reported.

 

Evidence-based practice innovation uptake of clinical interventions and/or delivery system interventions

All reviews cited the importance of sustaining service or program implementation, most of the included studies focused on singular incidents of implementation through pilot initiatives.

Patient and organisational outcomes achievement

Few studies focus on the process by which transfer or implementation of health services or programs occurred.

The cost effectiveness of implementation was mentioned in only two reviews.