1. From news to everyday use - the difficult art of implementation karin.guldbrandsson@fhi.se

2. The fight against scurvy We need evidence based methods for implementing evidence based methods

3. Another example Treatment of women who are in risk for premature child birth. The aim is to reduce difficulties in breathing for the newborn child. 1969 – the first studies on animals 1972 – the first studies on human beings 1979 – five RCTs, clear recommendations 1991 – used by 5-10% of all relevant clinics in the UK 1997 – used by 95% of all relevant clinics in the UK (Hanney 2005)

4. A litterature review Method Two comprehensive litterature reviews (Fixsen et al 2005, Greenhalgh et al 2005) Result A report from the Swedish National Institute of Public Health aimed for public health practicioners

5. Implementation - definitions ”A specified set of activities designed to put into practice an activity or program of known dimensions” (Fixsen 2005) ”Active and planned efforts to mainstream an innovation” (Greenhalgh 2005)

6. Definitions Diffusion: the process in which an innovation is communicated through certain channels over time among the members of a social system (Rogers 2003) Dissemination: a planned and active process intended to increase the rate and level of adoption above that which might have been achieved by diffusion alone (Greenhalgh 2005)

7. Method AND implementation The method Define the method components Anticipated effects of the method Program fidelity The implementation process Define the implementation components Anticipated effects of the method BOTH the method AND the implementation must work!

8. There needs to be a need Local needs are an important element for successful implementation ”we are not satisfied with how bullying problems are being handled at local schools” When the needs are expressed explicitly, there is more chance of successful implementation ”we need a new program to combat bullying in local schools”

9. Method criteria The implementation will work better if the method: has relative benefits (Greenhalgh 2005, Rogers 2003, Dirksen 1996, Aubert 2001) is in line with prevailing values, norms and working methods (Greenhalgh 2005, Rogers 2003, Denis 2002, Glaser 1980, Rohrbach 2006, Mihalic 2003, Aubert 2001, Ferlie 2001) is simple to use (Greenhalgh 2005, Rogers 2003, Meyer 1988, Denis 2002)

10. Method criteria The implementation will work better if the method: is possible to test ( Greenhalgh 2005, Rogers 2003, Yetton 1999 ) shows visible results quickly ( Greenhalgh 2005, Meyer 1988, Denis 2002 ) is possible to adapt to local conditions ( Greenhalgh 2005, Rogers 2003, Glaser 1980 ) offer knowledge that can be generelised ( Greenhalgh 2005, Aubert 2001 )

11. Implementation criteria A combination of measures (Gotham 2004, Fixsen 2005, Rohrbach 2006, Grol 2000, Bero 1998, Ager 2001, Kelly 2000) Early involvement of the users (Greenhalgh 2005) Resources (Rohrbach 2006, Mihalic 2003, Robinson 2006, Greenhalgh 2005, Rogers 2003, Fitzgerald 2002) Feedback (Fixsen 2005, Greenhalgh 2005) Information and training is not enough! (Fixsen 2005, Azocar 2003, Davis 1995, Denton 2003, Rogers 2002)

12. Actors in the implementation process RecipientChange agentSender The recipient experiences a need The change agent understands the recipient’s need and the sender’s method and mediates contact The sender has access to a method that meets the recipient’s need

13. The work of a change agent Help the recipient to become aware of a problem Establish a trusting relationship with the recipient Help the recipient to analyse why the problem cannot be dealt with by existing methods Motivate the recipient to choose a specific method Provide practical support Support the institutionalisation of the new method Hand over completely to the recipient

14. The Community readiness model No awareness of the problem or the solution Denial of the problem or the sollution Planning Preparation Implementation Stabilising the implemented method Strengthening and expansion

15. A checklist for implementation – an example There are locally defined needs□ Yes □ No Needs: The number of children with behaviour disorders in preschool has increased The proposed method can meet these needs □ Yes □ No Method: A structured method for parental support (e.g. COPE, Komet, Familjeverkstan)

16. A checklist for implementation – an example The method components are defined □ Yes □ No The method consists of: A written manual, skilled supervisors, video films, role plays, homework etc. Anticipated effects: Fewer children with behaviour disorders

17. A checklist for implementation - an example The implementation components are defined □ Yes □ No The implementation consists of: Staff education, practical training, feedback, adaptation of the organisation etc. Anticipated effects: x number of the staff use the method after finished education x number of parent support courses are given each year

18. A checklist for implementation – an example The method is: -relevant□ Yes □ No -better than current methods □ Yes □ No -effective (evidence-based)□ Yes □ No -cost-efficient□ Yes □ No

19. A checklist for implementation – an example The method is: -consistent with prevailing values □ Yes □ No -easy to use□ Yes □ No -possible to test on a small scale□ Yes □ No - possible to adapt to local conditions□ Yes □ No

20. A checklist for implementation – an example Risks could be dealt with □ Yes □ No The results can be quickly observed□ Yes □ No Knowledge can be generalised□ Yes □ No Users involved at an early stage□ Yes □ No Everyone involved has enough skills□ Yes □ No

21. A checklist for implementation – an example Systems for monitoring and feedback□ Yes □ No Plans to hand over to the users□ Yes □ No Resources (time, money and staff)□ Yes □ No Adequate and long-term budget□ Yes □ No

22. www.fhi.se/childhealth