Achieving health-promotion practice in primary care using a multifaceted implementation strategy: a non-randomized parallel group study.

Abstract

Background: Evidence-based healthcare recommendations exist for tobacco use, harmful alcohol consumption, low physical activity, and poor diet. However, the uptake of these recommendations in Swedish primary healthcare is poor, and the potential benefits for patients are not fully realized. Our aim was to evaluate the effect (i.e. the uptake) of a 12-month multifaceted implementation strategy to achieve a more health-promoting practice. We hypothesized that primary healthcare centers receiving this strategy would increase and sustain their health-promotion practices to a significantly greater extent than control centers, from baseline to the 6-month follow-up.

Methods: In a non-randomized parallel group study, 5 intervention centers and 5 matched control centers were compared regarding health-promotion activities delivered in relation to visits to each center. The intervention centers received a multifaceted implementation strategy over at least 12 months based on established strategies, the Astrakan model of leading change, and findings from pre-implementation studies. The main strategies were: using external and internal facilitators to combine bottom-up and top-down perspectives, and emphasizing leadership responsibility for change. Medical record data on health-promotion activities, including prescribed physical activity and use of lifestyle screening forms, were collected monthly for 2 years: 6 months before and after implementation, and during the implementation phase. The implementation strategy effect was estimated using generalized linear mixed models.

Results: During the 12-month implementation phase, the intervention and control sites had 135 002 and 160 987 healthcare visits, respectively; conducted 8839 and 6171 health-promotion activities, respectively; and administered 2423 and 282 lifestyle screening forms, respectively. A statistically significant higher relative uptake rate of health-promotion activities was found in intervention sites compared to control sites after the implementation period compared to before. The effect increased during the active phase, with the intervention sites having on average 1.07 and 2.0 times the uptake rate of the control sites at 1 and 12 months, respectively; this effect was largely maintained during the 6-month post-intervention phase. A significant absolute effect, in terms of difference in predicted uptake per 1000 visits, was evident 7 months into the implementation phase.

Conclusion: This multi-faceted implementation strategy was successful in achieving a more health-promoting practice. (ClinicalTrials.gov ref: NCT04 799,860, 03/04/2021, https://clinicaltrials.gov/study/NCT04799860 ).

Trial registration: This study is part of the Act in Time project, registered at ClinicalTrials.gov on 4 March 2021 (ref: NCT04 799,860).