Skip to main content Accessibility help
×
Home

Information:

  • Access
  • Open access

Actions:

      • Send article to Kindle

        To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

        Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

        Find out more about the Kindle Personal Document Service.

        Contextual factors influencing the implementation of innovations in community-based primary health care: the experience of 12 Canadian research teams
        Available formats
        ×

        Send article to Dropbox

        To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

        Contextual factors influencing the implementation of innovations in community-based primary health care: the experience of 12 Canadian research teams
        Available formats
        ×

        Send article to Google Drive

        To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

        Contextual factors influencing the implementation of innovations in community-based primary health care: the experience of 12 Canadian research teams
        Available formats
        ×
Export citation

Abstract

The objectives of this paper are to: (1) identify contextual factors such as policy that impacted the implementation of community-based primary health care (CBPHC) innovations among 12 Canadian research teams and (2) describe strategies used by the teams to address contextual factors influencing implementation of CBPHC innovations. In primary care settings, consideration of contextual factors when implementing change has been recognized as critically important to success. However, contextual factors are rarely recorded, analyzed or considered when implementing change. The lack of consideration of contextual factors has negative implications not only for successfully implementing primary health care (PHC) innovations, but also for their sustainability and scalability. For this evaluation, data collection was conducted using self-administered questionnaires and follow-up telephone interviews with team representatives. We used a combination of directed and conventional content analysis approaches to analyze the questionnaire and interview data. Representatives from all 12 teams completed the questionnaire and 11 teams participated in the interviews; 40 individuals participated in this evaluation. Four themes representing contextual factors that impacted the implementation of CBPHC innovations were identified: (I) diversity of jurisdictions (II) complexity of interactions and collaborations (III) policy, and (IV) the multifaceted nature of PHC. The teams used six strategies to address these contextual factors including: (1) conduct an environmental scan at the beginning (2) maintaining engagement among partners and stakeholders by encouraging open and inclusive communication; (3) contextualizing the innovation for different settings; (4) anticipating and addressing changes, delays, and the need for additional resources; (5) fostering a culture of research and innovation among partners and stakeholders; and (6) ensuring information about the innovation is widely available. Implementing CBPHC innovations across jurisdictions is complex and involves navigating through multiple contextual factors. Awareness of the dynamic nature of context should be considered when implementing innovations.

Introduction

Contextual factors, broadly defined as all intervening factors that affect a complex phenomenon (Stange et al., 2012; Bate et al., 2014), are recognized as critical to successful health care delivery and implementation of health care innovations (Ovretveit, 2011; Evans et al., 2017; Pfadenhauer et al., 2017; Abuzour et al., 2018). Examples of contextual factors are: (a) the external context (eg, policy and legislation, buy-in by internal or external stakeholders) (b) the organization (eg, organizational culture, leadership, resources, and relationships) (c) professionals (eg, roles, competency); and (d) intervention (eg, nature and characteristics, complexity) (Damschroder et al., 2009; Lau et al., 2016). In primary care settings, consideration of contextual factors when implementing health care innovations is recognized as a strategy for maximizing uptake and success (Lau et al., 2016).

Innovation in primary care consists of implementing creative solutions to provide high quality care for clients through efficient and strategic use of available resources (eg, funding and staff) (Okie, 2008). The lack of consideration of contextual factors has negative implications for successfully implementing health care innovations, sustainability, and scalability (Stirman et al., 2012; Milat et al., 2015). However, contextual factors are rarely recorded, analyzed or considered when implementing change (Tomoaia-Cotisel et al., 2013). Thus, attempts to implement or transfer innovations to other settings are often unsuccessful, because contextual factors are poorly integrated into change efforts (Shekelle et al., 2010; Kringos et al., 2015; May et al., 2016).

Previous work has explored the influence of contextual factors on change in primary care settings (Carlfjord et al., 2010; Tierney et al., 2014; Shea et al., 2018; Ward et al., 2018). This work suggests a number of contextual factors as important to consider for successful implementation of health care innovations, such as: teamwork climate (Shea et al., 2018), organizational capacity to take on new initiatives (Carlfjord et al., 2010; Shea et al., 2018), objectives and perceived value of the innovation (Shea et al., 2018; Ward et al., 2018), and top-level endorsement (Tierney et al., 2014).

Tomoaia-Cotisel et al. (2013) reported on contextual factors across 14 studies of primary care practice transformation to patient-centered medical homes (PCMHs). Using results from these 14 studies, they developed a novel framework for reporting contextual factors, based on the work of Stange and Glasgow (2013). Stange and Glasgow’s (2013) template includes the following contextual factors: national, provincial and local policy, community norms, organization of health care, practice culture, and historical factors. Tomoaia-Cotisel et al.’s (2013) framework expands on the template and describes contextual factors in three hierarchical dimensions (practice, larger organization, and external environment) and two cross-cutting dimensions (implementation pathway and motivations). While this paper provides a valuable framework that can be used to report contextual factors in primary care change initiatives, it is focused on one specific type of transformation, that of PCMHs, and does not describe strategies that could be used to address these contextual factors.

The purposes of this paper are to: (1) describe contextual factors that impacted the implementation of community-based primary health care (CBPHC) innovations among 12 Canadian research teams and (2) describe strategies used by the teams to address contextual factors influencing implementation of CBPHC innovations. In 2012, as part of a signature initiative in CBPHC research, the Canadian Institutes of Health Research (CIHR) funded 12 pan-Canadian research teams (hereafter referred to as 12 teams) to conduct five-year programmatic cross-jurisdictional innovative research projects (CIHR, 2012a; CIHR, 2013). The funding’s key aims included: (a) reduction of inequities in access to CBPHC and health outcomes of vulnerable populations and (b) prevention and management of chronic conditions (CIHR 2012b).

Teams were also required to collaborate and produce knowledge beyond what could be produced by any one team, including collection of data on a common set of patient and practice indicators (Wong et al., 2018) and description of the structures and context that influence the implementation and potential for scale-up of successful CBPHC innovations (Ben Charif et al., 2018). The 12 teams are composed of researchers, trainees, patient and community research partners and decision makers. The teams are located within rural and urban settings in multiple provinces across Canada (eg, Alberta, British Columbia, Manitoba, New Brunswick, Newfoundland and Labrador, Nova Scotia, Northwest Territories, Nunavut, Ontario, Prince Edward Island, and Quebec) and some teams included international partners (eg, Australia, Belgium, Denmark, France, New Zealand, Philippines, Singapore, and the United States). The areas of focus are varied and include, for example, prevention and management of chronic conditions and access to care for vulnerable groups. These teams are implementing innovative projects to improve CBPHC for diverse populations such as children, youth, older adults, immigrants, low-income groups and Indigenous Peoples. The teams have varied goals such as using technology to improve HIV care and self-management, using patient experiences in reshaping primary health care (PHC) to address the needs of First Nation communities, and partnering with local community health and social care providers to improve care for older adults with diabetes and multimorbidity. More detail about the 12 teams is available on the CIHR website: http://www.cihr-irsc.gc.ca/e/50370.html.

An example of one of the teams and their innovations follows. Canadian Team to Improve Community-Based Cancer Care along the Continuum (CanIMPACT) is a multi-disciplinary team of primary care providers, cancer specialists, researchers, patients and caregivers who are working together to improve care coordination for patients with cancer. In collaboration with the Champlain BASE™ eConsult team, CanIMPACT is evaluating an asynchronous online communication system (“eOncoNote”) that aims to improve communication between primary care providers and cancer specialists (Grunfeld, 2017; Grunfeld and Petrovic, 2017).

Methods

Design

A qualitative evaluation approach was used.

Data collection

Data collection was conducted using self-administered questionnaires and follow-up telephone interviews with representatives of the 12 teams, from May to December 2017. Two authors (KH and JP) developed a questionnaire adapted from Stange and Glasgow’s Context Matters Reporting Template (2013), and Tomoaia-Cotisel et al.’s (2013) framework of contextual factors in PHC. The questionnaire was piloted with the co-leads of one of the 12 teams to assess face validity (ie, questions were clear and relevant). The questionnaire asked teams to describe their project, study population, and partnering stakeholders (eg, clinicians, community members, and decision makers). Teams were then asked to describe contextual factors impacting the implementation of their innovations, regional public policy, and multi-jurisdictional nature of the work (See Supplementary material – Appendix 1 for survey questions).

Follow-up semi-structured individual and group telephone interviews, lasting 30–45 min, were conducted by two authors (KH and JP) with each team. One to three persons from each team were interviewed, including researchers and research staff (research coordinators and managers). Participants were asked to identify the contextual factors that had been most influential in the implementation of their innovation, how these factors had influenced their work, and strategies they used to address contextual factors. Additional probing questions were asked to clarify responses to the questionnaires. Interviews were audio-recorded and transcribed (See Supplementary material – Appendix 2 for sample interview questions).

Data analysis

We used a combination of directed and conventional content analysis approaches (Hsieh and Shannon, 2005) to analyze the questionnaire and interview data. Using a directed content analysis approach, we started with Tomoaia-Cotisel et al.’s (2013) framework to develop general codes and categories of the contextual factors that impacted the implementation of CBPHC innovations. Building on this framework, we then used a conventional content analysis approach where additional codes and categories were derived directly from the questionnaire and interview texts.

Three authors (KH, JP and MY) independently reviewed the questionnaire and interview data and developed initial codes and categories. These authors met monthly over four months to discuss and compare codes and categories and develop a final coding structure. Two authors (KH and MY) applied the final coding scheme to the data. Coded data were reviewed and themes and sub-themes were identified by consensus and reviewed by the larger research team. We used N-Vivo 11® (QSR International) to assist with qualitative data analysis.

We ensured rigor by using Lincoln and Guba’s (1985) validation criteria (ie, credibility, transferability, dependability, and confirmability). Credibility was established by seeking a broad range of participants (team leads, project managers, and research coordinators) and using investigator triangulation. In addition to the three primary data analysts (KH, JP, and MY), nine co-authors (SW, MF, CK, CL, MMR, BP, ED, CS, and WPW) with expertise in program evaluation, CBPHC, and qualitative research provided feedback on the themes to ensure that they were accurate and reflective of their experiences. Descriptions of the teams and their innovations help to ensure transferability of findings (Creswell, 2017). Dependability and confirmability were achieved by maintaining a record of all analytic decisions.

Ethics statement

All procedures contributing to this work comply with the ethical standards of the Tri-Council Policy Statement, Ethical Conduct for Research Involving Humans.

Results

Participants

Representatives from all 12 teams completed the questionnaire and 11 teams participated in the interviews (one team was not available for an interview). A total of 40 people participated in the data collection, of whom 29 (72%) were senior and junior researchers (principal investigators, collaborators, and postdoctoral researchers) and 11 (28%) were research staff (research managers and research coordinators). Between 1 and 6 people per team participated in the data collection (median = 3). The representatives were diverse in terms of gender, age, years of research experience, and work locations. Table 1 provides a brief summary of the 12 teams including location, study population, area of focus and research or innovation project.

Table 1. Overview of the 12 CBPHC teams

See Canadian Institutes of Health Research website for more information on the teams http://www.cihr-irsc.gc.ca/e/50370.html.

Contextual factors

We categorized the contextual factors that impacted the implementation of CBPHC innovations of the 12 teams into four main themes with related sub-themes: (I) diversity of jurisdictions (II) complexity of interactions and collaborations (III) policy, and (IV) the multifaceted nature of PHC (See Table 2 for a summary of themes and sub-themes). Descriptions of the themes and sample quotations from interviews and questionnaires are provided below. Additional quotes are displayed in Table 3 to provide rich examples from the 12 teams.

Table 2. Summary of contextual factors influencing CBPHC innovations of the 12 teams and strategies to address these factors

Table 3. Additional examples of data for contextual factors influencing implementation of CBPHC innovations by theme

Contextual theme I: diversity of jurisdictions

The diversity of settings and jurisdictions that teams worked in influenced the implementation of their innovations. Teams worked across multiple Canadian provinces and territories. Five teams had international partners and three teams worked with Indigenous communities in Canada.

Cross-jurisdictional nature of the work

Challenges in working across jurisdictions included differences in provincial structures, limited resources, and maintaining cohesiveness among the research team members.

“Ensuring cohesiveness among [project] activities and working toward common goals are some of the challenges related to managing a research team involving a large number of players, located in different jurisdictions.” (T07 questionnaire)

Working across jurisdictions was a barrier to implementing innovations due to the nature of cross-collaborative projects. Ethics approvals were required from multiple jurisdictions and institutions, each with their own set of requirements. Privacy regulations varied across provinces and impacted timely access to data. Working within rural and remote areas with limited access to health care services also impacted innovation implementation.

International partnerships

International partnerships promoted collaboration and shared suggestions in development of CBPHC innovations. Collaborating internationally acted both as a facilitator and barrier for shared learning for the teams. Some teams had international research trainees who attempted to replicate Canadian projects to fit their country’s context. Collaborating with international research partners also created challenges due to differences in time zones, research styles, PHC structures and privacy regulations.

“… the intellectual context in Europe is quite different. So there’s this intellectual exchange that is really important and the other was the notion of how their primary care system works…” (T11 interview)

Multiple languages

Recognizing the need for diversity in languages acted as a facilitator for implementing innovations. The broad term of language was perceived by teams as including unique terminology, cultural differences, and culture of work. Implementing innovations in settings with multiple languages, though challenging, increased the accessibility of the projects across diverse populations. Some teams recognized that concepts could not be easily translated from English into, for example, Indigenous languages.

“…even the concepts that we were trying to have a dialogue around like health and wellness and well-being and mental wellness. All of those concepts were very difficult to describe in Indigenous languages where the parallel definition did not exist…” (T05 interview)

Contextual theme II: complexity of interactions and collaborations

The success of implementing innovations in CBPHC was dependent on complex collaborations and interactions between research teams, community members, providers, decision makers, patients, and caregivers.

Establishing and maintaining relationships

The outcomes of teams’ innovations were dependent on new and existing relationships with diverse partners and stakeholders. Focusing on relationships with others was an enabler for innovation implementation. However, turnover in government officials, partnering decision makers, and clinicians required teams to build new relationships and sometimes modify aspects of their projects.

“All of those directors have changed, there has been some turnover. Talking about adapting our program to different contexts, well the context keeps changing and we need to keep adapting to their new priorities, new programs and new structure.” (T07 interview)

Similarly, turnover of clinicians and research personnel sometimes delayed implementation of innovations as new clinical or research staff needed time to be trained.

Complexity of being part of the CBPHC 12 teams

There were mixed findings about collaborating across the 12 teams as working within a large cross-jurisdictional network of independent research programs acted both as a barrier and facilitator in implementing innovations. Working across the 12 teams was seen as an opportunity to share ideas, learn about each other’s innovations and increase cross-team collaboration.

“I think it’s nice to think that you’re part of something bigger and I think that to learn things across 12 teams definitely has the potential to have some powerful outcomes.” (T06 interview)

One team, for example, adapted an innovation from another team to their own context. The funder’s expectation for the 12 teams to collect common process and outcome indicators, however, was at times recognized as inconsistent with the diversity of the teams in terms of their innovations, the communities and health systems they worked with and the team itself. This was a particularly challenging contextual factor for the teams working with Indigenous communities, where the communities made decisions pertaining to the data that was important to them.

Levels of engagement with stakeholders

The level of engagement of stakeholders, such as policy and decision makers as well as clinicians, patients and caregivers, was an important contextual factor that facilitated the successful implementation of innovations. This was often associated with recognizing the potential value of innovations for larger communities.

“I think in [province] we have achieved some excitement about [innovation] within our health authority…they have invested interest in [innovation], seeing how [innovation] can help inform the work that they’re doing.” (T02 interview)

Despite the teams’ best efforts in engaging stakeholders, some decision makers still did not “buy-in” to their projects or feel that their projects were worth implementing due to competing priorities and the dynamic nature of the policy worlds.

Leadership

Teams described the important contextual factor of leadership to facilitate implementation of innovations and often fostered leadership at various levels (individuals, communities, and organizations) to achieve success. Leadership was perceived by teams as consisting of supportive mentorship and led to trusting relationships among providers in team environments. Strong leadership helped teams to navigate the different perspectives of diverse stakeholders (eg, community members, decision makers, patients and caregivers, researchers). Teams recognized that effective leaders should encourage shared leadership, be open to change, promote and maintain commitment, and ensure that members have the resources to achieve their goals. This made it easier to conduct large CBPHC projects and offset issues that were not always in the control of the teams (eg, time and financial resources).

“The leadership, the engagement from the beginning and the commitment of the individuals involved in this topic all have led to a more engaged team than you would see in any other projects.” (T08 interview)

Working with Indigenous peoples

Involving Indigenous Peoples in research acted as a facilitator to promote the success of innovations. Recognizing the unique cultural and historical context of Indigenous Peoples in Canada, three teams working with Indigenous communities followed Ownership, Control, Access, and Possession (OCAP®) standards of how to conduct research with First Nations (First Nations Information Governance Centre, 2014). These guidelines assert that First Nations have control over data collection processes in their communities and they own and control how that data will be used.

“You have to have mutual respect that is spelled out through OCAP® on how to partner and work collaboratively with First Nations. The Truth and Reconciliation [Truth and Reconciliation Commission of Canada, 2018 ] is a list of recommendations that highlight the issues of colonialism in Canada with creating recommendations as a path to move forward…” (T01 interview)

When collaborating with Indigenous Peoples, teams also had to navigate complex health care funding structures and limited PHC resources to realize the implementation of innovations in these communities.

Contextual theme III: policy

National and provincial political structures and changes to these structures and policies impacted the implementation of CBPHC innovations.

Differences in provincial health care systems

The diversity of health care system structures across provinces acted as a barrier to innovation implementation. Researchers had to familiarize themselves with health care systems in different jurisdictions to determine how they could best implement innovations in different settings. These included differences in structure, services, regulations, and interests.

Funding models

Teams reported that funding models for PHC services varied within and across provinces, resulting in differences in available health care services, the organization and delivery of health and other social services, and ability to implement innovations across various sectors. Varying funding models acted as barriers to implementation of CBPHC innovations.

“Funding sources [for usual PHC] were the same in three sites but the funding models differed and, as a result, the services offered were different when comparing acute and community settings.” (T06 questionnaire)

Teams also discussed the need to create a line in the research budget of the region or province related to the innovation, to ensure sustainability beyond research funds.

Changes in legislation and health care priorities

Researchers considered the constant changes in political structures and regulations when implementing innovations. These changes impeded successful implementation of innovations. For example, the requirement of clinicians to meet new practice standards led to lower interest for clinicians and decision makers in supporting this type of research initiatives. Changes in legislation and priorities also led to changes in the organizational resources required for an intervention.

“…they [health ministry] imposed a quota of patients that practices had to take…well that would definitely influence the practices’ interest in taking part in things, and how we were going to roll out the intervention.” (T03 interview)

Contextual theme IV: the multifaceted nature of PHC

PHC is organized by multiple groups of care providers and stakeholders. Having multiple players involved in PHC has been perceived by the teams to lead to lack of communication with other tiers of service and complex care delivery.

The fragmented structure of PHC

Lack of PHC coordination and gaps in services were pronounced both in rural and remote as well as urban areas, influencing innovation implementation. The structure of the current state of PHC acted as a barrier to implementing innovations. The differences in defining PHC across jurisdictions impacted the types of innovations that could be implemented and the evaluation of innovations. The low penetration of information technology in PHC was seen as a particular contextual challenge for the teams.

“Imagine sort of the fragmentation [of primary care] in larger urban centres. I think that’s sort of a real challenge.” (T07 interview)

Competing priorities

Researchers experienced challenges in implementing innovations when PHC clinicians had to meet the high demands of providing clinical services over research.

“…we would produce something and then we wouldn’t hear from them [providers]…this is all because of different priorities, right? They have a huge responsibility in front of them and they need to prioritize that, they can’t let care delivery drop.” (T03 interview)

Researchers also recognized that clinicians were often engaged in a number of different research projects.

Strategies to address contextual factors

By reflecting on contextual factors that were influential in their work, representatives of the 12 teams also discussed strategies they used to address these factors in order to successfully implement innovations. Six main strategies were identified and are described below. See Table 4 for additional qualitative data.

Table 4. Additional examples of data for strategies to address contextual factors in CBPHC

  1. 1. Conduct an environmental scan at the beginning

Some teams conducted environmental scans, scoping and realist reviews, needs assessments and/or reviews at the start of their projects to understand what programs already exist, what works in different contexts, and what constitutes usual care related to the innovation. The evidence provided decision-making stakeholders with program options outside their context-bound purview and focused feedback from PHC providers regarding areas for improvement. Understanding the geographical, political, and social context helped the teams appropriately plan and fine-tune their innovations to better meet the needs of the communities.

“Our KT group conducted an environmental scan across Canada in terms of what kinds of initiatives have been conducted to improve coordination of care between primary care and [specialists]. So that really allowed us to kind of get a sense of what’s out there and really get input from these different areas in terms of the work that’s already been done.” (T12 interview)

  1. 2. Maintaining engagement among partners and stakeholders by encouraging open and inclusive communication

Teams recommended ensuring that all team members, partners, and stakeholders are appropriately engaged and committed throughout the course of their projects. The importance of meaningful engagement was particularly pronounced in the engagement of Indigenous Peoples.

“So, a lot of our resources went into that for our project to ensure that we had continual engagement of the community. But then I think…let the First Nations take the leadership role in determining some of the questions in the outcome and how things are structured…” (T05 interview)

To maintain meaningful engagement, teams tailored communication strategies such as workshops and in-person meetings to the particular needs of different partners and stakeholders. These strategies considered how feedback from others would be collected and incorporated into the projects. Teams used various methods of communication such as tele-conferences, newsletters, progress reports, websites and social media, and in-person gatherings.

“Regular meetings, a collaborative electronic platform and yearly face-to-face meetings have been essential to maintain the momentum for the study and learning from one another.” (T03 questionnaire)

Unique strategies to address the language context and improve communication across jurisdictions included having a bilingual research team, strong collaborations, investment in communication tools, and focusing on commonalities.

  1. 3. Contextualizing the innovation for different settings

The teams described how they tested the innovations in different settings and jurisdictions and tailored and adapted the innovation to fit the unique contexts as needed.

“…by actually testing and modifying the program in different settings, until you sort of demonstrated that yes, you’re going to get positive results, and the program is implementable across different settings, different populations, and of course different diseases.” (T07 interview)

Integrating feedback from communities and stakeholders was critical in adapting the innovations to local needs. Researchers discussed retaining the core principles of the innovation while tailoring flexible aspects (innovation components and implementation strategies) to ensure effective integration of the innovation into existing care systems.

  1. 4. Anticipating and addressing changes, delays, and the need for additional resources

Implementing a CBPHC innovation is a very complex process requiring engagement of multiple stakeholders and consideration of many contextual factors. Therefore, research teams recommended planning for changes in implementation plans, flexible timelines, and the need for additional resources.

“…just thinking about advice for someone who would be taking on this type of project would just be mindful that things will take a lot longer than you may have originally anticipated. It’s probably going to be for the better in the end because there’s going to be different inputs and it’ll lead to hopefully a better outcome.” (T12 interview)

Teams also had to be responsive to turnover and changes in team composition and expect delays in implementation while having a plan to address these. While collecting feedback and adapting the innovation led to longer implementation timelines, it also led to important program improvements.

  1. 5. Fostering a culture of research and innovation among partners and stakeholders

Researchers used multiple strategies to foster a culture of innovation among partners and stakeholders. They recognized that research may not be valued in the same ways in practice and policy environments as in academic environments and emphasized the importance of fostering a culture of innovation within health care.

…we need to think about how can we foster a research culture within our healthcare system?…when we would approach them [providers] we’re considered an outsider rather than seen as part of the team that can help improve patient care. I think that definitely affects uptake of intervention because it’s perceived as not my job, I’m too busy. (T06 interview)

Many teams were involved with building research capacity among their partners and stakeholders to help facilitate the uptake of innovations. Examples included involving patients and community members in research activities and creating faculty positions in the North.

  1. 6. Ensuring information about the innovation is widely available

Teams described using numerous strategies to promote awareness and sustainability of the innovation among stakeholders to enhance dissemination of findings. They ensured that information about their innovations was publicly available and developed tailored resources for various stakeholders. This ensured that findings were shared with community members who were not part of the research using social media, websites, policy briefs, newsletters, toolkits and other approaches.

“We wanted to use it [website] as a tool to disseminate what we were doing and eventually it will be a tool that people will use as a resource and various groups can eventually use it as a resource like teachers, clinicians, families, parents, children, youth…” (T09 interview)

Discussion

Key findings

Based on the perspectives of the 12 teams, implementing CBPHC innovations across jurisdictions is a complex experience involving multiple and interrelated contextual factors and this complexity should be recognized by decision-maker stakeholders. Teams had to frequently adapt their innovations to fit diverse settings. Further, it was challenging for teams to implement innovations in contexts where there were ongoing changes at government levels such as new policies, priorities, structures, and leaders. The 12 teams used a variety of strategies to ensure successful implementation of CBPHC innovations by addressing contextual factors, especially strategies focused on building and maintaining relationships with stakeholders including Indigenous peoples.

Comparison with the literature

This present study expands on the Tomoaia-Cotisel et al. (2013) framework by providing a much more detailed description of contextual factors that impact the implementation of CBPHC innovations. Rather than being limited to five domains of the framework (ie, practice, larger organization, external environment, implementation pathway, and motivation for implementation), our study highlights the interrelatedness and the interactive dynamic of contextual factors in how they mutually influence and transform one another. We also consider the diversity and landscape of jurisdictions as an important factor to consider when implementing innovations across Canada and beyond (Sutherland and Busse, 2016). The current study further extends the work of Tomoaia-Cotisel et al. (2013) by providing concrete examples of strategies used by the 12 teams to address contextual factors in implementing PHC innovations.

The contextual factors identified align well with some of the key contextual factors identified by Lau and colleagues (2016) in their review of reviews of complex changes in primary care: (a) professional: attitudes to change; (b) organization: relationships, and processes and systems; and (c) external context: stakeholder buy-in, governance and financing, and policy and legislation. The present study makes a new contribution by highlighting the importance of selected contextual factors, namely, diversity in settings and jurisdictions, and establishing and maintaining relationships with a broad range of stakeholders, including Indigenous peoples. It is critical that PHC innovations take into consideration the contextual challenges faced by Indigenous peoples such as the inadequate patchwork of policies and health care practices currently in existence (Katz et al., 2017).

Our results also confirm the conclusions by Lau et al. (2016) of the importance of being aware of the dynamic nature of context, as the 12 teams encountered ongoing changes in areas such as decision-maker partners and government priorities and funding. It is not enough to simply assess context at the start of a change project; this needs to be an ongoing effort throughout the phases of implementing the innovation. Teams felt that the poor uptake of information technology was a barrier to health care coordination. There is a need for more innovative approaches in using technology as an instrumental component to practice rather than an electronic documentation system (Gray et al., 2018).

The opportunities for shared learning across the 12 teams in this study, and the 14 teams in the study by Tomoaia-Cotisel et al. (2013) share some similarities with what has been described as learning communities (Carpenter et al., 2018): “a select group of potential adopters and stakeholders who engage in a shared learning process to facilitate adaptation and implementation of innovations” (Carpenter et al., 2018: 567). The new incremental learnings generated by the 12 teams have certainly advanced our understanding of the contextual factors important for the implementation of PHC innovations.

Strengths and limitations

A strength of this evaluation was the inclusion of 12 CBPHC research teams representing diversity in terms of the jurisdictions and settings they involved, the target populations including Indigenous peoples, and the focus of innovation. Two data sources (ie, questionnaires and interviews) contributed to the richness of the data and a rigorous analytic method was used.

However, participants in this evaluation included only researchers and their team members; the inclusion of decision makers, providers, patient and public research partners could have provided different understandings of contextual factors influencing primary care innovation implementation. Such broader stakeholder sampling is recommended for future research. The PHC innovations were focused, as required by the funder, on two key areas, namely, improving access for vulnerable populations, and innovations in chronic disease management and prevention; thus, the contextual factors and strategies to address these factors might be different for other focal areas of PHC.

Conclusion

This paper provides a comprehensive overview of contextual factors impacting the implementation of CBPHC innovations among 12 multi-jurisdictional teams. Strategies used by the teams to address common contextual factors provide guidance for other research teams interested in implementing CBPHC innovations across different jurisdictions. Research teams should be considering and accommodating context by ensuring flexibility of their programs. Yet funders do not necessarily facilitate such accommodation. Grant requirements and specificities can create rigid barriers for teams to effectively and meaningfully (a) engage different stakeholders (b) develop meaningful partnerships, and (c) achieve results in a dedicated timeframe using specific tools. Future research should explore the relationship between context and outcome measures associated with innovations. Contextual factors also need to be explored in relation to how they impact spread and scale-up of CBPHC innovations. Finally, future research should examine which contextual factors are important, and how, why, when and for whom they are important in various settings, such as the planned realist review on healthcare quality improvement initiatives (Coles et al., 2017).

Author ORCIDs

Christian Dimaano 0000-0001-8168-8449

Acknowledgements

The authors thank the 12 teams who participated in this project and the numerous partners, stakeholders, policy-makers, and decision makers who supported and assisted the 12 teams in implementing their innovations.

Conflicts of interest

None.

Financial support

This work was supported by the Canadian Institutes of Health Research Signature Initiative in Community Based Primary Health Care: (J.P., grant number TTF-128261) (S.W., grant number 128265) (C.K., grant number TT5-128270) (M.F., grant number TT2-128268) (C. L., grant number FRN TT5-128270) (B.P (PI: E.G), grant number-128272) (E.D. (PI: J.H.), grant number-130729), and (W.P.W., grant number TTF-128263 and the Health Research Council of New Zealand grant number 12/850).

Supplementary material

To view supplementary material for this article, please visit https://doi.org/10.1017/S1463423619000483.

References

Abuzour, AS, Lewis, PJ and Tully, MP (2018) Factors influencing secondary care pharmacist and nurse independent prescribers’ clinical reasoning: an interprofessional analysis. Journal of Interprofessional Care 32, 160168.
Bate, P, Robert, G, Fulop, N, Ovretveit, J and Dixon-Woods, M (2014) Perspectives on context. A selection of essays considering the role of context in successful quality improvement. London: The Health Foundation.
Ben Charif, A, Hassani, K, Wong, S, Zomahoun, H, Fortin, M, Freitas, A, Katz, A, Kendall, C, Liddy, C, Nicholson, K, Petrovic, B, Ploeg, J and Légaré, F (2018) Assessment of scalability of evidence-based innovations in community-based primary health care: a cross-sectional study. Canadian Medical Association Journal Open 6, E520E527.
Canadian Institutes of Health Research (2012a) CBPHC partnerships. Retrieved 17 October 2018 from http://www.cihr-irsc.gc.ca/e/47013.html
Canadian Institutes of Health Research (2012b) Team grant: community-based primary healthcare (the transformative community-based primary healthcare initiative). Retrieved 17 October 2018 from https://www.researchnet-recherchenet.ca/rnr16/viewOpportunityDetails.do?progCd=10282&language=E&fodAgency=CIHR&view=browseArchive&browseArc=true&org=CIHR
Canadian Institutes of Health Research (2013) Community-based primary health care: featured research. Retrieved 17 October 2018 from http://www.cihr-irsc.gc.ca/e/45817.html
Canadian Institutes of Health Research (2018) Community-based primary health care: research profiles. Retrieved 17 October 2018 from http://www.cihr-irsc.gc.ca/e/50370.html
Canadian Institutes of Health Research, Natural Sciences and Engineering Research Council of Canada, Social Sciences and Humanities Research Council of Canada (2014) Tri-council policy statement: ethical conduct for research involving humans. Canadian Institutes of Health Research, Natural Sciences and Engineering Research Council of Canada, Social Sciences and Humanities Research Council of Canada. Retrieved 22 October 2018 from http://www.pre.ethics.gc.ca/pdf/eng/tcp2014/TCPS_2_FINAL_Web.pdf
Carlfjord, S, Lindberg, M, Bendtsen, P, Nilsen, P and Andersson, A (2010) Key factors influencing adoption of an innovation in primary health care: a qualitative study based on implementation theory. BMC Family Practice 11, 111.
Carpenter, D, Hassell, S, Mardon, R, Fair, S, Johnson, M, Siegel, S and Nix, M (2018) Using learning communities to support adoption of health care innovations. The Joint Commission Journal on Quality and Patient Safety 44, 566573.
Coles, E, Wells, M, Maxwell, M, Harris, FM, Anderson, J, Gray, NM, Milner, G and MacGillivray, S (2017) The influence of contextual factors on healthcare quality improvement initiatives: what works, for whom and in what setting? Protocol for a realist review. Systematic Reviews 6, 110.
Creswell, JW (2017) Qualitative inquiry and research design: Choosing among five approaches, fourth edition. Thousands Oak, CA: Sage Publications.
Damschroder, LJ, Aron, DC, Keith, RE, Kirsh, SR, Alexander, JA and Lowery, JC (2009) Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Science 4, 115.
Evans, JM, Grudniewicz, A, Gray, CS, Wodchis, WP, Carswell, P and Baker, GR (2017) Organizational context matters: a research toolkit for conducting standardized case studies of integrated care initiatives. International Journal of Integrated Care 17, 110.
First Nations Information Governance Centre (2014) Ownership, Control, Access and Possession (OCAP™): the path to First Nations information governance. Ottawa: First Nations Information Governance Centre.
Gray, CS, Barnsley, J, Gagnon, D, Belzile, L, Kenealy, T, Shaw, J, Sheridan, N, Nji, PW and Wodchis, WP (2018) Using information communication technology in models of integrated community-based primary health care: learning from the iCOACH case studies. Implementation Science 13, 114.
Grunfeld, E (2017) The two solitudes of primary care and cancer specialist care: is there a bridge? Current Oncology 24, 6970.
Grunfeld, E and Petrovic, B (2017) Consultative workshop proceedings of the Canadian team to improve community-based cancer care along the continuum. Current Oncology 24, 135140.
Hsieh, HF and Shannon, SE (2005) Three approaches to qualitative content analysis. Qualitative Health Research 15, 12771288.
Kaplan, HC, Brady, PW, Dritz, MC, Hooper, DK, Linam, W, Froehle, CM and Margolis, P (2010) The influence of context on quality improvement success in health care: a systematic review of the literature. The Milbank Quarterly 88, 500559.
Katz, A, Enns, J and Kinew, KA (2017) Canada needs a holistic First Nations health strategy. Canadian Medical Association Journal 189, E1006E1007.
Kringos, DS, Sunol, R, Wagner, C, Mannion, R, Michel, P, Klazinga, NS and Groene, O (2015) The influence of context on the effectiveness of hospital quality improvement strategies: a review of systematic reviews. BMC Health Services Research 15, 113.
Lau, R, Stevenson, F, Ong, BN, Dziedzic, K, Treweek, S, Eldridge, S, Everitt, H, Kennedy, A, Qureshi, N, Rogers, A, Peacock, R and Murray, E (2016) Achieving change in primary care – causes of the evidence to practice gap: systematic review of reviews. Implementation Science 11, 139.
Lincoln, YS and Guba, EG (1985) Naturalistic inquiry. Beverly Hills, CA: Sage Publications.
Markle-Reid, M, Ploeg, J, Fraser, K, Fisher, KA, Bartholomew, A, Griffith, LE, Miklavcic, J, Gafni, A, Thabane, L and Upshur, R (2018) Community program improves quality of life and self-management in older adults with diabetes mellitus and comorbidity. Journal of the American Geriatrics Society 66, 263273.
May, CR, Johnson, M and Finch, T (2016) Implementation, context and complexity. Implementation Science 11, 112.
Milat, AJ, Bauman, A and Redman, S (2015) Narrative review of models and success factors for scaling up public health interventions. Implementation Science 10, 111.
Okie, S (2008) Innovation in primary care—staying one step ahead of burnout. New England Journal of Medicine 359, 23052309.
Ovretveit, J (2011) Understanding the conditions for improvement: research to discover which context influences affect improvement success. BMJ Quality and Safety 201, 1823.
Pfadenhauer, LM, Gerhardus, A, Mozygemba, K, Lysdahl, KB, Booth, A, Hofmann, B, Wahlster, P, Polus, S, Burns, J, Brereton, L and Rehfuess, E (2017) Making sense of complexity in context and implementation: the Context and Implementation of Complex Interventions (CICI) framework. Implementation Science 12, 117.
Shea, CM, Turner, K, Albritton, J and Reiter, KL (2018) Contextual factors that influence quality improvement implementation in primary care: the role of organizations, teams and individuals. Health Care Management Review 43, 261269.
Shekelle, PG, Pronovost, PJ, Wachter, RM, Taylor, SL, Dy, S, Foy, RC, Hempel, S, McDonald, K, Ovretveit, J and Rubenstein, L (2010) Assessing the evidence for context-sensitive effectiveness and safety of patient safety practices: developing criteria. AHRQ Publication No. 11-0006-EF. Rockville, MD: Agency for Healthcare Research and Quality.
Stange, KC, Breslau, ES, Dietrich, AJ and Glasgow, RE (2012) State-of-the-art and future directions in multilevel interventions across the cancer control continuum. Journal of the National Cancer Institute Monographs 2012, 2031.
Stange, KC and Glasgow, RE (2013) Considering and reporting important contextual factors in research on the patient-centered medical home. AHRQ Publication No. 13-0045-EF. Rockville, MD: Agency for Healthcare Research and Quality.
Stirman, SW, Kimberly, J, Cook, N, Calloway, A, Castro, F and Charns, M (2012) The sustainability of new programs and innovations: a review of the empirical literature and recommendations for future research. Implementation Science 7, 119.
Sutherland, JM and Busse, R (2016) Canada: focus on a country’s health system with provincial diversity. Health Policy 120, 729731.
Tierney, S, Kislov, R and Deaton, C (2014) A qualitative study of a primary-care based intervention to improve the management of patients with heart failure: the dynamic relationship between facilitation and context. BMC Family Practice 15, 110.
Tomoaia-Cotisel, A, Scammon, DL, Waitzman, NJ, Cronholm, PF, Halladay, JR, Driscoll, DL, Solberg, LI, Hsu, C, Tai-Seale, M, Hiratsuka, V and Shih, SC (2013) Context matters: the experience of 14 research teams in systematically reporting contextual factors important for practice change. The Annals of Family Medicine 11, S115S123.
Truth and Reconciliation Commission of Canada (2018) Our Mandate. Retrieved 18 October 2018 from http://www.trc.ca/websites/trcinstitution/index.php?p=7#nine
Ward, B, Lane, R, McDonald, J, Powell-Davies, G, Fuller, J, Dennis, S, Kearns, R and Russell, G (2018) Context matters for primary health care access: a multi-method comparative study of contextual influences on health service access arrangements across models of primary health care. International Journal for Equity in Health 17, 112.
Wong, ST, Langton, JM, Katz, A, Fortin, M, Godwin, M, Green, M, Grunfeld, E, Hassani, K, Kendall, C, Liddy, C, Ploeg, J, Wodchis, W and Haggerty, J (2018) Promoting cross-jurisdictional primary health care research: developing a set of common indicators across 12 community based primary health care teams in Canada. Primary Health Care Research and Development, 20, 17.