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SUPPORT Tools for Evidence-informed Policymaking in health 6: Using research evidence to address how an option will be implemented

Abstract

This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers.

After a policy decision has been made, the next key challenge is transforming this stated policy position into practical actions. What strategies, for instance, are available to facilitate effective implementation, and what is known about the effectiveness of such strategies? We suggest five questions that can be considered by policymakers when implementing a health policy or programme. These are: 1. What are the potential barriers to the successful implementation of a new policy? 2. What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary behavioural changes among healthcare recipients and citizens? 3. What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary behavioural changes in healthcare professionals? 4. What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary organisational changes? 5. What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary systems changes?

About STP

This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers. The series is intended to help such people ensure that their decisions are well-informed by the best available research evidence. The SUPPORT tools and the ways in which they can be used are described in more detail in the Introduction to this series [1]. A glossary for the entire series is attached to each article (see Additional File 1). Links to Spanish, Portuguese, French and Chinese translations of this series can be found on the SUPPORT website http://www.support-collaboration.org. Feedback about how to improve the tools in this series is welcome and should be sent to: STP@nokc.no.

Scenarios

Scenario 1: You are a senior civil servant with responsibility for the rollout of a new reform programme in the health services. You want to ensure that implementation takes place as effectively as possible.

Scenario 2: You work in the Ministry of Health and have been instructed to prepare an implementation plan for the rollout of the government's recently adopted reform programme for the health services. You wish to explore what types of strategies to consider in such a plan.

Scenario 3: You work in an independent unit that supports the Ministry of Health in its use of evidence in policymaking. You are preparing a document on the effects of various interventions that could be included in a national implementation strategy for the new health services reform programme, and need guidance on how to do this.

Background

For policymakers (Scenario 1), this article suggests a number of questions that they might ask their staff to consider when the implementation of a new policy is being planned.

For those who support policymakers (Scenarios 2 and 3), this article suggests a number of questions that we believe are worth considering when discussing programme implementation and potentially useful approaches.

The process of translating policy into practice can be challenging and is often done in an unsystematic way. Careful planning is needed to prevent otherwise good policies being hampered by poor implementation. But the implementation process is not always a straightforward one: it may involve a complex set of actions at various levels of the health system as well as within communities.

Two key issues should be considered by those responsible for policy implementation, namely: "How can the activities related to the policy option be implemented to produce real changes on the ground?", and "Which strategies are available to facilitate effective implementation?"

A number of entry points can be used when planning policy implementation. Our suggested approach entails first identifying barriers to implementation, and then tailoring the implementation strategies to address the barriers - and facilitators - that are found.

This article is the third of three articles about clarifying evidence needs (see also Articles 4 and 5). (Figure 1 outlines the processes involved in clarifying these needs).

Figure 1
figure1

Clarifying evidence needs.

Questions to consider

  1. 1.

    What are the potential barriers to the successful implementation of a new policy?

  2. 2.

    What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary behavioural changes among healthcare recipients and citizens?

  3. 3.

    What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary behavioural changes in healthcare professionals?

  4. 4.

    What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary organisational changes?

  5. 5.

    What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary systems changes?

1. What are the potential barriers to the successful implementation of a new policy?

A useful starting point for anyone wanting to elicit change is the identification of likely barriers to change. Knowing what - and where - the major hurdles are that may affect successful implementation is useful during the planning process. These challenges will often vary from policy to policy, and between different contexts. Both research findings on barriers to policy implementation in other settings, and lessons learnt from previous experiences may be informative, but they may not be sufficient.

There is no standard approach to identifying barriers to change. This process is often done informally by taking perceived barriers into account and in an implicit and unsystematic way. We propose a more structured approach to identifying barriers.

The people who will be affected by a policy - the stakeholders - are the ones likely to be best placed to foresee possible barriers to policy implementation. A number of methods can be used to explore the views of stakeholder groups about new policies including, for example, a 'mixed methods approach' for undertaking a so-called 'diagnostic analysis'. This approach may include brainstorming, focus group discussions, interviews and other qualitative methods, or a combination of these. Such activities can provide new insights into stakeholders' perceptions and identify both barriers - and facilitators - to policy implementation. Surveys can also be useful. For example, respondents could be asked to rate the extent to which a list of potential barriers actually represents obstacles to change. Practical examples of such processes are provided in Table 1[2, 3].

Table 1 Examples of how barriers to policy implementation can be identified

Several frameworks and checklists have been developed to help identify potential barriers to implementing health interventions. These are often based on a combination of behavioural theories, empirical data, and common sense, and may be useful tools in guiding the process of identifying barriers. Some frameworks cover a broad range of potential barriers in various parts of the health system. For example, in one framework, barriers are categorised according to the level at which the constraints operate [4]. These levels include: the household and community, delivery of health services, health sector policy and strategic management, public policies cutting across sectors, and environmental and contextual characteristics. Examples of barriers identified at each of these levels are shown in Table 2.

Table 2 Constraints to improving access to priority health interventions, by level (from [4])

We have adopted a similar approach by focusing on constraints to policy implementation at three levels in the health system:

  • Among healthcare recipients and citizens

  • Among healthcare professionals

  • At the organisational level

Once the likely barriers to policy implementation have been identified, the next step is to identify implementation strategies or interventions that can address these (Table 3 shows examples of possible links between barriers and interventions among healthcare recipients and citizens). The choice of strategies should also be guided by the available evidence of their effectiveness and costs, as well as stakeholders' views, etc. The issue of how to find and assess evidence that may be relevant is addressed in other articles in this series [59].

Table 3 Examples of possible links between barriers and interventions among healthcare recipients and citizens

2. What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary behavioural changes among healthcare recipients and citizens?

The behaviour of healthcare recipients and citizens, particularly in relation to the use of health services (e.g. under-utilisation, non-adherence to recommended lifestyle changes or treatment schedules, etc.), may be a potentially significant obstacle to successful policy implementation. It is necessary to understand why the targeted recipients behave in particular ways as this will influence the choices they make in utilising health services. Well-conducted qualitative studies can provide insights into the behaviour of healthcare recipients [10].

One framework that can be used to identify factors that may influence the behaviour of healthcare recipients and citizens was proposed by a WHO working group on adherence to long-term therapies. They suggested five dimensions to consider [11]:

  • Socio-economic related factors

  • Health system and healthcare-related factors

  • Therapy-related factors

  • Factors-related to the particular health conditions of patients

  • Patient-related factors

As these factors are related more specifically to clinical interventions, they may be particularly useful when considering barriers to the delivery of care arrangements. For example, some of the socio-economic factors that can affect adherence to treatment among patients with tuberculosis include: a lack of effective social support networks and unstable living circumstances, cultural and lay beliefs, ethnicity, gender, age, the high cost of medication and transport, and the role of criminal justice [11, 12].

The Cochrane Consumer and Communication Review Group has extensively documented the effects of interventions to improve interactions between consumers and healthcare providers and systems, and has developed a taxonomy of interventions that target healthcare recipients and citizens [13]. This may be helpful when conceptualising and considering what kinds of interventions to use. The taxonomy includes:

  • Provision of education or information

  • Support for changing behaviour

  • Support for developing skills and competencies

  • Personal support

  • Facilitation of communication and decision making, and

  • System participation

Several studies and reviews have evaluated the effects of interventions that address constraints to effective health service delivery at the level of healthcare recipients and citizens. In one review, the authors found positive effects from community participation in overcoming such constraints [14]. In this instance, community participation was obtained using a variety of intervention approaches, including: health education (e.g. meetings, group teachings), encouraging a participative approach (mobilising leaders and stakeholders to understand and buy into the intervention), using an outreach strategy (targeting households and high-risk groups), and the training and supervision of providers (e.g. nurses and/or mothers). These interventions resulted in increased health-related knowledge and community empowerment and improved coverage in immunisation and sanitation practices.

Financial incentives, such as conditional cash transfers, may be worth considering if socio-economic related barriers are seen as playing an important role. This is because evidence, particularly from low- and middle-income countries, indicates that these may have an impact on the use of health services [15] (see Table 4 for details). A further illustrative example of evidence on the impacts of financial incentives is provided in Table 5[16].

Table 4 Summary of key findings from systematic review of conditional cash transfer programmes in low- and middle-income countries [15]
Table 5 Example of evidence that can inform the design of an implementation strategy targeted at healthcare recipients and citizens

If patient-related factors, such as a lack of information appear to be important barriers to policy implementation, interventions to improve information provision might be worth considering. A systematic review has shown that mass media interventions, for example, "can encourage increased utilisation of health services". But this finding should be approached with caution given that the study was based almost exclusively on studies from high-income countries [17] and therefore may not be applicable to other settings.

3. What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary behavioural changes in healthcare professionals?

The implementation of a policy or programme will often require changes in the behaviour of those healthcare professionals responsible for implementing the policy on the ground. Changes in professional behaviour do not always necessarily happen automatically. Active and directed approaches may therefore be necessary. The identification of barriers to change or factors that influence professional practice may help to inform the design of interventions for policy implementation. Cabana and colleagues conducted a systematic review of research addressing barriers to guideline adherence among physicians [18] and identified seven main categories of barriers. These can be used as a framework for identifying barriers to policy implementation among healthcare professionals:

  • Lack of awareness

  • Lack of familiarity

  • Lack of agreement

  • Lack of self-efficacy

  • Lack of outcome-expectancy

  • Inertia of previous practice

  • External barriers

Examples of how identifying barriers can inform implementation are provided in Table 6.

Table 6 Examples of possible links between barriers and interventions among healthcare professionals

The Effective Practice and Organisation of Care (EPOC) Review Group in the Cochrane Collaboration has developed a taxonomy of provider-targeted interventions which provides an overview of the types of interventions that may be considered for implementation purposes [19]. These are:

  • Educational materials

  • Educational meetings

  • Educational outreach visits

  • Local opinion leaders

  • Local consensus processes

  • Peer review

  • Audit and feedback

  • Reminders and prompts

  • Tailored interventions

  • Patient-mediated interventions

  • Multi-faceted interventions

Several strategies aimed at achieving behavioural change among healthcare professionals have been rigorously assessed [2023]. Typically, these have taken the form of evaluations of guideline implementation strategies targeted directly at healthcare professionals. Most, but not all, have been conducted in high-income settings [24]. The findings demonstrate that many interventions can influence professional behaviour effectively to a modest or moderate extent. But passive interventions, such as the circulation of guidelines or the hosting of educational meetings, seem only to have smaller impacts. Educational outreach visits and multi-faceted interventions that specifically target identified barriers to change are among the more promising approaches.

Financial incentives may be used as a means of influencing professional behaviour but these have been evaluated almost entirely in high-income settings. These can be effective in influencing individual healthcare professionals when simple and well-defined behavioural goals are provided, such as increases in the delivery of immunisations - at least in the short term [25]. However, several potentially negative consequences of such programmes have been identified and the use of financial incentives may not necessarily be cost-effective.

Regulatory measures are inexpensive and potentially effective means of eliciting changes in professional behaviour but may be poorly received by professional groups [26]. The impact of regulations per se as a means of achieving behavioural change among healthcare professionals has not been reviewed systematically, therefore available knowledge about their effectiveness is limited [27].

See Table 7 for further illustrative examples of evidence on the effects of interventions to achieve behavioural change among healthcare professionals [28, 29].

Table 7 Examples of evidence that can inform the design of implementation strategies targeted at healthcare professionals

4. What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary organisational changes?

Many organisational change strategies see the measures that should be taken as steps in a process that leads to change. Defining why there is a need for change and identifying barriers to change are tasks that are typically included in this process.

Pexton has proposed a list of the most common barriers to organisational change and this can also be used as a framework for barrier-identification [30]:

  • Cultural complacency (resistance or scepticism)

  • Lack of communication

  • Lack of alignment and accountability

  • Passive or absent leadership

  • Micro-management

  • An overloaded workforce

  • Inadequate systems and structures

Ways to address each of these types of barriers are suggested in Table 8.

Table 8 Proposed list of common organisational barriers to change (adapted from [30])

Examples of the tools and approaches often recommended to organisations assessing preparations for change include [31]:

  • Analytic models for understanding complexity, interdependence and fragmentation (such as Weisbord's six-box organisational model, the 7S model, and process models)

  • Tools for assessing why change is needed, such as SWOT analysis

  • Tools for determining who and what can change, such as force field analysis and total quality management

  • Tools for making changes, such as organisational development, action research and project management

Most commonly used organisational change strategies are based almost entirely on theory, or else on one-off applications and opinion. Sometimes these are supplemented with case studies or anecdotes, mainly from high-income settings [31]. Evidence about the effectiveness of these strategies is hard to come by, making it difficult to predict whether or not a specific method is likely to lead to the desired organisational change.

Although the impacts of such change management strategies are uncertain, they may still be useful as processes allowing for active reflection on how change in an organisation can be facilitated.

5. What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary systems changes?

When a policy is to be implemented, changes at the general level of a health system may be necessary. These may include changes to governance arrangements, financial arrangements and delivery arrangements [32]. For example, when considering the financing of a policy option, should all costs be incurred by the government, or are additional sources of funding needed? Can the current system cope with the additional bureaucratic or logistical workload, or is a new mechanism needed to deliver the service? The body of evidence on how to implement such changes is small: those making decisions will usually have to draw on case studies and experiences in other jurisdictions. For particular policy implementation issues systematic reviews may be useful, such as those related to the costs of scaling up interventions [33] or factors that may affect the sustainability of health programmes [34]. In a recent overview, the authors summarised the evidence from systematic reviews on the effects of governance, financial and delivery arrangements, and implementation strategies that have the potential to improve the delivery of cost-effective interventions in primary health care in LMICs [27].

When identifying the need for system changes it may be useful to review the components of a health system and to identify where changes are required. Table 9 shows a framework that can be used as a starting point for such analyses [35].

Table 9 Various components of health systems (adapted from Lavis et al [35])

Conclusion

A consideration of the aspects of policy implementation described in this article should enable policymakers and those who support them to employ a structured approach that includes the use of research findings in the design of implementation strategies. Currently, implementation plans often are developed on an ad hoc basis, and are rarely informed by available evidence. As the approach outlined in this article is not widely used, we encourage the sharing of experiences in this area of evidence-informed policy implementation.

Resources

Useful documents and further reading

Shared decision-making in health care. Achieving evidence-based patient choice (2nd edition, Edited by Edwards A and Elwyn G). Oxford University Press, 2009.

Changing Professional Practice (Edited by: Thorsen T and Mäkelä M) Copenhagen: Danish Institute for Health Services Research and Development, 1999. http://www.dsi.dk/projects/cpp/Monograph/DSI9905.pdf

Grol R, Wensing M, Eccles M. Improving Patient Care: The Implementation of Change in Clinical Practice. Oxford: Elsevier, 2005.

Fretheim A, Schünemann HJ, Oxman AD. Improving the use of research evidence in guideline development: 15. Disseminating and implementing guidelines. Health Research Policy and Systems 2006, 4:27. http://www.health-policy-systems.com/content/4/1/27

NorthStar - how to design and evaluate healthcare quality improvement interventions. The ReBEQI Collaboration 2005: http://www.rebeqi.org/?pageID=34&ItemID=35

Iles V, Sutherland K. Organisational Change. A review for health care managers, professionals and researchers. 2001. London, National Co-ordinating Centre for NHS Service Delivery and Organisation R & D http://www.sdo.nihr.ac.uk/files/adhoc/change-management-review.pdf.

Links to websites

Cochrane Consumers and Communication Review Group Resource Bank: http://www.latrobe.edu.au/chcp/cochrane/resourcebank/index.html - The Cochrane Consumers and Communication Review Group is part of the Cochrane Collaboration, an international, non-profit organisation that aims to help people make well-informed decisions about healthcare. The Consumers and Communication Review Group co-ordinates the production of systematic reviews of interventions which affect consumers' interactions with healthcare professionals, services and researchers. This resource bank is a list of Cochrane systematic reviews relevant to people's health communication and participation needs, and has been produced by manually searching The Cochrane Library.

Cochrane Effective Practice and Organisation of Care (EPOC) Review Group: http://www.epoc.cochrane.org/en/index.html - EPOC is a Collaborative Review Group of the Cochrane Collaboration and produces systematic reviews of educational, behavioural, financial, regulatory and organisational interventions that are designed to improve healthcare professional practice and the organisation of health care services.

References

  1. 1.

    Lavis JN, Oxman AD, Lewin S, Fretheim A: SUPPORT Tools for evidence-informed health Policymaking (STP). Introduction. Health Res Policy Syst. 2009, 7 (Suppl 1): I1-10.1186/1478-4505-7-S1-I1.

  2. 2.

    Deskins S, Harris CV, Bradlyn AS, Cottrell L, Coffman JW, Olexa J, Neal W: Preventive care in Appalachia: use of the theory of planned behavior to identify barriers to participation in cholesterol screenings among West Virginians. J Rural Health. 2006, 22: 367-74. 10.1111/j.1748-0361.2006.00060.x.

  3. 3.

    Mshana GH, Wamoyi J, Busza J, Zaba B, Changalucha J, Kaluvya S, Urassa M: Barriers to accessing antiretroviral therapy in Kisesa, Tanzania: a qualitative study of early rural referrals to the national program. AIDS Patient Care STDS. 2006, 20: 649-57. 10.1089/apc.2006.20.649.

  4. 4.

    Hanson K, Ranson MK, Oliveira-Cruz V, Mills A: Expanding access to priority health interventions: a framework for understanding the constraints to scaling-up. J Int Dev. 2003, 15: 1-14. 10.1002/jid.963.

  5. 5.

    Lavis JN, Oxman AD, Grimshaw J, Johansen M, Boyko JA, Lewin S, Fretheim A: SUPPORT Tools for evidence-informed health Policymaking (STP). 7. Finding systematic reviews. Health Res Policy Syst. 2009, 7 (Suppl 1): S7-10.1186/1478-4505-7-S1-S7.

  6. 6.

    Lavis JN, Oxman AD, Souza NM, Lewin S, Gruen RL, Fretheim A: SUPPORT Tools for evidence-informed health Policymaking (STP). 9. Assessing the applicability of the findings of a systematic review. Health Res Policy Syst. 2009, 7 (Suppl 1): S9-10.1186/1478-4505-7-S1-S9.

  7. 7.

    Lewin S, Oxman AD, Lavis JN, Fretheim A, García Martí S, Munabi-Babigumira S: SUPPORT Tools for evidence-informed health Policymaking (STP). 11. Finding and using research evidence about local conditions. Health Res Policy Syst. 2009, 7 (Suppl 1): S11-10.1186/1478-4505-7-S1-S11.

  8. 8.

    Lewin S, Oxman AD, Lavis JN, Fretheim A: SUPPORT Tools for evidence-informed health Policymaking (STP). 8. Deciding how much confidence to place in a systematic review. Health Res Policy Syst. 2009, 7 (Suppl 1): S8-10.1186/1478-4505-7-S1-S8.

  9. 9.

    Oxman AD, Lavis JN, Lewin S, Fretheim A: SUPPORT Tools for evidence-informed health Policymaking (STP). 10. Taking equity into consideration when assessing the findings of a systematic review. Health Res Policy Syst. 2009, 7 (Suppl 1): S9-10.1186/1478-4505-7-S1-S9.

  10. 10.

    Green J, Thorogood N: Qualitative methods for health research. 2004, London: London School of Hygiene & Topical Medicine

  11. 11.

    World Health Organization (WHO): Adherence to long-term therapies: evidence for action. 2003, Geneva, World Health Organization (WHO), [http://www.who.int/chp/knowledge/publications/adherence_full_report.pdf]

  12. 12.

    Munro SA, Lewin SA, Smith HJ, Engel ME, Fretheim A, Volmink J: Patient adherence to tuberculosis treatment: a systematic review of qualitative research. PLoS Med. 2007, 4: e238-10.1371/journal.pmed.0040238.

  13. 13.

    Santesso N, Ryan R, Hill S, Grimshaw J: A Taxonomy of Interventions Directed at Consumers to Promote Evidence-based Prescribing and Drug Use. 2007, Poster presentation at The Canadian Agency for Drugs and Technologies in Health Symposium, [http://www.latrobe.edu.au/chcp/assets/downloads/CADTH07_poster.pdf]

  14. 14.

    Oliveira-Cruz V, Hanson K, Mills A: Approaches to overcoming constraints to effective health service delivery: A review of the Evidence. J Int Dev. 2003, 15: 41-65. 10.1002/jid.965.

  15. 15.

    Lagarde M, Haines A, Palmer N: Conditional cash transfers for improving uptake of health interventions in low- and middle-income countries: a systematic review. JAMA. 2007, 298: 1900-10. 10.1001/jama.298.16.1900.

  16. 16.

    Thornton R: The Demand for, and Impact of, Learning HIV Status. American Economic Review. 2008, 98: 1829-63. 10.1257/aer.98.5.1829.

  17. 17.

    Grilli R, Ramsay C, Minozzi S: Mass media interventions: effects on health services utilisation. Cochrane Database Syst Rev. 2002, 1: CD000389-

  18. 18.

    Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR: Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999, 282: 1458-65. 10.1001/jama.282.15.1458.

  19. 19.

    Cochrane Effective Practice and Organisation of Care Review Group: Data Collection Check List. 2002, [http://www.epoc.cochrane.org/Files/Website%20files/Documents/Reviewer%20Resources/datacollectionchecklist.pdf]

  20. 20.

    Althabe F, Bergel E, Cafferata ML, Gibbons L, Ciapponi A, Aleman A, Colantonio L, Palacios AR: Strategies for improving the quality of health care in maternal and child health in low- and middle-income countries: an overview of systematic reviews. Paediatr Perinat Epidemiol. 2008, 22 (Suppl 1): 42-60. 10.1111/j.1365-3016.2007.00912.x.

  21. 21.

    Grimshaw JM, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L, Grilli R, Harvey E, Oxman AD, O'Brien MA: Changing provider behavior: an overview of systematic reviews of interventions. Med Care. 2001, 39: II2-45. 10.1097/00005650-200108002-00002.

  22. 22.

    Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay CR, Vale L, Whitty P, Eccles MP, Matowe L, Shirran L: Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004, 8: iii-72.

  23. 23.

    Prior M, Guerin M, Grimmer-Somers K: The effectiveness of clinical guideline implementation strategies--a synthesis of systematic review findings. J Eval Clin Pract. 2008, 14: 888-97.

  24. 24.

    Haines A, Kuruvilla S, Borchert M: Bridging the implementation gap between knowledge and action for health. Bull World Health Organ. 2004, 82: 724-31.

  25. 25.

    Oxman AD, Fretheim A: An overview of research on the effects of results-based financing. Report Nr 16-2008. 2008, Oslo, Nasjonalt kunnskapssenter for helsetjenesten, [http://www.kunnskapssenteret.no/binary?download=true&id=5800]

  26. 26.

    Fretheim A, Havelsrud K, MacLennan G, Kristoffersen DT, Oxman AD: The effects of mandatory prescribing of thiazides for newly treated, uncomplicated hypertension: interrupted time-series analysis. PLoS Med. 2007, 4: e232-10.1371/journal.pmed.0040232.

  27. 27.

    Lewin S, Lavis JN, Oxman AD, Bastias G, Chopra M, Ciapponi A, Flottorp S, Marti SG, Pantoja T, Rada G: Supporting the delivery of cost-effective interventions in primary health-care systems in low-income and middle-income countries: an overview of systematic reviews. Lancet. 2008, 372: 928-39. 10.1016/S0140-6736(08)61403-8.

  28. 28.

    Uttekar BP, Barge S, Khan W, Deshpande Y, Uttekar V, Sharma J, Shahane S, Chakrawar B, Shahane: Assessment of ASHA and Janani Suraksha Yojana in Rajasthan. 2007, Vadodora, India, Centre for Operations Research & Training (CORT), [http://www.cortindia.com/RP/RP-2007-0302.pdf]

  29. 29.

    Zwarenstein M, Bheekie A, Lombard C, Swingler G, Ehrlich R, Eccles M, Sladden M, Pather S, Grimshaw J, Oxman AD: Educational outreach to general practitioners reduces children's asthma symptoms: a cluster randomised controlled trial. Implement Sci. 2007, 2: 30-10.1186/1748-5908-2-30.

  30. 30.

    Pexton C: Overcoming Organizational Barriers to Change in Healthcare. 2009, [http://www.ftpress.com/articles/article.aspx?p=1327759]

  31. 31.

    Iles V, Sutherland K: Organisational Change: A review for health care managers, professionals and researchers. 2001, London, National Co-ordinating Centre for NHS Service Delivery and Organisation R & D, [http://www.sdo.nihr.ac.uk/files/adhoc/change-management-review.pdf]

  32. 32.

    Lavis JN, Posada FB, Haines A, Osei E: Use of research to inform public policymaking. Lancet. 2004, 364: 1615-21. 10.1016/S0140-6736(04)17317-0.

  33. 33.

    Johns B, Torres TT: Costs of scaling up health interventions: a systematic review. Health Policy Plan. 2005, 20: 1-13. 10.1093/heapol/czi001.

  34. 34.

    Gruen RL, Elliott JH, Nolan ML, Lawton PD, Parkhill A, McLaren CJ, Lavis JN: Sustainability science: an integrated approach for health-programme planning. Lancet. 2008, 372: 1579-89. 10.1016/S0140-6736(08)61659-1.

  35. 35.

    Lavis JN, Ross SE, Hurley JE, Hohenadel JM, Stoddart GL, Woodward CA, Abelson J: Examining the role of health services research in public policymaking. Milbank Quarterly. 2002, 80: 125-54. 10.1111/1468-0009.00005.

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Acknowledgements

Please see the Introduction to this series for acknowledgements of funders and contributors. In addition, we would like to acknowledge Valerie Iles for helpful comments on an earlier version of this article.

This article has been published as part of Health Research Policy and Systems Volume 7 Supplement 1, 2009: SUPPORT Tools for evidence-informed health Policymaking (STP). The full contents of the supplement are available online at http://www.health-policy-systems.com/content/7/S1.

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Correspondence to Atle Fretheim.

Additional information

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

AF prepared the first draft of this article. SMB, ADO, JNL and SL contributed to drafting and revising it.

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Additional file 1: Glossary (DOC 79 KB)

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Keywords

  • Healthcare Professional
  • Implementation Strategy
  • Policy Implementation
  • Educational Outreach Visit
  • Delivery Arrangement