Understanding the factors influencing the implementation of participatory interventions to improve care coordination. An analytical framework based on an evaluation in Latin America

Abstract

Healthcare coordination is considered key to improving care quality. Although participatory action research (PAR) has been used effectively to bridge the gap between evidence and practice in other areas, little is known about the key success factors of its use in healthcare organizations. This article analyses the factors influencing the implementation of PAR interventions to improve clinical coordination from the perspective of actors in public healthcare networks of Brazil, Chile, Colombia, Mexico and Uruguay. A qualitative, descriptive-interpretative study was conducted in each country’s healthcare network. Focus groups and semi-structured individual interviews were conducted to a criterion sample of: local steering committee (LSC) (29), professional platform (PP) (28), health professionals (49) and managers (28). Thematic content analysis was conducted, segmented by country and themes. The PAR process led by the LSC covered the return of baseline results, selection of problems and interventions and design, implementation and adjustment of the intervention, with PP. Interventions were implemented to improve communication and clinical agreement between primary and secondary care. Results reveal that contextual factors, the PAR process and the intervention’s content influenced their implementation, interacting across time. First, institutional support providing necessary resources, and professionals’ and managers’ willingness to participate, emerge as contextual pivotal factors, influenced by other factors related to: the system (alignment with policy and political cycle), networks (lack of time due to work overload and inadequate working conditions) and individuals (not knowing each other and mutual mistrust). Second, different characteristics of the PAR process have a bearing, in turn, on institutional support and professionals’ motivation: participation, flexibility, consensual decision-making, the LSC’s leadership and the facilitating role of researchers. Evidence is provided that implementation through an adequate PAR process can become a factor of motivation and cohesion that is crucial to the adoption of care coordination interventions, leading to better results when certain contextual factors converge.

Can care coordination across levels be improved through the implementation of participatory action research interventions? Outcomes and conditions for sustaining changes in five Latin American countries

“…The cases in which informants could barely identify any contributions to the improvement of care coordinationoffline virtual consultations and use of the referral and reply letterappear to be related to both contextual barriers and deficiencies in the PAR process and in the content of the interventions [33], aggravated in some cases by a short implementation period, which resulted in low uptake of these mechanisms. An appropriate application of the PAR process in a favourable context also emerged across the board as a necessary condition for the extension, sustainability and replicability of the interventions in other contexts.…”

“…Joint meetings between levels: wide-ranging results on the clinical management and administrative coordination, varying according to the needs of the context It is striking that such an apparently simple intervention meetings between professionals, in person or online, to find solutions together to the problems of coordinating patient care, whether the purpose is to discuss clinical cases, give training, establish joint protocols or the induction of staff into the networkshould obtain such wide-ranging and diverse results in the improvement of clinical management coordination (communication in follow-up, clinical agreement, appropriateness of referrals) and administrative coordination. This may be related to the PAR approach adopted in the design and implementation of these interventions and the reflexive and participatory methods used during the sessions, which entailed joint reflection on cross-level working practice aimed at reaching agreements and the continuous evaluation and adjustment of methodology and content [33]. Firstly, the professionals' participation in the problematization of the fragmentation of the network facilitated their engagement, as they were tackling a problem they felt to be their own.…”

“…The Equity-LA II project combines quantitative methods to analyze the effectiveness of the interventions on care coordination [31] and continuity of care [32] with qualitative data collection methods to evaluate the design and implementation process [33] and the perceived contributions of the interventions to care coordination from the participants' viewpoint. The latter objective is the focus of this paper.…”

“…In the second phase, an inter-level professional platform (PP) was created with those interested in taking action, through which the baseline study results were problematized and interventions were chosen [38]. Subsequently, the interventions were designed and implemented through three types of process: 1) in Colombia, Brazil and Mexico, two PARs cycles: i) a short initial design by the PP and/or LSC followed by implementation and ii) adjustment and implementation; 2) in Chile, long design with high participation through inter-level working groups of professionals and LSC, in several cycles of actionreflection, with pilot tests and implementation; and 3) in Argentina and Uruguay, open design to be agreed upon later with the PP and subsequent implementation [33]. Argentina is not included in this paper because the selected intervention (shared care guideline for hypertension and diabetes) was not implemented [38].…”

“…More PC doctors participated than SC doctors, except in the case of virtual joint clinical conferences in Chile (13 months), where the number of specialists that took part was also high. By contrast, participation figures were low for offline virtual consultations in Brazil (3 months) and Mexico (14 months), use of the referral and reply letter in Uruguay (7 months) and joint meetings on mental health in Brazil (7 months) [33]. An analysis of the PAR design and implementation process and the content of the interventions has already been published in two previous publications [33,38].…”