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Health Promotion International, Vol. 15, No. 2, 113-124,
June 2000
© Oxford University Press 2000
The dissemination of a smoking cessation program: predictors of program awareness, adoption and maintenance
Midwifery Practice and Research Unit, St George Hospital, James Law House, Kogarah, NSW 2217, Australia
Address for correspondence: M. Cooke Family Health Research Unit St George Hospital Gray Street Kogarth NSW 2217, Australia
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SUMMARY |
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 TOP SUMMARY INTRODUCTIONMETHODRESULTSDISCUSSIONRECOMMENDATIONSACKNOWLEDGEMENTSREFERENCES |
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A self-report survey was used to collect data 18 months after the dissemination of a smoking cessation program to 23 antenatal clinics. Sixty-six percent of clinic staff (n = 187) completed and returned the survey. The study uses regression modeling to examine the relationship between organizational characteristics, individual clinician characteristics and methods of dissemination on program awareness, adoption, implementation/maintenance and change in clinician smoking cessation intervention (SCI). The results indicated that participation in decision-making, working in a clinic at the time of the initial program dissemination, professional status and dissemination method were significant predictors of all stages of the dissemination process. Structural variables, e.g. policy, formalization of rules and organizational complexity, influenced early dissemination processes, e.g. awareness and adoption. Perceived hospital innovativeness and the degree to which smoking intervention was used in a clinic prior to dissemination were associated with program adoption. Clinician self-efficacy was associated with program maintenance and improved smoking cessation intervention.
Key words: dissemination; smoking cessation education; antenatal care
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONMETHODRESULTSDISCUSSIONRECOMMENDATIONSACKNOWLEDGEMENTSREFERENCES |
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It is estimated that between 20 and 40% of pregnant women continue to smoke during pregnancy despite the risks associated with smoking (US Department of Health and Human Services, 1992
; Taylor and Pym, 1995). This study explores the variables which are associated with the dissemination and use of a smoking cessation program during pregnancy. The program was disseminated to antenatal clinics situated in 23 large public hospitals in New South Wales (NSW). These clinics were selected to ensure that the program was disseminated to the largest possible number of clinicians and therefore the largest number of pregnant smokers. In NSW, more women obtain antenatal care from public hospitals than from private obstetricians (Taylor and Pym, 1995; Taylor and Pym, 1996). Women who attend public hospitals are more likely to be younger and to be categorized as low socio-economic status. These women are also more likely to smoke than women who attend private obstetricians (Davis et al., 1990; Cornelius et al., 1994).
Research indicates that the most effective interventions are not being used by health professionals during pregnancy despite effective brief smoking cessation programs being identified (Gillies et al., 1990; Floyd et al., 1991; Walsh, 1994; Clasper and White, 1995; Walsh et al., 1995; Cooke et al., 1996; Walsh et al., 1997b; Cooke et al., 1998; Lowe et al., 1998). It is suggested that the active dissemination and widespread use of effective smoking cessation programs are required for such interventions to be a successful public health strategy. This study investigates the active and planned dissemination of a smoking cessation intervention (SCI) program called ‘Fresh Start’, which has been specifically designed for use during pregnancy (Walsh et al., 1997a). The ‘Fresh Start’ smoking cessation program has been found to have a 9% validated consecutive smoking cessation rate for pregnant women when used by clinicians in a randomized controlled trial (Walsh et al., 1997a).
Dissemination is the planned and active diffusion of a new idea to a social system (Basch et al., 1986). Rogers' diffusion theory states that the dissemination process can be described by five stages (Rogers, 1995). These stages are: knowledge, persuasion, decision, implementation and confirmation. The dissemination process occurs over time and dissemination failure can occur at any of these stages. The theory infers that different strategies may be required to promote dissemination during each dissemination stage (Orlandi, 1987; Parcel et al., 1990; Scott and Bruce, 1994). This study explores the factors which predict dissemination outcomes at different stages of the dissemination process. It examines the variables which are associated with program awareness, program adoption, program maintenance and improved clinician smoking cessation intervention (SCI).
Several authors suggest that investigating the process of program adoption and implementation is as important as investigating the client outcomes (Norman et al., 1990; Halvorsen et al., 1993; Sussman et al., 1993; Edmundson et al., 1994; Israel et al., 1995). It has been argued that knowledge about the dissemination process in specific contexts is required to enable a better understanding of the interaction between social contexts, individual characteristics, dissemination methods and the program itself (Norman et al., 1990; Israel et al., 1995). Such knowledge may prevent costly dissemination failure in the future, and can improve dissemination strategies and the ultimate effectiveness of programs.
The method used to disseminate health promotion programs may be critical to their uptake and use by health professionals. Two studies have investigated the effect, on the uptake of the program by doctors, of program dissemination by simple mail-out and intensive dissemination (with personal facilitation) (Cockburn et al., 1992; Kottke et al., 1994). They found that when personal facilitation was used to disseminate the program, uptake of the program improved but program implementation was not widespread or systematic. Similar poor implementation of programs and use of smoking cessation interventions have been described by others (Doherty et al., 1988; Power et al., 1989; Cockburn et al., 1992; Clasper and White, 1995; Walsh et al., 1995). This study investigates the impact of different methods of dissemination (simple mail-out and intensive dissemination) on awareness, adoption and implementation of a smoking cessation program.
Other variables have also been implicated as barriers to the use of smoking cessation intervention. Clinician smoking status, beliefs about smoking cessation, counselling skills, self-efficacy and training have all been found to be associated with the use of smoking cessation interventions by health professionals (Goldstein et al., 1987; Mullen and Holcomb, 1990; Kottke, 1994; Clasper and White, 1995). Furthermore, health professionals appear to vary in their uptake and use of smoking cessation programs (Mullen and Holcomb, 1990; Zahnd et al., 1990; Clasper and White, 1995). Nurses and midwives are more likely to use smoking cessation interventions than doctors and obstetricians (Zahnd et al., 1990; Clasper and White, 1995). This research will investigate the relationship between the dissemination process and clinician characteristics, e.g. professional status, smoking status, training, perceived ability in smoking cessation counselling, knowledge of smoking risks and the perceived barriers to providing SCI to patients.
Some authors argue that the individual characteristics of clinicians are not the only factors which impact on program implementation. They suggest that organizational factors, e.g. workload, administrative difficulties, staff resources, colleague support and teamwork affect clinical compliance to programs (Doherty et al., 1988; Mullen and Holcomb, 1990; Frame 1992; Kottke 1994). However, much of this evidence is anecdotal. Only recently has the impact of organizational factors on the use of smoking interventions been investigated in a more systematic way.
A broad range of organizational variables have been examined in research investigating the introduction of tobacco prevention curricula to schools (Steckler et al., 1989; Parcel et al., 1995). The size of the school, level of teacher involvement in curricula training and a favorable work climate increased the rate of adoption and implementation of the new curricula. Organizational factors, e.g. organizational size and administrative support for policy, have also been found to influence the implementation of ‘smoking ban’ policies in hospitals (Gottlieb et al., 1992; Emmons and Biener, 1993; Pucci and Haglund, 1994). This study will investigate the relationship between the dissemination process and factors, e.g. the presence of a specific SCI policy and work climate variables (e.g. staff cohesiveness, supervisor support, work pressure, clarity of rules, and organizational emphasis on change and innovation within the work environment).
Some organizational factors which influence the dissemination of health promotion programs have been identified. But, Abrams argues that the organizational factors and their relationships to the dissemination process remain poorly specified (Abrams, 1991). Organizational research indicates that variables, e.g. organizational size, structure and work climate have an impact on innovation adoption and implementation (Damanpour, 1992; Rogers, 1995). The relationship between these organizational characteristics and the stage of dissemination process is complex. For example, while centralization of decision-making, formalization of rules and organizational complexity are negatively associated with innovation adoption (Damanpour, 1991), it has been argued that centralization of decision-making and formalization of rules may improve the implementation process (Hage and Aiken, 1970; Zaltman et al., 1973; Pierce and Delbecq, 1977). This study investigates the association between the dissemination process and centralization, hierarchy, formalization of rules, size of hospital and type of hospital (see Table 1 for more complete definitions).
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The diffusion theory infers that only a small number of organizations, and the clinicians who work in them, will be ‘ready’ to implement a new smoking cessation program when it is offered to them (Rogers, 1995
). A greater understanding of the variables which impact on the dissemination process may improve the development and planning of dissemination strategies, and increase the number of clinicians willing to adopt and implement new programs. In summary, this study asks, what are the important predictors of different stages of the dissemination process? It investigates the relationship between the dissemination process (i.e. program awareness, adoption and maintenance, and current use of smoking cessation interventions) and variables, e.g. dissemination methods, clinician characteristics and organizational characteristics. |
METHOD |
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TOPSUMMARYINTRODUCTIONMETHODRESULTSDISCUSSIONRECOMMENDATIONSACKNOWLEDGEMENTSREFERENCES |
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Fresh Start smoking cessation program
This study is part of a series of studies investigating the dissemination of a SCI program called ‘Fresh Start’. The program was developed to motivate clinicians to provide systematic, individualized and frequent SCI to smokers during pregnancy. It consisted of multiple components, e.g. a staff training video, information flip chart, patient report stickers, sample SCI policy, computerized feedback, patient self-help video and patient self-help booklet. The program also describes a seven-step approach to SCI. This approach includes smoking assessment, the provision of individualized information about smoking risk, advice to quit, negotiation of a quit date, counselling about quit strategies (if appropriate), provision of self-help materials (written and audiovisual) and follow-up.
Participants
All publicly funded hospitals within a 400 km radius of the research unit in NSW, which had more than 500 births/year, were asked to participate (n = 25). Twenty-three hospitals were recruited to the study from 10 health areas. Two eligible hospitals were not recruited due to delays in their ethics approval procedures. Of the 23 hospitals which agreed to participate in the research, clinicians in 21 hospitals returned follow-up surveys. The two hospitals which did not return follow-up surveys did not adopt/ implement any components of the program. One of the non-responding hospitals was in the simple dissemination group and reportedly did not receive the initial mail-out of the program. The other non-responding hospital was in the intensive dissemination group and did not implement the program because the clinic manager, at the time of implementation, did not approve of the program.
All midwives and medical staff working in the antenatal clinics during a specified time period were asked to complete a survey. In larger hospitals, the data collection took place over 1 week, and in smaller hospitals it occurred over 2 weeks. The population (n = 283) consisted of 41% doctors and 59% midwives. Sixty-six percent of the population (n = 187) returned the survey. There was no difference in the proportion of doctors or midwives who returned surveys in the two dissemination groups (
2 = 1.21, p = 0.27). Slightly more midwives than doctors returned the follow-up survey, but this was not statistically significant. The dissemination groups did not differ significantly in the number of antenatal clinic staff, number of births or proportion of smoking clients. Nor did they differ on structural variables. That is, both intensive and simple dissemination hospitals had similar mean levels of hierarchy, centralization, formalization of rules and specific policies for SCI prior to dissemination. The two dissemination groups had similarly low levels of smoking cessation intervention prior to dissemination (Cooke, 1999).
The clinicians who responded had been working in the obstetric field for a mean of 10 years (sd = 9). Half the participants had commenced working in the clinic after the initial dissemination of the ‘Fresh Start’ program. Only one-third of the participants worked in the clinic full time. Eight percent of the participants were current smokers, 26% were ex-smokers and 66% were non-smokers.
Survey
A self-report survey was used to collect data on individual clinician characteristics, organizational structure, organizational environment and program dissemination. The variables used in the analysis are described in Table 1
. Only scales which had adequate reliability (Cronbach's alpha > 0.7) were used in the analyses. More detail about the scales used in the survey is reported elsewhere (Cooke et al., 1998)
Program dissemination
Two methods of dissemination were used to transfer the program to 23 hospital antenatal clinics. The clinics were stratified according to clinic size and proportion of smoking patients, and then randomly assigned to simple (n = 12) or intensive dissemination (n = 11) methods. Simple dissemination (SD) consisted of a letter accompanying program components, which were mailed to clinic managers. This letter provided information about the risks of smoking during pregnancy, the effectiveness of smoking cessation interventions and a description of how the ‘Fresh Start’ program could be used in the clinic. Each SD clinic was also provided with all the program components described above, except computer evaluation. The intensive dissemination (ID) clinics were provided with additional support and information. They were given specific feedback about the proportion of clients who were smokers and the proportion of clients who reported that they had received information about smoking cessation. ID clinics also received training and support from midwives, who acted as external change agents to facilitate program adoption.
A baseline staff survey of SCI practice was carried out prior to dissemination. A follow-up staff survey and interviews with midwifery managers were carried out 18 months after the initial dissemination of the program. The data reported here are from the follow-up staff survey of clinicians.
Design
A longitudinal cohort analysis has been suggested as an appropriate design to measure the diffusion process (Rogers, 1995). However, a retrospective cross-sectional design was chosen for this study for several reasons. The number of antenatal clinics which were able to be investigated and the sample size were constrained by research resources and geographical distance to the antenatal clinics. About 50% of staff who were working in the clinics during the initial dissemination were transferred from the antenatal clinics to other work areas or hospitals. The size of staff turnover would have a significant impact on the sample size in a cohort design and would have restricted the number of variables which could be investigated (Norman et al., 1990; Abrams, 1991; Susser, 1995). A cross-sectional design provided a larger sample size and allowed a larger number of variables to be examined.
Procedure
Approximately 18 months after the initial program dissemination, clinic managers were notified and reminded about the follow-up survey. The surveys were distributed to all clinicians working in the antenatal clinics. Each participant received a two dollar lottery ticket. One month after the survey was distributed, another letter and survey was mailed to the staff who had not returned the survey. This letter reiterated the aims of the research and the importance of the participants' contribution.
Analyses
Exploratory analyses using regression modeling were used to investigate the relationship between the stages of dissemination, use of smoking cessation interventions and organizational and individual predictors. Three functional sets of predictors were examined (Practitioner, Structural, and Work climate). The mean number of smoking cessation interventions used in the clinics (calculated from a baseline survey of staff) was used to control for the smoking cessation intervention in the clinic prior to dissemination (Cooke et al., 1998). The dissemination group (SD, ID) and each predictor set were then entered into the regression models. The same method of analyses was used for the four dependent variables. The dependent variables were: awareness to the ‘Fresh Start’ program (yes, no), adoption of ‘Fresh Start’ program components (i.e. number of components ever used), implementation of ‘Fresh Start’ components (i.e. number of components used in the last month), and the number of different types of smoking cessation interventions used. Logistic regression was used for the analyses of program awareness, which was a dichotomous variable, and linear regression was used for the other dependent variables.
To reduce the likelihood of Type I errors occurring, an adaptation of Fisher's protected t-test was used (Cohen and Cohen, 1983). That is, when the overall F-test for the full model failed to be statistically significant at 
< 0.05, no further statistical tests of significance for predictors were carried out. If the F-test was significant, t-tests were performed for all variables at the same level as the full model.
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RESULTS |
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TOPSUMMARYINTRODUCTIONMETHODRESULTSDISCUSSIONRECOMMENDATIONSACKNOWLEDGEMENTSREFERENCES |
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Predictors of awareness of a new smoking cessation program
The overall F-test for the full set of work climate variables failed to be statistically significant at
< 0.05 for program awareness and no further statistical tests of significance for predictors were carried out. Both the structural and the practitioner set of variables significantly predicted program awareness (Table 2). The significant predictors of program awareness in the structural set of variables were: hospital description, centralization of decision-making about policy and resources, SCI policy and the interaction between policy and the level of formalization of rules. That is, clinicians in large urban hospitals and hospitals with a high degree of centralization in decision-making were less likely to be aware of a new smoking cessation program. Hospitals which had no SCI policy and high degree of rule formalization were less likely to be aware of the new program than hospitals with a SCI policy, regardless of the level of formalization.
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The significant predictors of awareness in the practitioner set of variables were professional status, baseline and risk (Table 2
). That is, midwives were more aware of the program than doctors. Participants who had been working in a clinic during the initial dissemination (baseline) were more aware than those who had not been working in the clinic at this time, and participants who believed that smoking had greater risks to their patients were more likely to be aware of the program.
Predictors of program adoption
All three sets of variables (Structural, Work climate, Practitioner) predicted program adoption (Table 2). Perceived hospital innovativeness was the only significant predictor of program adoption in the work climate set of predictors. The more clinicians perceived the clinic and the hospital to be innovative, the more likely they were to adopt the new smoking cessation program. The structural predictors of program adoption were similar and of the same effect size to those found to predict program awareness. The practitioner variables were also similar to those which predicted program awareness with one exception. Clinician knowledge of smoking risk predicted program awareness but not program adoption.
Program implementation/maintenance
All three sets of variables significantly predicted program implementation and maintenance (i.e. use of program components in the last week). Perceived hospital innovativeness was again found to be the only important work climate variable. In the structural set of predictors, only centralization of decision-making significantly predicted program implementation/maintenance. Professional status and working in the clinic during the initial program dissemination also continued to be significant predictors for the implementation stage of the dissemination process. However, unlike the earlier stages of dissemination process, perceived ability to provide smoking cessation also predicted program implementation/ maintenance.
The method of dissemination and the degree to which SCI was used in a clinic prior to dissemination were significant predictors of program maintenance. Participants who worked in clinics which had intensive dissemination were more likely to maintain the program than participants who worked in clinics in which the program was disseminated using simple mail-out. Also, the more clinics provided smoking intervention prior to dissemination, the more likely participants were to maintain a new smoking cessation program.
Predictors of smoking cessation intervention
Work climate variables did not predict the level of smoking cessation intervention provided by clinicians after program dissemination. Similar to all the stages of dissemination described above, centralization of decision-making continued to be significant and predicted SCI practice. No other structural variables predicted SCI practice. Professional status and perceived ability to provide smoking cessation counselling also predicted reported smoking cessation intervention. However, working in a clinic when the program was disseminated was not a significant predictor of smoking cessation intervention. Also, clinic SCI practice prior to dissemination and dissemination method did not predict reported smoking cessation intervention except in the regression model for structural factors (Table 2).
Patterns across the dissemination process
The analysis suggested that some variables which influence the dissemination process are consistent across the stages of dissemination, although the size of their effect may change. For example, centralization, professional status, dissemination method and working in a clinic during the initial dissemination predicted at least three of the four dissemination outcomes. This consistency is logical because behavior in each dissemination stage is necessarily related to the behavior in the previous stage. However, there were variables which were only significant predictors for one or two dissemination stages. In particular, structural variables, e.g. hospital type, policy and formalization of rules were only important during the awareness and adoption stages. The level of SCI practice in the clinic prior to dissemination and the perceived innovativeness of the organization influenced program adoption and program maintenance. Whereas, perceived ability to provide smoking cessation counselling appears to only be an important predictor for program maintenance and the degree to which smoking cessation interventions are used by clinicians.
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DISCUSSION |
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TOPSUMMARYINTRODUCTIONMETHODRESULTSDISCUSSIONRECOMMENDATIONSACKNOWLEDGEMENTSREFERENCES |
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This study explored the dissemination process within public hospital antenatal clinics for a smoking cessation program. It examined the relationship between different stages of dissemination (awareness, adoption, implementation/ maintenance) and method of dissemination, individual and organizational variables. It investigated whether the variables which are associated with dissemination are consistent or vary across dissemination processes. A large number of statistical tests were carried out because of the exploratory nature of the analysis of dissemination processes. This increases the likelihood of significant results occurring by chance and one should be cautious of accepting these results without further testing. Nevertheless, the results, to a certain degree, support individual and organizational change theory (Beyer and Trice, 1978
; Prochaska and DiClemente, 1994; Rogers, 1995). The results indicate that variables, e.g. centralization of decision-making, dissemination method, working in clinics during the initial dissemination of the program and professional status are important predictors of all the dissemination processes examined. Other factors seem to be influential during specific dissemination processes. The implications of these results are discussed below.
Dissemination method
Two hospitals did not respond at follow-up (one intensive dissemination and one simple dissemination). The simple dissemination hospital which did not respond at follow-up reported that they did not receive the program during the initial mail-out and were not using the program. The intensive dissemination hospital also did not appear to be using the program based on program facilitators' logbooks. Logbook entries also indicated that the clinic manager of this hospital did not approve of the program.
The analysis indicated that intensive dissemination improved program awareness, adoption, implementation and use of smoking cessation interventions when compared to simple dissemination methods. However, a repeated measures analysis of the same data using hospitals as the unit of measure (rather than individual clinicians) indicated that the level of SCI used by clinicians improved after program dissemination, but the differences between simple and intensive dissemination methods were not significant (Cooke, 1999). The discrepancy in results may be due to the lack of power in the repeated measures analysis, due to the small sample size. An alternative explanation is that the difference between the dissemination groups is marginal. Other analyses of the data indicate that the use of the program was not systematic or widespread in the clinics, regardless of the method used to disseminate the program (Cooke, 1999). It could be argued that intensive dissemination failed to persuade at least one manager who disapproved of the program to implement the program. Future analyses of data from pregnant smokers collected during this research will determine the relative cost effectiveness of the two methods of dissemination.
Organizational variables
One of the most important organizational variables which influenced all stages of dissemination was centralization of decision-making. Organizational theory suggests that the way decisions are made within an organization has a powerful effect on behavior and performance. Increased lower level participation in decision-making (i.e. decentralization) is said to increase the motivation to accept change (Hage and Aiken, 1970; Chisolm and Ziegenfuss, 1986; Vroom and Jago, 1988; Field et al., 1990; Tannenbaum and Dupree-Bruno, 1994). It is also believed that managers on the upper levels of a centralized, hierarchical organization are poorly positioned to identify a performance gap at an operational level and to suggest new ideas to overcome the gap (Rogers, 1995). In this study, the more hospitals were perceived to have decentralized decision-making about policy and resources, the more clinicians were aware of the program, the more program components were adopted and the more smoking cessation interventions were provided.
Centralization was positively associated with formalization of rules within organizations. Theory suggests that high formalization of rules also inhibits the adoption of new ideas (Rogers, 1995). Formalized, written rules, e.g. those found in hospitals, are said to encourage minimum acceptable performance and may lead to inappropriate rule compliance by organizational members (Dunford, 1992). However, the results of this study suggest that formalization of rules, in conjunction with a SCI policy, is associated with increased awareness of a smoking cessation program and program adoption. That is, program adoption by clinicians was more likely to occur when the power to make decisions about policy was available at an operational level, when rules and activities were also clearly defined and understood, and when there was a specific SCI policy.
Clinicians working in large complex urban hospitals were less likely to be aware of and to adopt the program compared to clinicians in less complex, rural hospitals. This result is also in accord with organizational theory, which suggests that a high degree of organizational complexity decreases innovation adoption by organizations (Damapour, 1991). A caveat to this result is that the relationship and importance of organizational characteristics for dissemination in smaller hospitals and private clinics cannot be predicted from these results. The organizational structure and work environment of small hospitals and private clinics would necessarily differ from the structure and environment found in the larger hospitals investigated in this research.
Practitioner variables
While organizational factors seem to be more important during the earlier stages of dissemination, practitioner factors, e.g. the perceived ability to provide SCI, were important during the latter dissemination stages and for SCI practice. The greater the self-efficacy or perceived ability for SCI, the greater the number of program components implemented and maintained, and the more interventions for smoking cessation were used by clinicians. These results are similar to those found in the baseline survey prior to dissemination, where perceived ability predicted the use of smoking cessation interventions by clinicians (Cooke et al., 1998). The importance of self-efficacy has also been found in studies investigating behavior change in smokers (Velicer et al., 1990). These authors suggest that self-efficacy only predicts stage of progression in ‘action’ and ‘maintenance’ stages of change, when behavior change is occurring, and not in earlier awareness and decision stages (DiClemente et al., 1985; Velicer et al., 1990; Prochaska, 1994).
Professional status also appears to be a critical factor for all the dissemination processes. Midwives were more likely to be aware of the program, to adopt and implement the program, and to use a greater variety of smoking cessation interventions. The possible reasons for these differences are complex and have been described elsewhere (Cooke, 1999). In summary, midwives were more likely to perceive health promotion to be part of their role, they had more time to provide the program, and they perceived the risks due to smoking to be greater. Midwives were more likely to perceive that they required training in SCI, to be offered training and to attend training when it was offered. Finally, the program ‘facilitators' and clinic managers were midwives and were likely to have had a greater affinity and rapport with midwives than with doctors.
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RECOMMENDATIONS |
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TOPSUMMARYINTRODUCTIONMETHODRESULTSDISCUSSIONRECOMMENDATIONSACKNOWLEDGEMENTSREFERENCES |
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This research was exploratory in nature and more research is required to investigate the interactions between variables which influence different stages of the dissemination process. Organizational factors, e.g. policy development, appear to be more relevant to earlier stages of dissemination, to promote program awareness and program adoption. But, clinician self-efficacy is more important during program implementation and clinician behavior change. Strategies which improve policy development may be more effective if used early in dissemination, while other strategies to improve clinician skills and self-efficacy (e.g. training) may be more effective if provided later in dissemination planning.
However, participation in decision-making and the distinct role of midwives and doctors within the clinic appear to be important at all stages of dissemination. Therefore, it is recommended that there should be a high degree of involvement of both doctors and midwives in the way the program is marketed, disseminated and implemented within clinics. Some adjustment to the program may be required, such that it is in keeping with medical and midwifery roles, whilst maintaining the critical elements of the program for patients.
Finally, the analyses indicate that one of the critical factors for all the dissemination processes is working in the clinic at the time of the initial dissemination. Participants who worked in the clinic at the time of dissemination are more likely to report being aware of the program, to adopt the program and to maintain their use of the program. It may be that the demand for these individuals to falsely report using the program is greater than for those participants who were not working in the clinic during the initial dissemination of the program. However, an alternative explanation is that the intense marketing and training offered to clinics during this time was effective but not sustained for a long enough period. Repeated marketing should occur until the practice has become routine in everyday practice.
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ACKNOWLEDGEMENTS |
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This research was a collaborative project between The Cancer Education Research Project (NSW Cancer Council, University of Newcastle) and the National Drug and Alcohol Research Centre (University of New South Wales). It was supported by a grant received by Newcastle University from the Public Health Research Development Committee and a PhD scholarship from the Drug & Alcohol Directorate, NSW Department of Health. The author would like to thank Prof. Lesley Barclay (Midwifery Practice and Research Unit) and Assoc. Prof. (National Drug and Alcohol Research Unit) for assistance with editing.
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