Telethon Kids Institute, University of Western Australia, Western Australia, Australia.
Charles Darwin University, Darwin, Northern Territory, Australia.
J Am Heart Assoc. 2018 Jul 17;7(14):e009376. doi: 10.1161/JAHA.118.009376.
Rheumatic heart disease is a high-burden condition in Australian Aboriginal communities. We evaluated a stepped-wedge, community, randomized trial at 10 Aboriginal communities from 2013 to 2015. A multifaceted intervention was implemented using quality improvement and chronic care model approaches to improve delivery of penicillin prophylaxis for rheumatic heart disease. The trial did not improve penicillin adherence. This mixed-methods evaluation, designed a priori aimed to determine the association between methodological approaches and outcomes.
An evaluation framework was developed to measure the success of project implementation and of the underlying program theory. The program theory posited that penicillin delivery would be improved through activities implemented at clinics that addressed elements of the chronic care model. Qualitative data were derived from interviews with health-center staff, informants, and clients; participant observation; and project officer reports. Quantitative data comprised numbers and types of "action items," which were developed by participating clinic staff with project officers to improve delivery of penicillin injections. Interview data from 121 health-center staff, 22 informants, and 72 clients revealed barriers to achieving the trial's aims, including project-level factors (short trial duration), implementation factors (types of activities implemented), and contextual factors (high staff turnover and the complex sociocultural environment). Insufficient actions were implemented addressing "self-management support" and "community linkage" streams of the chronic care model. Increased momentum was evident in later stages of the study.
The program theory underpinning the study was sound. The limited impact made by the study on adherence was attributable to complex implementation challenges.
风湿性心脏病是澳大利亚原住民社区的高负担疾病。我们于 2013 年至 2015 年在 10 个原住民社区评估了一项阶梯式、社区、随机试验。采用质量改进和慢性病管理模式方法实施了多方面的干预措施，以改善风湿性心脏病青霉素预防的提供。该试验并没有提高青霉素的依从性。这项混合方法评估是预先设计的，旨在确定方法学方法与结果之间的关联。
制定了一个评估框架来衡量项目实施和潜在计划理论的成功。该计划理论假设，通过在诊所实施的活动可以改善青霉素的提供，这些活动针对慢性病管理模型的要素。定性数据来自于对卫生中心工作人员、知情人和客户的访谈、参与性观察和项目官员报告。定量数据包括由参与诊所工作人员与项目官员共同制定的“行动项目”的数量和类型，以改善青霉素注射的提供。对 121 名卫生中心工作人员、22 名知情人和 72 名客户的访谈数据显示，实现试验目标存在障碍，包括项目层面的因素（试验持续时间短）、实施因素（实施的活动类型）和背景因素（员工高流动率和复杂的社会文化环境）。慢性病管理模型的“自我管理支持”和“社区联系”流的实施行动不足。研究后期的动力明显增强。
研究的基础计划理论是合理的。研究对依从性的影响有限，这归因于复杂的实施挑战。
