Data_Sheet_2_How to “Start Small and Just Keep Moving Forward”: Mixed Methods Results From a Stepped-Wedge Trial to Support Evidence-Based Processes in Local Health Departments.pdf

BackgroundLocal health departments (LHDs) in the United States are charged with preventing disease and promoting health in their respective communities. Understanding and addressing what supports LHD's need to foster a climate and culture supportive of evidence-based decision making (EBDM) processes can enhance delivery of effective practices and services.
MethodsWe employed a stepped-wedge trial design to test staggered delivery of implementation supports in 12 LHDs (Missouri, USA) to expand capacity for EBDM processes. The intervention was an in-person training in EBDM and continued support by the research team over 24 months (March 2018–February 2020). We used a mixed-methods approach to evaluate: (1) individuals' EBDM skills, (2) organizational supports for EBDM, and (3) administered evidence-based interventions. LHD staff completed a quantitative survey at 4 time points measuring their EBDM skills, organizational supports, and evidence-based interventions. We selected 4 LHDs with high contact and engagement during the intervention period to interview staff (n = 17) about facilitators and barriers to EBDM. We used mixed-effects linear regression to examine quantitative survey outcomes. Interviews were transcribed verbatim and coded through a dual independent process.
ResultsOverall, 519 LHD staff were eligible and invited to complete quantitative surveys during control periods and 593 during intervention (365 unique individuals). A total of 434 completed during control and 492 during intervention (83.6 and 83.0% response, respectively). In both trial modes, half the participants had at least a master's degree (49.7–51.7%) and most were female (82.1–83.8%). No significant intervention effects were found in EBDM skills or in implementing evidence-based interventions. Two organizational supports scores decreased in intervention vs. control periods: awareness (−0.14, 95% CI −0.26 to −0.01, p < 0.05) and climate cultivation (−0.14, 95% CI −0.27 to −0.02, p < 0.05) but improved over time among all participants. Interviewees noted staff turnover, limited time, resources and momentum as challenges to continue EBDM work. Setting expectations, programmatic reviews, and pre-existing practices were seen as facilitators.
ConclusionsChallenges (e.g., turnover, resources) may disrupt LHDs' abilities to fully embed organizational processes which support EBDM. This study and related literature provides understanding on how best to support LHDs in building capacity to use and sustain evidence-based practices.

【研究背景】美国地方卫生部门（Local Health Departments, LHDs）肩负着在各自管辖社区内预防疾病、促进民众健康的职责。明晰并解决能够支撑地方卫生部门构建利于循证决策（Evidence-based Decision Making, EBDM）流程的环境与文化的相关需求，可助力提升有效实践与服务的交付质量。【研究方法】本研究采用阶梯楔试验（stepped-wedge trial）设计，在美国密苏里州的12家地方卫生部门中测试分期提供的实施支持方案，以拓展其循证决策流程的实施能力。干预措施包括为期24个月（2018年3月—2020年2月）的现场循证决策培训，以及研究团队提供的持续支持。本研究采用混合研究方法对以下三项内容进行评估：（1）个体的循证决策技能；（2）组织层面的循证决策支持条件；（3）已实施的循证干预措施。地方卫生部门工作人员在4个时间点完成定量调查问卷，用以评估其循证决策技能、组织支持条件与循证干预措施实施情况。本研究选取干预期间接触与参与度较高的4家地方卫生部门，对其17名工作人员进行访谈，以探讨循证决策实施的促进因素与阻碍因素。本研究采用混合效应线性回归分析定量调查结果，并对访谈录音进行逐字转录，通过双独立编码流程完成编码工作。【研究结果】本研究在对照阶段共纳入519名符合入组标准的地方卫生部门工作人员并邀请其完成定量问卷，干预阶段则纳入593名工作人员（共365名独特个体）。对照阶段共有434人完成问卷，干预阶段共有492人完成问卷，对应应答率分别为83.6%与83.0%。在两种试验模式下，均有半数参与者拥有硕士及以上学历（占比49.7%~51.7%），且绝大多数为女性（占比82.1%~83.8%）。研究未发现干预措施对循证决策技能或循证干预措施实施情况存在显著影响。与对照阶段相比，干预阶段有两项组织支持维度的得分出现下降：知晓度（得分变化-0.14，95%置信区间[-0.26, -0.01]，p<0.05）与文化培育（得分变化-0.14，95%置信区间[-0.27, -0.02]，p<0.05），但全体参与者的得分随时间推移均有所提升。受访工作人员指出，人员流动、时间与资源匮乏以及动力不足是阻碍循证决策工作持续推进的主要挑战；而明确的预期要求、项目审查机制与既有实践基础则被视为促进循证决策实施的有利因素。【研究结论】人员流动、资源匮乏等挑战可能会阻碍地方卫生部门完全构建支撑循证决策的组织流程。本研究结合相关文献，明确了如何为地方卫生部门提供最佳支持，以帮助其提升循证实践的应用与持续开展能力。