A WHO-HPH operational program versus usual routines for implementing clinical health promotion: an RCT in health promoting hospitals (HPH)

Jeff Kirk Svane, Shu-Ti Chiou, Oliver Groene, Milena Kalvachova, Mirna Zagrajski Brkić, Isao Fukuba, Tiiu Härm, Jerneja Farkas, Yen Ang, Mikkel Østerheden Andersen, Hanne Tønnesen, Jeff Kirk Svane, Shu-Ti Chiou, Oliver Groene, Milena Kalvachova, Mirna Zagrajski Brkić, Isao Fukuba, Tiiu Härm, Jerneja Farkas, Yen Ang, Mikkel Østerheden Andersen, Hanne Tønnesen

Abstract

Background: Implementation of clinical health promotion (CHP) aiming at better health gain is slow despite its effect. CHP focuses on potentially modifiable lifestyle risks such as smoking, alcohol, diet, and physical inactivity. An operational program was created to improve implementation. It included patients, staff, and the organization, and it combined existing standards, indicators, documentation models, a performance recognition process, and a fast-track implementation model. The aim of this study was to evaluate if the operational program improved implementation of CHP in clinical hospital departments, as measured by health status of patients and staff, frequency of CHP service delivery, and standards compliance.

Methods: Forty-eight hospital departments were recruited via open call and stratified by country. Departments were assigned to the operational program (intervention) or usual routine (control group). Data for analyses included 36 of these departments and their 5285 patients (median 147 per department; range 29-201), 2529 staff members (70; 10-393), 1750 medical records (50; 50-50), and standards compliance assessments. Follow-up was measured after 1 year. The outcomes were health status, service delivery, and standards compliance.

Results: No health differences between groups were found, but the intervention group had higher identification of lifestyle risk (81% versus 60%, p < 0.01), related information/short intervention and intensive intervention (54% versus 39%, p < 0.01 and 43% versus 25%, p < 0.01, respectively), and standards compliance (95% versus 80%, p = 0.02).

Conclusions: The operational program improved implementation by way of lifestyle risk identification, CHP service delivery, and standards compliance. The unknown health effects, the bias, and the limitations should be considered in implementation efforts and further studies.

Trial registration: ClinicalTrials.gov : NCT01563575. Registered 27 March 2012. https://ichgcp.net/clinical-trials-registry/NCT01563575.

Keywords: Clinical health promotion; Fast-track implementation; Health promoting hospitals; Hospital staff; Lifestyle risk; Patients; Quality improvement; Strategic implementation.

Conflict of interest statement

Ethics approval and consent to participate

All data were anonymized at the source, and no person-identifiable information was recorded or transferred. The study included no biological material. The anonymized data were stored and secured by Capital Region Denmark CIMT. Paper records were maintained under double lock. Only the international research team had access to all data. The study was approved by the Internal Review Board of Bispebjerg-Frederiksberg Hospital, University of Copenhagen, Denmark, and by the Danish Data Protection Agency (j.nr. 2012-41-0152 / 2017-41-5029). All participating departments had local approval from their internal review body, department head, and hospital management. Participation in the study was not associated with any risks. The time required to complete forms and surveys was considered a minor inconvenience.

Consent for publication

All participating clinical departments that delivered data obtained local approval from their internal review body, approval from the head of the department, and from the hospital management. Consent from individual patients or staff was not required as no person-identifiable data was captured at any point.

Competing interests

All authors completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare that they have no competing interest for the submitted work.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Trial profile
Fig. 2
Fig. 2
Comparison of the (n = 36) intervention (black) and control (red) departments’ patients (n = 5285. Median 147; range 29–201) and staff (n = 2529. 70; 10–393) health status by Short Form 36 version 2 (SF36v2) presented as median physical component score (PCS) and mental component score (MCS)
Fig. 3
Fig. 3
Comparison of the intervention (black) and control (red) departments’ documentation of their 1750 patients’ risks in the medical records (2a) and related delivery of information/shorter intervention (2b) and intensive intervention (2c) to at-risk patients (3% missing data. *P < 0.05)
Fig. 4
Fig. 4
Compliance with WHO standards for health promotion in hospitals (in %) in the clinical departments of the intervention group (baseline n = 22, 1-year follow-up n = 18) and of the control group (n = 18)

References

    1. Morris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. J R Soc Med. 2011;104(12):510–520. doi: 10.1258/jrsm.2011.110180.
    1. Balas EA, Boren SA. Yearbook of medical informatics: managing clinical knowledge for health care improvement. Stuttgart: Schattauer Verlagsgesellschaft mbH; 2000.
    1. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4(1):50.
    1. Glasgow RE, Klesges LM, Dzewaltowski DA, Bull SS, Estabrooks P. The future of health behavior change research: what is needed to improve translation of research into health promotion practice? Ann Behav Med. 2004;27(1):3–12. doi: 10.1207/s15324796abm2701_2.
    1. World health organization. Ottawa charter for health promotion. Health Promot Int. 1986;1(4):405.
    1. World Health Organization (WHO). Health promotion glossary [cited 2018 April 24].
    1. Smith BJ, Tank KC, Nutbeam DWHO. Health promotion glossary: new terms. Oxford University Press, Oxford UK; 2006. .
    1. Tønnesen H. Clinical health promotion - what does it mean? Clin Health Promotion. 2011;1(2):39–40.
    1. The working group concerning prevention, health promotion and population health under the Danish National Terminologi Counsel for Healthcare [Arbejdsgruppen vedrørende forebyggelse, sundhedsfremme og folkesundhed under Det Nationale Begrebsråd for Sundhedsvæsenet]. Terminology: Prevention, health promotion and population health [Terminologi: Forebyggelse, sundhedsfremme og folkesundhed]: Danish National Board of Health; 2005.
    1. Golechha M. Health promotion methods for smoking prevention and cessation: a comprehensive review of effectiveness and the way forward. Int J Prev Med. 2016;7:7. doi: 10.4103/2008-7802.173797.
    1. Pell JP, Haw S, Cobbe S, Newby DE, Pell AC, Fischbacher C, et al. Smoke-free legislation and hospitalizations for acute coronary syndrome. N Engl J Med. 2008;359(5):482–491. doi: 10.1056/NEJMsa0706740.
    1. Mackay DF, Irfan MO, Haw S, Pell JP. Meta-analysis of the effect of comprehensive smoke-free legislation on acute coronary events. Heart. 2010;96(19):1525–1530. doi: 10.1136/hrt.2010.199026.
    1. National Board of Health and Social Affairs [Socialstyrelsen]. Swedish national guidelines for prevention and treatment of unhealthy lifestyle habits [Nationella riktlinjer för prevention och behandling vid ohälsosamma levnadsvanor] 2017.
    1. World Health Organization (WHO). Health impact assessment (HIA). The determinants of health [cited 2018 April 24].
    1. Nutbeam D. The evolving concept of health literacy. Soc Sci Med. 2008;67(12):2072–2078. doi: 10.1016/j.socscimed.2008.09.050.
    1. Thomsen T, Villebro N, Møller AM. Interventions for preoperative smoking cessation. Cochrane Database Syst Rev. 2014;(3):CD002294.
    1. Egholm JWM, Pedersen B, Adami J, Møller A, Tønnesen H. Perioperative alcohol cessation intervention for postoperative complications. Cochrane Database Syst Rev. 2018;(11):CD008343.
    1. Beier-Holgersen R, Boesby S. Influence of postoperative enteral nutrition on postsurgical infections. Gut. 1996;39(6):833–835. doi: 10.1136/gut.39.6.833.
    1. Nielsen PR, Andreasen J, Asmussen M, Tønnesen H. Costs and quality of life for prehabilitation and early rehabilitation after surgery of the lumbar spine. BMC Health Serv Res. 2008;8(1):209. doi: 10.1186/1472-6963-8-209.
    1. Cnattingius S. The epidemiology of smoking during pregnancy: smoking prevalence, maternal characteristics and pregnancy outcomes. Nicotine Tob Res. 2004;6(Suppl 2):S125–S140. doi: 10.1080/14622200410001669187.
    1. Rasmussen M, Heitmann BL, Tønnesen H. Effectiveness of the gold standard programmes (GSP) for smoking cessation in pregnant and non-pregnant women. Int J Environ Res Public Health. 2013;10(8):3653–3666. doi: 10.3390/ijerph10083653.
    1. Ota E, Hori H, Mori R, Tobe-Gai R, Farrar D. Antenatal dietary education and supplementation to increase energy and protein intake. Cochrane Database Syst Rev. 2015;(6):CD000032.
    1. Heiwe S, Jacobson SH. Exercise training for adults with chronic kidney disease. Cochrane Database Syst Rev. 2011;(10):CD0032362011.
    1. Anderson L, Taylor RS. Cardiac rehabilitation for people with heart disease: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev. 2014;(12):CD011273.
    1. Thomas DE, Elliott EJ, Naughton GA. Exercise for type 2 diabetes mellitus. Cochrane Database Syst Rev. 2006;3:CD002968.
    1. McKeough ZJ, Velloso M, Lima VP, Alison JA. Upper limb exercise training for COPD. Cochrane Database Syst Rev. 2016;11:CD011434.
    1. Oellgaard J, Gaede P, Rossing P, Rorth R, Kober L, Parving HH, et al. Reduced risk of heart failure with intensified multifactorial intervention in individuals with type 2 diabetes and microalbuminuria: 21 years of follow-up in the randomised Steno-2 study. Diabetologia. 2018;61(8):1724–1733. doi: 10.1007/s00125-018-4642-y.
    1. Taylor G, McNeill A, Girling A, Farley A, Lindson-Hawley N, Aveyard P. Change in mental health after smoking cessation: systematic review and meta-analysis. BMJ. 2014;348:g1151. doi: 10.1136/bmj.g1151.
    1. Pedersen B, Hansen PE, Tønnesen H. Scand-ankle: cost-effectiveness of alcohol cessation intervention in acute fracture surgery. Clin Health Promot. 2014;2 suppl:1–68.
    1. Møller AM, Villebro NM. Preoperative smoking intervention: what do patients think? A qualitative study. Ugeskr Laeger. 2004;166:3714–3718.
    1. Lindström D, Sundberg-Petersson I, Adami J, Tønnesen H. Disappointment and drop-out rate after being allocated to control group in a smoking cessation trial. Contemp Clin Trials. 2010;31(1):22–26. doi: 10.1016/j.cct.2009.09.003.
    1. Lauridsen SV, Thomsen T, Kaldan G, Lydom LN, Tønnesen H. Smoking and alcohol cessation intervention in relation to radical cystectomy: a qualitative study of heavy smokers and risky drinkers’ experiences. BMC Cancer. 2017;17:793
    1. Nolan MB, Warner DO. Perioperative tobacco use treatments: putting them into practice. BMJ. 2017;358:j3340
    1. WHO. Implementing health promotion in hospitals: manual and self-assessment forms: WHO Regional Office for Europe; 2010.
    1. International Network of Health Promoting Hospitals & Health Services (HPH). [cited 2018 April 24].
    1. Groene O, Jorgensen SJ, Fugleholm AM, Møller L, Garcia-Barbero M. Standards for health promotion in hospitals: development and pilot test in nine European countries. Int J Health Care Qual Assur. 2005;18(4):300–307. doi: 10.1108/09526860510602569.
    1. Groene O, Alonso J, Klazinga N. Development and validation of the WHO self-assessment tool for health promotion in hospitals: results of a study in 38 hospitals in eight countries. Health Promot Int. 2010;25(2):221–229. doi: 10.1093/heapro/daq013.
    1. ISQua. Guidelines and principles for the development of health and social care standards. ; 2015.
    1. Tønnesen H, Svane JK, Lenzi L, et al. Handling clinical health promotion in the HPH DATA model: basic documentation of health determinants in medical records of tobacco, malnutrition, overweight, physical inactivity & alcohol. Clin Health Promot. 2012;2:5–11.
    1. Tønnesen H, Christensen ME, Groene O, O'Riordan A, Simonelli F, Suurorg L, et al. An evaluation of a model for the systematic documentation of hospital based health promotion activities: results from a multicentre study. BMC Health Serv Res. 2007;7:145
    1. Tønnesen H, Svane JK, Groene O, Chiou ST. The WHO-HPH recognition project: fast-track implementation of clinical health promotion - a protocol for a multi-center RCT. Clin Health Promot. 2016;6(1):13–20.
    1. Birken SA, Powell BJ, Presseau J, Kirk MA, Lorencatto F, Gould NJ, et al. Combined use of the Consolidated Framework for Implementation Research (CFIR) and the Theoretical Domains Framework (TDF): a systematic review. Implement Sci. 2017;12(1):2. doi: 10.1186/s13012-016-0534-z.
    1. Bauer MS, Damschroder L, Hagedorn H, Smith J, Kilbourne AM. An introduction to implementation science for the non-specialist. BMC Psychol. 2015;3(1):32.
    1. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89(9):1322–1327. doi: 10.2105/AJPH.89.9.1322.
    1. Glasgow RE, Klesges LM, Dzewaltowski DA, Estabrooks PA, Vogt TM. Evaluating the impact of health promotion programs: using the RE-AIM framework to form summary measures for decision making involving complex issues. Health Educ Res. 2006;21(5):688–694. doi: 10.1093/her/cyl081.
    1. Gaglio B, Shoup JA, Glasgow RE. The RE-AIM framework: a systematic review of use over time. Am J Public Health. 2013;103(6):e38–e46. doi: 10.2105/AJPH.2013.301299.
    1. Pantoja T, Opiyo N, Lewin S, Paulsen E, Ciapponi A, Wiysonge CS, et al. Implementation strategies for health systems in low-income countries: an overview of systematic reviews. Cochrane Database Syst Rev. 2017;(9):CD011086.
    1. Rubenstein LV, Pugh J. Strategies for promoting organizational and practice change by advancing implementation research. J Gen Intern Med. 2006;21(S2):S58–S64. doi: 10.1007/s11606-006-0276-8.
    1. Nilsen P. Making sense of implementation theories, models and frameworks. Implement Sci. 2015;10(1):53.
    1. Moen R, Norman C. Evolution of the PDCA cycle. Tokyo: Asian Network for Quality Conference; 2009.
    1. Svane JK, Egerod I, Tønnesen H. Staff experiences with strategic implementation of clinical health promotion: a nested qualitative study in the WHO-HPH Recognition Process RCT. Sage Open Medicine. 2018;6:1–12. doi: 10.1177/2050312118792394.
    1. McHorney CA, Johne W, Anastasiae R. The MOS 36-item short-form health survey (SF-36) Med Care. 1993;31(3):247–263. doi: 10.1097/00005650-199303000-00006.
    1. Jenkinson C, Stewart-Brown S, Petersen S, Paice C. Assessment of the SF-36 version 2 in the United Kingdom. J Epidemiol Community Health. 1999;53(1):46–50. doi: 10.1136/jech.53.1.46.
    1. Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report. Am J Prev Med. 2008;35(2):158–176. doi: 10.1016/j.amepre.2008.04.009.
    1. Rasmussen M. Efficacy of intensive face-to-face interventions for smoking cessation (prospective registry of a systematic review). Prospero. 2018.
    1. Svane JK, Raisova B, Stanecka Z, Dolezel Z, Richter M, Cahlikova J, et al. Clinical health promotion in the Czech Republic: standards compliance and service provision. Clin Health Promot. 2014;4(1):15–21.
    1. Svane JK, Chiou ST, Chang YL, Shen SH, Huang CH, Pan CY, et al. Integration of health promotion in clinical hospital departments: standards fulfilment, documentation of needs and service delivery. Clin Health Promot. 2015;5(1):11–17.
    1. Ferketich AK, Khan Y, Wewers ME. Are physicians asking about tobacco use and assisting with cessation? Results from the 2001-2004 national ambulatory medical care survey (NAMCS) Prev Med. 2006;43(6):472–476. doi: 10.1016/j.ypmed.2006.07.009.
    1. Jamal A, Dube SR, King BA. Tobacco use screening and counseling during hospital outpatient visits among US adults, 2005-2010. Prev Chronic Dis. 2015;12:E132. doi: 10.5888/pcd12.140529.
    1. Kemppainen V, Tossavainen K, Turunen H. Nurses’ roles in health promotion practice: an integrative review. Health Promot Int. 2013;28(4):490–501. doi: 10.1093/heapro/das034.
    1. Burke LE, Fair J. Promoting prevention: skill sets and attributes of health care providers who deliver behavioral interventions. J Cardiovasc Nurs. 2003;18(4):256–266. doi: 10.1097/00005082-200309000-00004.
    1. Joint Commision International (JCI) 2010. Screening and treating tobacco and alcohol use.
    1. Fiore MC, Goplerud E, Schroeder SA. The joint commission’s new tobacco-cessation measures — will hospitals do the right thing? N Engl J Med. 2012;366:1172–1174. doi: 10.1056/NEJMp1115176.
    1. Makdissi R, Stewart SH. Care for hospitalized patients with unhealthy alcohol use: a narrative review. Addict Sci Clin Pract. 2013;8:11. doi: 10.1186/1940-0640-8-11.
    1. American College of Surgeons. Business case for the National Surgical Quality Improvement Program.
    1. Greenfield D, Pawsey M, Hinchcliff R, Moldovan M, Braithwaite J. The standard of healthcare accreditation standards: a review of empirical research underpinning their development and impact. BMC Health Serv Res. 2012;12(1):329. doi: 10.1186/1472-6963-12-329.
    1. Flodgren G, Gonçalves-Bradley DC, Pomey M-P. External inspection of compliance with standards for improved healthcare outcomes. Cochrane Database Syst Rev. 2016;(12):CD008992.
    1. Nicklin W, Dickson S. The value and impact of health care accreditation: a literature review. : Accreditation Canada; 2011.
    1. Brubakk K, Vist GE, Bukholm G, Barach P, Tjomsland O. A systematic review of hospital accreditation: the challenges of measuring complex intervention effects. BMC Health Serv Res. 2015;15(1):280.
    1. Greenfield D, Braithwaite J. Health sector accreditation research: a systematic review. Int J Qual Health Care. 2008;20(3):172–183. doi: 10.1093/intqhc/mzn005.
    1. Hinchcliff R, Greenfield D, Moldovan M, Westbrook JI, Pawsey M, Mumford V, et al. Narrative synthesis of health service accreditation literature. BMJ Qual Saf. 2012;21(12):979–991. doi: 10.1136/bmjqs-2012-000852.
    1. Vist GE, Nøstberg AM, Brubakk K, Munkeby BH. Effects of certification and accreditation of hospitals. Oslo: Norwegian knowledge Center for the Health Services [Nasjonalt Kunnskapssenter for helsetjenester]; 2009.
    1. Scales DC. A multifaceted intervention for quality improvement in a network of intensive care units. JAMA. 2011;305(4):363. doi: 10.1001/jama.2010.2000.
    1. Cavalcanti AB, Bozza FA, Machado FR, Salluh JIF, Campagnucci VP, Vendramim P, et al. Effect of a quality improvement intervention with daily round checklists, goal setting, and clinician prompting on mortality of critically ill patients. JAMA. 2016;315(14):1480. doi: 10.1001/jama.2016.0154.
    1. Du X, Gao R, Turnbull F, Wu Y, Rong Y, Lo S, et al. Hospital quality improvement initiative for patients with acute coronary syndromes in China: a cluster randomized, controlled trial. Circ Cardiovasc Qual Outcomes. 2014;7(2):217–226. doi: 10.1161/CIRCOUTCOMES.113.000526.
    1. Salmon JW, Heavens J, Lombard C, Tavrow P. The impact of accreditation on the quality of hospital care: KwaZulu-Natal Province, Republic of South Africa. Operations Research Results US Agency for International Development (USAID), Quality Assurance Project, University Research Co. LLC Bethesda. 2003;2(17):1–49.
    1. Falstie-Jensen AM, Larsson H, Hollnagel E, Norgaard M, Svendsen MLO, Johnsen SP. Compliance with hospital accreditation and patient mortality: a Danish nationwide population-based study. Int J Qual Health Care. 2015;27(3):165–174. doi: 10.1093/intqhc/mzv023.
    1. OPM evaluation team. Evaluation of the healthcare commission’s healthcare associated infections inspection programme. OPM Report. 2009:1–23.
    1. Rigotti NA, Tindle HA, Regan S, Levy DE, Chang Y, Carpenter KM, et al. A post-discharge smoking-cessation intervention for hospital patients: helping hand 2 randomized clinical trial. Am J Prev Med. 2016;51(4):597–608. doi: 10.1016/j.amepre.2016.04.005.
    1. US Department of Labor OSaHA. Worker safety in hospitals 2017.
    1. Sejr HS, Osler M. Do smoking and health education influence student nurses’ knowledge, attitudes, and professional behavior? Prev Med. 2002;34(2):260–265. doi: 10.1006/pmed.2001.0981.
    1. Zabeen S, Tsourtos G, Campion J, Lawn S. Type of unit and population served matters when implementing a smoke-free policy in mental health settings: perceptions of unit managers across England. Int J Soc Psychiatry. 2015;61(7):700–710. doi: 10.1177/0020764015575799.
    1. Willaing I, Iversen L, Jørgensen T. What are the effects of healthcare staffs’ individual smoking habits on knowledge, attitudes and councelling practices related to smoking? [Hvad betyder sygehuspersonalets individuelle rygevaner for viden, holdning og rådgivningspraksis relateret til rygning?] Ugeskr Laeger. 2001;163(32):4180–4181.
    1. Sarna L, Bialous SA, Wells M, Kotlerman J, Wewers ME, Froelicher ES. Frequency of nurses’ smoking cessation interventions: report from a national survey. J Clin Nurs. 2009;18(14):2066–2077. doi: 10.1111/j.1365-2702.2009.02796.x.
    1. Roelen C, Rhenen W, Schaufeli W, Klink J, Magerøy N, Moen B, et al. Mental and physical health-related functioning mediates between psychological job demands and sickness absence among nurses 2013.
    1. Wilson PM, Sales A, Wensing M, Aarons GA, Flottorp S, Glidewell L, et al. Enhancing the reporting of implementation research. Implement Sci. 2017;12(1):13. doi: 10.1186/s13012-017-0546-3.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe