Understanding Context

Researchers need to be acutely aware of the elements in the organization in which an intervention will be embedded, as discussed in detail in Chapter 20. The characteristics of the environmental context of a practice setting, organization, and agency can influence the likelihood or speed of dissemination and eventual adoption of an intervention (Simpson & Dansereau, 2007). In addition to specific organization or agency characteristics for an intervention, the larger context of policy and societal trends and values also influence dissemination and wide-scale adoption as suggested in Chapter 1, Figure 1.2.

Certain characteristics of practice settings may yield differential outcomes for dissemination. For example, it has been found that a high level of environmental uncertainty may actually increase an organization’s willingness to embrace change (O’Neill, Pouder, & Bucholtz, 1998). If a proven intervention can enable an organization to respond directly to a perceived threat, it may be taken up quickly (Bradley et al., 2004). Proven interventions that reflect novel ideas that are in fashion or are promoted by well-respected leaders may also be more likely to be adopted than those that do not (Abrahamson, 1996; Carlile, 2004). Alternately, the more radical or disruptive an intervention is to an organization and its workflow, staffing, and/or budgeting, the more value (e.g., cost savings, significant health benefits to individuals) it will need to generate and the more difficult it may be to find support for its adoption.

In some cases, an intervention may be too innovative, and may be adopted only with the passage of time or evolution of a particular practice or health policy environment. For example, years after they were first tested, interdisciplinary care coordination models in primary care, such as patient-centered medical homes and transitional care programs from hospital to home (including Coleman’s Care Transition Program® [www.caretransitions.org/] and Naylor’s Transitional Care Model [www.caretransitions.org/]), are receiving favorable attention in health care and community settings. Affordable Care Act programs (e.g., ACOs) and reimbursement changes that favor these approaches are making these evidence-based and well-tested models more attractive to organizations.

Another characteristic that influences dissemination potential involves whether an organization or setting has previously been an “early adopter” of an intervention (Rogers, 2003), or has a track record of taking on new programs. Organizations that have a track record of being early adopters may be more “receptive to change” than those that do not (Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004). Conversely, dissemination may falter when organizations with limited financial and staff resources are unable to take on new programs without significant external support. For example, Get Busy Get Better (originally known as Beat the Blues) is a community-based depression intervention designed for delivery within senior centers (Gitlin et al., 2012, 2013). However, better resourced mental health departments and state societies of geriatric care managers are more interested in the program as they have resources, including staff and allocations for staff training, to more easily support the program’s training requirements than senior centers.

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