Identifying the determinants of use of the G&G interventions for older adults in health and social care: protocol of a multilevel approach

Overview of the project

The study described in this protocol is part of a larger project that aims to promote
and support the use of the evidence-based GG interventions in health and social care
organizations in the northern part of the Netherlands. Besides identifying the determinants
of use of the GG interventions, another goal of the larger project is to determine
the effectiveness of the GG interventions again. However, the study protocol at hand
will only describe the former study, i.e. the study on the determinants of successful
implementation of the GG interventions.

Four partly overlapping phases can be distinguished in the study at hand. In phase
1 the GG interventions are disseminated to the field of social and health care organizations.
This is being done by means of GG workshops, given by the GG project team, at strategic
meetings where professionals and managers of organizations gather. Because the larger
project, of which this study is part, is not a ‘top-down’ initiative, organizations
participate voluntarily. So, any organization that wants to adopt the GG-interventions
can take part in the project. The goal of phase 1 is to motivate at least 15 organizations
to adopt the GG interventions and participate in the study.

In phase 2 at least 30 professionals (two per organization) are trained to perform
the GG interventions. In phase 3 the trained professionals start implementing the
GG interventions in their organizations by recruiting older adults for participation
and, subsequently, delivering the GG interventions to them. The core of the empirical
study takes place in phase 3. During that phase, the stages of implementation each
organization goes through, are being monitored continuously by the project team, and
the facilitating and impeding factors will be assessed at all stakeholder levels in
three data collection waves. In phase 4 the data analyses will be executed. A detailed
description of the four phases is given in Additional file 2.

The study protocol has been evaluated by the ethics committee of the University Medical
Center of Groningen in May 2010. The study was considered to evaluate care as usual
and therefore the study was exempted from the Medical Research Involving Human Subjects
Act. The study was further performed in accordance with the Helsinki declaration.
Informed consent will be given orally.

The interventions

The two GG interventions have the same theoretical basis 11], but are available in two delivery modes: the GG home visits and the GG group course.
Both are considered in the empirical study at hand. The GG home visits are delivered
by a GG coach in six individual home visits of 1.5 h. The GG group course is delivered
by two GG teachers in 6 weekly meetings of 2.5 h and a booster session after 3 months.
The home visits are intended to be delivered to both women and men, aged ?65 years,
who are physically and psycho-socially vulnerable and unable to travel to a group
location. The group course is intended to be delivered to a group of around n = 10
socially vulnerable women, aged ?55 years, who subscribe individually, and are physically
capable of travelling to a group location. Both GG interventions are described in
detail in manuals, one for the GG coach and one for the GG teachers. There is also
a workbook for each participant. The content of the GG interventions is described
in detail elsewhere 9], 10].

The training by which professionals become a certified GG coach or GG teacher involves
two and a half days, and is given by master trainers of the GG Program of the University
Medical Center of the University of Groningen. In the first part of the training,
the theoretical body of thought behind the GG interventions is explained. In the
second part, the intervention-manual is practiced through modeling and role-play.
At the end of the training the professionals are being instructed on the content of
the GG implementation toolkit, which is developed by the GG project team, and which
offers a variety of materials supporting their implementation activities (e.g. PR
materials, press release examples, brochures, etc.). The trained professionals are
also informed about various facilitating activities offered by the GG project team
(i.e. website, annual work conference, and site visits).

Study setting

The study is performed in health and social care organizations for older adults in
the northern part of the Netherlands. Since 2007 municipal authorities are responsible
for supervision and execution of the Social Support Act, which prescribes that vulnerable
older adults and other vulnerable citizens need to be supported to recapture or maintain
their ability to manage their own well-being. In consultation with the management
of health and social care organizations, municipal policies are determined and available
resources are allocated. Each municipality has one or more health and social care
organizations that employ a variety of professionals. Professionals can either be
social workers employed in welfare organizations or health professionals employed
in home care organizations, providing both physical and psychosocial care to their
clients. They can also be activity leaders employed in retirement homes, striving
to empower residents and older adults living in sheltered accommodations next to the
home.

Study sample

The study sample consists of actors at four different hierarchical stakeholder levels
(i.e. target group, professionals, organizations and financial-political context)
as depicted in Figure 2. Therefore, there are four groups of informants.

Figure 2. Hierarchical stakeholder levels.

The first group (i.e. the target group) consists of the older adults at risk of becoming
vulnerable. The second group are the trained professionals, who deliver the GG interventions.
The third group consists of the managers of the participating organizations. When
organizations have multiple management-layers, the manager who is closest to the work
floor will be invited to act as key-informant. The fourth and final group consists
of key informants at the level of the financial-political context. These are local
policymakers who are well informed on the execution of the Social Support Act. They
will be invited to act as informants for our study.

Based on experiences from an earlier pilot-implementation of the GG interventions,
it is feasible to include at least 15 new organizations in a period of 12 months 35]. Counting with 15 organizations, the sample size at the organizational and financial-political
level will be 15 managers and 15 local policymakers. With a minimum of two GG professionals
per organization, the sample size at the professional level will be at least 30 GG
professionals.

With respect to the reach of the target group, concrete performance goals are communicated
with the GG professionals. Each GG coach is expected to deliver the GG home visits
to at least three older adults (15 GG coaches × 3 home-visits × 1 participant = 45
participants) and each pair of GG teachers is expected to deliver at least three
group courses, with an average of ten older adults per course (15 GG teacher pairs × 3
group-courses × 10 participants = 450 participants). In the 2-year period of the data-collection,
the sample size at the level of the target group will thus amount to approximately
495 older adults. Taking into account a drop-out rate of 8% 36] a maximum number of 400 older adults participating in the GG interventions is expected
to be feasible.

Procedure and measures

The degree of implementation success will be assessed per organization, and is being
operationalized by four parameters: use (yes/no), pace (time to initial use), performance
(extent of use) and prolongation (intention to continue use beyond the timeframe of
the study). The rationale behind the selection of these four parameters is that they
assess the transitions between the three consecutive implementation stages in the
Fleuren model (see Figure 1). The ‘use’ parameter measures the transition of organizations from adoption to implementation
and the ‘prolongation’ parameter measures the transition from implementation to continuation.
Next, we expect the ‘pace’ and ‘performance’ parameter to add to the explanation of
both transitions.

Use, pace and performance can be easily assessed and with very high validity, because
the actual performance of all organizations regarding the use of the GG interventions
will be monitored continuously throughout the study by the project team. The fourth
and final parameter (i.e. intention to continue use of the GG interventions beyond
the time frame of the study) can necessarily only be measured as an estimation of
the relevant actors. The intention of each professional, each manager, and each financial-political
key informant, to continue the use of the GG interventions beyond the timeframe of
the study (i.e. prolongation) is operationalized with a single question with four
answer categories ranging from (0) no intention to (3) strong intention. This question
will be asked at the final measurement point of the study.

The facilitating and impeding factors that possibly affect the use of the GG interventions
are being measured at multiple measurement moments, simultaneously at the four hierarchical
levels (i.e. target group, professionals, organizations and financial-political context).
The content of the questionnaires varies somewhat per measurement point, because some
factors only apply to the specific stage the organizations are in. For example, “ownership”
is only applicable when users move from the adoption to the (initial) implementation
stage, while “observability of effects” is applicable only when users move from the
implementation to the continuation stage. In the following a brief outline of the
measures is given. Details on the specific measurement moments, and at what point
in time we measure which factors, are described in Additional File 3.

Target group

The impeding and facilitating factors at the level of the target group will be measured
via the perception of the GG professionals. This indirect way is necessary, because
the factors at this level relate to possible participants, not to actual participants
of the intervention. A sample of all possible participants (in the population) is
hard to delineate. Therefore, the professionals will be asked to answer the questions
of the target group level. The professionals will well be able to give an estimation
of the impeding and facilitating factors that possibly play a role for older adults
to participate (or not) in the GG interventions, due to their large experience with
the target group. The predefined factors of the theoretical framework at the level
of the target group are thus translated into questions to be answered by the professionals.
For example, the factor “awareness of benefits” is translated into the question: “Do
you think older adults understand the benefits of participating in the GG interventions?”
The questions contain six answer categories ranging from (0) ‘not at all’ to (5) ‘completely’.

Professionals

The impeding and facilitating factors at the level of the professionals will be assessed
by means of digital questionnaires. All professionals who have been trained and certified
as GG coach and/or GG teacher will be invited to fill out the questionnaire. The
predefined factors of the theoretical framework at the level of the professionals
are translated into one or more questions per factor. For example, the factor “ownership”
is translated into the question “To what extent do you feel responsible for GG intervention
start-up?” Each question contains six answer categories ranging from (0) ‘not at all’
to (5) ‘completely’.

Organizations

The impeding and facilitating factors at the level of the organizations will be measured
by means of a telephone interview with the managers. The predefined factors of the
theoretical framework at the level of the organization are translated into one or
more questions per factor. For example, the factor “staff capacity” is translated
into the question “Is your staff capacity sufficient to spend time on integrating
the GG interventions in routine practice?” The questions contain six answer categories
ranging from (0) ‘not at all’ to (5) ‘completely’.

Financial-political context

The impeding and facilitating factors at the level of the financial-political context
will also be measured by means of a telephone interview with a strategic or financial
local policymaker. The predefined factors of the theoretical framework at this level
are translated into one or more questions per factor. For example, the factor “added
value” is translated into the question “To what extent do you think that the GG interventions
add something to the existing services for older people in your community?” The questions
contain six answer categories ranging from (0) ‘not at all’ to (5) ‘completely’.

Data analysis

All data will be imported in SPSS statistics 20. Descriptive analysis will be used
to characterize use, time to initial use (pace), extent of use (performance) and the
intention to continue use beyond the timeframe of the study (prolongation). Data collected
at the four stakeholder levels will be merged and aggregated. Intra-class correlations
will be calculated to assess the reliability of individual data aggregated at group
levels in hierarchical models (i.e. professionals nested in organizations). The relevance
of applying multilevel modeling to the data will be assessed by testing an unconditional
or null model in which no predictors are specified. Only when significant variations
in the dependent variables are present across organizations or municipalities, multilevel
regression modeling will be applied. If no significant variation in use, pace, performance
or prolongation is found across organizations or municipalities, we confine to single-level
modeling techniques.