Identifying the Facilitators and Barriers in Disseminating and Adopting a Health Intervention Developed by a Community

Abstract

The literature regarding implementation science of evidence-based health interventions in Māori communities is limited, and there is a push for new and innovative delivery methods of health interventions in New Zealand. The purpose of the study was to identify the facilitators and barriers in implementing a health intervention designed by others and was framed by the Consolidated Framework for Implementation Research (CFIR). This study explored general perceptions of the implementation process and also included a case study, the Kaumātua Mana Motuhake (older people’s autonomy and self-actualization) project; a codesigned peer education intervention for older Māori. Semistructured interviews (N = 17) were conducted via face-to-face, phone, or Zoom with health and social service professionals with experience working with Māori communities. Thematic analysis was used to analyze the data. The facilitators included community engagement, program structure, program adaptability and creators’ experience. The barriers consisted of funding access, funding constraints and organizational constraints. The findings support key elements within the CFIR, highlighting the importance of community engagement and adaptability. Additionally, this study identified nuanced aspects of funding and resources that constrain organisations in employing health interventions designed by others.

Keywords

community-based participatory research community health implementation science interventions

Māori are the Indigenous people of Aotearoa/New Zealand and comprise about 17% of the total population, and they face some of the greatest health inequities in New Zealand. For example, in an audit of primary care and diabetes support program, Māori experienced greater potentially avoidable hospitalizations and higher mortality rates within 30 days of undergoing surgery compared with non-Māori (Yu et al., 2020). Substantial inequities were also observed in deaths from diabetes (Māori five times greater mortality than non-Māori) and with circulatory and respiratory conditions (non-Māori dying at approximately 40% the rate of Māori; Yu et al., 2020). Racism, income, lower access to health care, and high proportion living in rural settings are key social determinants to explain these inequities (Ministry of Health, 2016; Stanley et al., 2019).

Health equity is a significant concern in New Zealand with attention and resources from the government, health system, and health care workers dedicated to enhancing it. For example, the mission-led National Science Challenges (NSC), particularly those focused on health and well-being, have a stated goal of reducing the burden of health inequities faced by Māori (Ageing Well National Science Challenge, n.d.; Healthier Lives, 2016). Researchers associated with these NSC have developed evidence-based interventions (EBI) to address diabetes, cardiovascular disease, obesity, health ageing, and other health conditions (e.g., Pylypchuk et al., 2018) including some that have been codesigned through participatory methods with Māori communities (e.g., Ni Mhurchu et al., 2019; Oetzel et al., 2020). EBI are critical to address health outcomes and health equity, and they are seen as more efficient than designing a new intervention for a particular community or provider (Lhachimi et al., 2016). However, they often require adaption to a new context, particularly for cultural fit (Kirk et al., 2020). Furthermore, there are additional challenges around disseminating and implementing EBI to other contexts including implementation process, scaling up, and sustainability (Harding & Oetzel, 2019; Milat et al., 2015). A key to understanding these implementation challenges for Indigenous communities is to understand the facilitators and barriers to implementing EBI (Gibson et al., 2015).

Facilitators and barriers to implementation need to be understood within a larger implementation framework. While there are a number of implementation frameworks, this study uses the Consolidated Framework for Implementation Research (CFIR). CFIR is a comprehensive framework that integrates 19 different theories or models of implementation science (Damschroder et al., 2009). It has been widely used in various implementation contexts (Kirk et al., 2016), including in Indigenous communities (Sebastian et al., 2020).

There are five key domains in the CFIR: intervention, inner setting, outer setting, individuals involved, and process (Damschroder et al., 2009). Intervention refers to its characteristics including supporting evidence, relative advantage, compatibility, complexity, trialability, and observability (Rogers, 2003) as well as whether the intervention has been adapted to the local context; adaptation relates to both core functions and forms or peripheral features (Kirk et al., 2020). Inner setting includes the organizational characteristics and support from where the intervention is implemented. The outer setting refers to the larger political, social, structural, and economic context where the organization is located (Damschroder et al., 2009). Individuals are the people responsible for implementing the EBI, and this domain includes individual skills, cultural values, affiliations, and mindsets. Process refers to the means of implementation; processes involve multiple people and occur among multiple levels of the settings (Damschroder et al., 2009).

The literature regarding implementation science of EBI in Māori communities is limited. Furthermore, even when an intervention has been culturally adapted or even created for a particular cultural community, it is unknown whether the EBI can be implemented directly or whether adaptations are needed prior to implementation. This is particularly important in New Zealand where there are more than 100 different iwi (tribes) and hapū (subtribes) with variations in cultural practices and some negative histories.

The purpose of the study is to identify the facilitators and barriers in implementing an evidence-based health intervention developed by one community organization to another community organization. In particular, this study examines not only general implementation of EBI to Māori communities but also a specific EBI codeveloped by a Māori organization and university research team (Oetzel et al., 2020). The research questions for this study were as follows:

Research Question 1: What facilitators do health professionals in New Zealand identify when implementing an evidence-based intervention designed by others?

Research Question 2: What barriers do health professionals in New Zealand identify when implementing an evidence-based intervention designed by others?

Method

The research design was an interpretive interview design guided by Kaupapa Māori methodology (KM). KM normalizes Māori knowledge, language, customs, and practices in research and emphasizes trust and relationships with participants and collaborators (Pihama et al., 2004). KM recognizes the history of colonization and the importance of cultural integrity when analyzing Māori issues and provides the tools to facilitate a Māori understanding of the political and historical context of Aotearoa (Pihama et al., 2004). Research that employs KM aims to create positive outcomes for Māori communities and thus is action oriented (Barnes, 2000). Barnes (2000) observes that Māori preferred interests have been dominated and excluded by Pākeha (non-Māori; primarily New Zealand European). KM works to remove these threats to the Māori culture by arguing that in order to understand, explain, or respond to Māori issues, there must be an approach that is embedded in Māori epistemologies or ways of knowing (Pihama et al., 2004). Even though KM works to decolonize Western research approaches and methods, it still holds space for non-Māori researchers to engage with and create research that allows those (researchers and participants) involved to feel comfortable and to focus on benefit for Māori communities.

This exploratory study used a locally developed evidence-based health intervention as a case study. The case was presented to participants as an example of a successful health intervention that they then explored how it might be adopted in their communities. The case was the Kaumatua Mana Motuhake (KMM) project; a codesigned peer education intervention for older Māori (Oetzel et al., 2020; Simpson et al., 2020). The purpose of KMM was to enhance the capacity of kaumātua (older Māori) serving as peer educators and to enhance the hauora (well-being) and mana motuhake (self-actualization and autonomy) of the recipients who faced various life transitions (e.g., loss of spouse, change in health condition). It was developed using KM through a collaboration of university and community researchers, two advisory boards, and kaumātua including development, implementation, and evaluation of the intervention. It also reflects Māori epistemology in defining the nature of a peer relationship and how information should be shared.

Sampling

Participants were health and social service professionals who worked in Māori and non-Māori health organizations throughout New Zealand. Māori health organizations are grounded in a Māori worldview, although both serve Māori communities. The inclusion criterion was whether participants had experience in implementing, adapting, or adopting evidence-based health interventions designed by others in their own organizations and communities. Previous engagement with the KMM project was not an inclusion criterion. Recruitment used snowball sampling, which benefits from interpersonal relationships and networks to contact other people who may provide further insights, which consistent with KM given its focus on relationships (Pihama et al., 2004). Potential participants were initially contacted via email and phone calls. Seventeen health professionals were interviewed; 12 women and five men; 12 Māori and five non-Māori; seven general managers, four CEOs, three community health workers, an advisor, a clinic manager, and a director. A supplemental file provides a table of the participants demographic details. Direct incentives were not provided; however, consistent with Māori cultural practices, snacks, tea, and coffee were provided for face-to-face interviews.

Data Collection

Given this project sought to elicit personal experiences, perceptions and opinions about adapting or adopting EBI in general as well as the KMM intervention specifically, semistructured interviews were chosen (Barriball & While 1994). Semistructured interviews relate to KM by allowing participants to share their knowledge, whether it is cultural or not, in a safe environment that will bring no harm to them (Pihama et al., 2004). Interviews were conducted via face-to-face (n = 7), phone (n = 2), or Zoom (n = 8). Interviews conducted via media were convenient and flexible and the ethical issues and processes being similar to face-to-face interviews (Janghorban et al., 2014). Participants provided informed consent process and interviews lasted on average 45 minutes. They were recorded and transcribed. The Human Research Ethics Committee at the lead author’s university approved this study (FMIS 16/19).

The interview guide (see Supplemental Appendix) was organized in three sections: (a) general experiences of adopting/adapting health interventions designed by others, (b) perceived facilitators and barriers in implementing health interventions designed by others and, (c) general perceptions of adopting/adapting the specific KMM project within participants’ organizations. A brief report of the KMM project was provided to participants and discussed by the interviewer. The interview guide included open questions about participant experiences and perceptions with probes about key categories associated with the CFIR and implementation science literature (i.e., intervention, organization, context, process, and individuals). The guide was not directly adapted from previous research but was created with the grounding of the extant literature and the research questions in mind. The interviews were conducted by the first author, a Māori researcher with expertise in semistructured interviewing and KM research methodology.

Data Analysis

Thematic analysis enabled exploration and interpretation of the various aspects of the topic and provided a rich and detailed breakdown of the data collected (Braun & Clarke, 2006; Simpson et al., 2020). Thematic analysis complements KM principles through its open approach (Simpson et al., 2020). Furthermore, thematic analysis is adaptable to uphold Māori values, beliefs, and traditions so as to cater to the nature and cultural aspects of this study.

The research around identifying facilitators and barriers to adapting or adopting EBI has multiple interpretations, as well as the opportunity to generate themes that go beyond the personal experiences of the participants. The data were initially coded and reoccurring patterns were identified to develop key themes. Attention was paid to any demographic differences in themes (ethnicity, gender, and position) although no distinct patterns were identified. The analysis was completed by the first author and then corroborated by the other authors. Furthermore, findings were shared with members of an academic/community research partnership with experience in implementation of EBI for a validation check with no major changes to themes requested.

Results

This section is organized around the two research questions. Table 1 presents a summary of the themes each with an exemplar quote. Pseudonyms are used for all participants.

Table 1.

Exemplar Quotes and Description of Key Themes.

Theme	Description	Quotes
Research Question 1: Facilitators
Community engagement	The creators and end users must build relationships with community members to ensure acceptance of the original intervention	“That’s about engaging with your client base and making certain that their needs are met, and it also gives the community the feeling of love and caring and that people do care about them and think about them.” (Tracy)
Program adaptability	Being able to adapt interventions that have been designed by others to better suit the communities they serve is a facilitator of adoption	“There were lots of other things that weren’t in the intervention that we did with our kaumātua because we were looking at their lives holistically—from a Māori viewpoint.” (Clint)
Program structure	Having a well-established structure for the intervention designed by others is an enabler to using the intervention	“We’ve actually taken heaps from the original team because they’ve done their systems and stuff so amazingly.” (Mary)
Creator’s experience	The experiences the original project could provide for end users wanting to implement the intervention in their communities.	“So, if you can provide kind of a fuller explanation of how it all works, plus any resources, if you have like a training manual for tuakana, to help them understand their role as a mentor, or a process that they work through; it would make it a great deal easier to pick up.” (Michelle)
Research Question 2: Barriers
Funding access	How funding affects end users wanting to take the intervention on board.	“It would require some seed funding to get it off the ground in a new area. If you’re going to develop something new, it takes time and staff time costs money.” (Karen)
Funding constraints	The limitations of the funding and the impact it has for the end user on the implementation of the program.	“There’s not an equity lens in the funding formula, you know what I mean? So we can’t generate a lot of money to pay for all the things that we wanna do.” (Danielle)
Organizational constraints	The resources that would affect the implementation of the intervention in different organizations.	“I think it’s the usual, probably around simply finding the time and resource to implement something new; so that can be a barrier.” (Josephine)

Facilitators

The first research question explored the facilitators when implementing an EBI designed by others. The key themes were community engagement, program adaptability, program structure, and creators’ experience. The themes are inclusive of general experiences and specific examples participants drew from the KMM project. In the themes, a creator has developed the intervention and end user is the entity/organization considering adopting the intervention.

Community Engagement

Participants identified the importance of end users building relationships with community members to ensure acceptance of the new intervention. Participants were clear that in order for interventions designed by others to thrive, community engagement was essential to ensuring the positive outcomes and sustainability of the intervention. Tash, a general manager at a Māori health organization shared:

The majority of them were programmes that had some quite specific guidelines in regards to what they wanted to see happen, and the outcomes that they wanted. However, we were able to work with the whānau (extended family) so that they would be more user friendly, if you want to use that word, in regards to Māori whānau specifically.

Tash believes that by involving the community members in the adaptation of the intervention from its original idea to fit the community, it will have better outcomes for the community the end user is serving.

Furthermore, participants believed that the relationships built by end users and the community encourages better interventions in which the community members can engage. This facilitates the implementation of an existing intervention by making it culturally relevant. Tane, CEO of a Māori health organization, supported this view:

“What we tend to do is take Pākehā (Western) mainstream programmes and then say, “Thank you. Thank you for that programme. Thank you for that money, now we’re going to wrap our Kaupapa Māori lens and work with our whānau because it doesn’t work for our people.”

Tane reinforces the idea that engagement with the community is the key to a successful intervention regardless of funder needs and the intentions of the creator of the intervention.

Program Adaptability

Another important facilitator, and related to community engagement, is that end users want creators to ensure the intervention could be adapted in order to reflect the community who would be using it. Participants shared how their organizations adapted interventions that have been designed by others to better suit the communities they serve. Michelle, a director for a health organization shared,

You have to look at the cultural context in which you’re working, and the particular issues of that community . . . you can take the ideas and the frameworks and then if the community identify that’s what they need, want, or think is important, then allow them to fit within the way that they are working or what their priorities are.

Michelle highlights the importance of adapting the intervention to the cultural context and to the priorities of the community.

Jane, a health promotion manager, reinforced this adaptability theme and mentioned how she would adapt the KMM project to the physical locations of their community: “Instead of them sitting down and having a conversation it would be taking them to the beach and letting them share their whakaaro (thoughts) on a brisk walk along the beach or something like that.” Similarly, many other participants shared that they would feel more comfortable implementing the KMM project if they would be allowed to make (relatively minor) changes to the program to suit their communities.

Program Structure

Participants’ experiences with implementing health interventions designed by others identified a well-established structure for the intervention as an enabler to adoption. Participants shared that the intervention structure provided reliable information as to how the project had previously worked. Linda, an advisor for a charitable health organization shared, “It provides a really simple how-to; so, what does this look like, how is it done, what have we learned so far by doing this, and what tools and resources have been developed in this programme.” Linda explained the structure provides an insight into what the creators have learned and offers a format for others.

When participants discussed structure in relation to the KMM project and in particular an ageing population, they reinforced the points from Linda. Yvette, a general manager at a Māori health organization offered, “I think we’d need the framework of the programme and how that was set up by the original crew.” It was important for participants to see the structure of the intervention and the processes the creators went through when implementing it, particularly with an ageing population. The “how tos” of the program enable the organization to have a blueprint of how it can work and thus make it easier for them. The structure of an intervention designed by others is a facilitator as it offers reliable and trustworthy information regarding the intervention.

Creators’ Experience

A final facilitating aspect was the supporting resources the creators could give end users by coding their experiences. Participants highlighted that it might be useful for members from the original project to speak to the end users and/or the communities involved to provide insight into the program. Tane explained, “I think there would be an appetite around coming and talking to the programme around the shared experience and articulate what the benefits have been, giving an insight.” Similarly, many participants identified that the experiences the administrators from the original program could share would provide valuable information for the implementation with their communities.

When discussing the KMM project participants shared their thoughts on what the project could offer to facilitate the dissemination and implementation. Emma, a clinic manager for a Māori health organization shared,

“Maybe it’s kind of like having a little workshop somewhere, where you bring along some of the people who have been doing the programme maybe even some kaumātua, to talk to a small group of people who are thinking about the programme; so that they’re almost mentoring them into it as well, and sharing the knowledge and the learnings.”

Emma highlights including those who ran the program and those who have personally experienced the intervention as being able to provide mentoring throughout the dissemination and implementation process. Overall, the participants were open to having support from the original group and considered the potential benefits that would come with their experience.

Barriers

The second research question explored the barriers when implementing an EBI designed by others. The themes identified were funding access, funding constraints, and organizational constraints.

Funding Access

A concern for many participants was accessing funding and the length of time programs usually take to implement; without funding it would cause a financial strain on the end user and the program may not come to fruition. Josephine, a general manager for a Māori health trust, shared, “No, we can’t carry it (intervention) out without funding, because it’s for too long.” This was also supported by Yvette who shared, “we’re gonna need some resource funding no doubt about that.” Participants were clear that if they were to take on a project there would need to be funding.

Participants were asked if funding would be a barrier for implementing the KMM project in their communities. Jane responded, “Without the funding we couldn’t do it, if that’s what you mean, without this particular contract because that gives us the capacity to have a full-time staff member in there.” This was a common perspective among participants who believed that the program would require funding, that without, the project would not reach its full potential. Participants shared that funding always affects implementing health interventions; the money that backs the program is just as important as the program itself.

Funding Constraints

Participants identified the barriers funding constraints have on implementing any intervention designed by others. One such was the restrictions that came with funding for implementing interventions designed by others. Clint, a general manager of a Māori health unit shared his experience:

The fact is, is that if we had applied for funding elsewhere . . . we would have had our programme according to the needs of those kaumātua because they would have had an input into how the programme should be run. But because the funding was provided by the DHB (District Health Board) that took away that ownership.

Clint explained that their funding required them to stick to strict guidelines provided by the funders. Participants identified that funders had an influence in how the program would be run, which at times excluded the community voice and potential adaptability of the intervention to fit the community needs.

In relation to the KMM project participants discussed the need for flexibility of the funding. Linda shared, “There’d have to be funding attached to it and then it would be viable in terms of how it could work; and I could see how it could work.” Linda and other participants felt that while funding was important for the program, the terms of said funding would need to allow for end users to use the funding within their means and goals. Participants were weary that by taking on KMM (and other interventions) end users would be reliant on funding and did not want that to affect their autonomy over how the program would look for their communities.

Structural Resources

Another identified barrier was the human and organizational resources that would be affected to implement the intervention in their communities. Participants were wary of the limits in their workforce and their own organization’s capacity when taking on a new intervention such as the KMM program. Tamati, a regional Māori health manager, shared his personal experiences: “But the challenge is in terms of Māori workforce, it’s a real limited resource and our kaimahi (workers) Māori and our workforce are getting older.” Tamati and others perceived staffing to be important as end users who are engaging with Māori communities need staff with cultural capacity to provide this program.

Another aspect was the additional resources (such as a training program) that end users tend to lack when implementing health interventions designed by others. Pearl, a CEO of a Māori trust, shared her ideas on how to combat this barrier:

I would think a little kete (resource kit) of all the things – like what does the training programme look like, how do you go about setting them up? Sort of the ‘how to’ and the actual physical resources that will help.

This participant identified the practical resources the original program could provide for end users to remove this barrier.

Discussion

This study aimed to explore the facilitators and barriers health professionals in New Zealand identified when implementing a health intervention designed by others. This study also included an evidence-based intervention, the KMM Project, for participants to draw on and provide specific examples on the facilitators and barriers they would face implementing the project in their communities. The key themes from the study are discussed in relation to the CFIR and other related implementation science literature.

The key facilitators for participants centred on the intervention, external support, process, and adaptability. These largely reflect CFIR categories with the exception of individuals, which was not a key theme with our participants (Damschroder et al., 2009). In terms of the intervention and external support, participants reported that the structure of the programme and creator experiences are facilitators for adoption as they provide evidence and reputable data to remove any concern end users may have about the relevance of the health intervention. These themes provide observable experiences and evidence of effectiveness to determine whether the intervention makes sense for the community (Damschroder et al., 2009; Rogers, 2003). Furthermore, creator experiences that are shared directly with administrators and community members provide direct external support; they allow prospective organisations to see the value of the EBI and the support the creator can provide, which increases likelihood to adopt the health intervention (Mendel et al., 2008).

A further facilitating aspect is whether there is a process of community engagement during implementation (Damschroder et al., 2009). Community engagement is a key element of dissemination and implementation, particularly when working with Indigenous communities (Harding & Oetzel, 2019; Oetzel et al., 2017). A specific Indigenous implementation framework, the He Pikinga Waiora framework (Enhancing Wellbeing), emphasises the importance of participatory and codesign processes with Indigenous communities to enhance fit of the intervention to culture and community, to enable self-determination, and to encourage holistic thinking to increase the effectiveness and sustainability of the intervention (Oetzel et al., 2017).

Participants also want to be able to adapt the intervention during the community-engagement process. Adaptability is a common focus in implementation science with the expectation that adaption of the form is needed to enhance cultural/community fit and increase ownership, while protecting the core functions of the interventions (Damschroder et al., 2009; Kirk et al., 2020; Power et al., 2019). The model for adaption design and impact suggests that three domains of adaption are important: adaptation to the intervention, the adaptation process, and adaptation outcomes. Participants in the current study emphasised the first two domains although they felt that outcomes would be enhanced as a resulted.

Participants also identified several barriers related to funding and structural resources, consistent with the inner and outer settings of the CFIR (Damschroder et al., 2009). The funders of health organisations in New Zealand are primarily government based and the implications relevant to this study are the requirements organisations must meet to be eligible for funding. Strict funding constraints limits the organisation’s ability to adapt an EBI, which participants in this study perceived to limit effectiveness of the intervention and lower the likelihood of adopting it. Furthermore, participants noted that it is important for organisations to consider if they have the capacity (staff and infrastructure) to adopt the intervention as many lose staff when funding is cut or stops (Wandersman et al., 2008).

A limitation of this study is that there was a heavy focus on those receiving the intervention rather then those who created it. Therefore, the experiences described in this study are reflective of the end-users perspective. Furthermore, snowball sampling may have introduced a bias in that “like-minded” participants were included and may have limited access to different implementation perspectives. Another limitation is the use of phone and online interviews. Many interviews had to be conducted with minimal to no physical contact due to the restrictions of COVID-19. However, these interviews were still conducted in a similar manner as the face-to-face interviews (same interview transcript and procedures). Finally, future studies should focus on the sustainability of implementing health interventions designed by others. These studies should aim to discuss how organisations can move away from traditional funding avenues in persuit of finding more sustainable options for their programmes.

In conclusion, this study has implications for the field of implementation science as it adresses key facilitators and barriers of adopting and adapting health interventions created by another organisation, even one that is from the same cultural group as the population it aims to serve. This study highlighted the importance of community engagement and adaptability of the EBI to enhance fit to the community, while also use the programme structure and creator experience as core functions for the EBI. Furthermore, the study identified nuanced aspects of funding and resources for organisations that constrain organisations in employing health interventions designed by others. These facilitators and barriers provide important insights for Indigneous implementation science as framed by the Consolidated Framework for Implementation Research.

Supplemental Material

sj-docx-1-heb-10.1177_10901981211033228 – Supplemental material for Identifying the Facilitators and Barriers in Disseminating and Adopting a Health Intervention Developed by a Community–Academic Partnership

Supplemental material, sj-docx-1-heb-10.1177_10901981211033228 for Identifying the Facilitators and Barriers in Disseminating and Adopting a Health Intervention Developed by a Community–Academic Partnership by Truely Harding, John Oetzel, Mary Simpson and Sophie Nock in Health Education & Behavior

Supplemental Material

sj-docx-2-heb-10.1177_10901981211033228 – Supplemental material for Identifying the Facilitators and Barriers in Disseminating and Adopting a Health Intervention Developed by a Community–Academic Partnership

Supplemental material, sj-docx-2-heb-10.1177_10901981211033228 for Identifying the Facilitators and Barriers in Disseminating and Adopting a Health Intervention Developed by a Community–Academic Partnership by Truely Harding, John Oetzel, Mary Simpson and Sophie Nock in Health Education & Behavior

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for the first author was received from the Ministry of Business, Innovation and Employment (NZ) Healthier Lives National Science Challenge (HL-T1CR-D 13058/1 SUB1320). Funding for the other authors provided by the Ministry of Business, Innovation and Employment (NZ) Ageing Well National Science Challenge (UOOX1508, SUB1484).

ORCID iD

Truely Harding

Supplemental Material

Supplemental material for this article is available online at .

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