BETTER 2 (Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care 2): Qualitative Evaluation

Regions: Sahtu Settlement Area, North Slave Region, South Slave Region

Tags: health care evaluation, chronic disease, participatory research

Principal Investigator: Manca, Donna P (6)
Licence Number: 15513
Organization: Department of Family Medicine, University of Alberta
Licensed Year(s): 2014
Issued: Jul 18, 2014
Project Team: Kami Kandola (Co-Investigator, Government of NWT), Vee Faria (Territorial Prevention Coordinator, Government of NWT), Nicolette Sopcak (Qualitative Research Assistant, University of Alberta), Carolina Aguilar (BETTER Program Coordinator, University of Alberta)

Objective(s): To improve chronic disease prevention and screening.

Project Description: The overarching aim of BETTER 2 is to improve chronic disease prevention and screening. The purpose of the proposed evaluation is to examine how the BETTER 2 approach can be adapted to different settings in the Northwest Territories and how it can be sustained. The qualitative evaluation will draw on the perspectives of health care providers, administrators, and patients involved in the program. The four guiding questions are:

1. What is the impact of BETTER 2 on the health setting in each community?
2. How has BETTER 2 been adapted to each community?
3. What barriers and enablers are key to implement BETTER 2?
4. How can BETTER 2 be improved?

Qualitative Program Evaluation
Due to the cooperation between health care providers, administrators and the BETTER 2 team, this program uses a collaborative approach. The BETTER 2 program is community driven and adapts to the specific needs of patients, clinic members, and the community culture. Implementing BETTER 2 has a mutual effect: As BETTER 2 affects a primary care setting by introducing a new role, the prevention practitioner, the BETTER 2 approach is changed by the way that a clinic team adapts and refines BETTER 2 in their setting. Furthermore, the BETTER 2 approach is based on teamwork. Health care providers, administrators and the BETTER 2 team provide their expertise for successful uptake of BETTER 2 and have established positive relationships with members of the health care community in each setting. These relationships have developed as a result of interactions with communities in the Northwest Territories through training sessions on the BETTER 2 approach and informal conversations. The research team noticed during training sessions and informal conversations with participating community members that some components of BETTER 2 were adapted differently or needed to be adapted to work in a particular setting. Community members also shared some of the specific characteristics and possible challenges the program could face in their community and made us aware that some components of the program may be easier to implement than others. Thus, it would be beneficial to more formally evaluate how the communities currently participating in BETTER 2 adapt the program to ensure successful implementation and to share, in a confidential manner, the gained knowledge with other communities interested in or in the process of implementing BETTER 2. This qualitative program evaluation would also help to understand the evaluation of program effectiveness (as described in the Information Sharing Agreement) as it would describe the community adaptations needed to achieve the results observed.

Formative evaluation
Since the research team are interested in the process of implementing and adapting BETTER 2 to particular communities, a formative evaluation seems to be best suited. A formative evaluation is typically introduced in the early stages of implementation of a new program, so that changes can be made early in the process to refine and improve the program. A formative evaluation involves interviews and focus groups to gain insights into the perspectives of those who are involved with the program. Changes resulting from these insights will impact the program’s success and may reduce costs.

To gain insight into different perspectives on BETTER 2, the research team aims to have three groups involved in this qualitative evaluation: Health care providers at the participating sites, administrators, and patients.
1) Health care providers: Since clinicians and clinic staff at each participating site are the frontline people using the BETTER 2 approach, their perspectives on the impact of the program and their ideas on how to improve or adapt BETTER 2 are invaluable. The research team aim to have one or two focus group meetings with each site. For sites where implementation of BETTER 2 goes as planned, the team will only have one focus group which will occur at the end of the qualitative program evaluation. For sites that experience more challenges or require larger changes, an early focus group may be necessary to identify issues and to adapt the program. A follow up focus group at the end will then evaluate the outcome of the changes.
2) Administrators: Administrators facilitate the implementation of programs at multiple levels by coordinating program processes (e. g., coordinating schedules, tracking of information, advertising the program, answering questions etc.) and facilitating relationships between all partners. The research team are particularly interested in the perspectives of administrators involved in the implementation of BETTER 2, their perspectives on community or regional needs and health vision for the Northwest Territories.
3) Patients: Patients’ feedback is important, as they are the recipients of BETTER 2. To be considerate of patients’ time and to protect patients’ privacy, the prevention practitioner will give a feedback form to the patient at the end of their prevention visit. The feedback form is anonymous and can be completed in approximately 2-5 minutes. Patients are asked about their gender, number of visits with the prevention practitioner, how they became involved in the program, what they liked about BETTER 2, and what they would like to be different. Patients can place their anonymous feedback inside an envelope (also provided at the end of the visit) and place it in a feedback box at the health care facility.

Data collection strategies
Data collection strategies will include focus groups and one-on-one, semi-structured interviews with health care providers and administrators involved in the BETTER 2 program. The research team will hold focus groups or interviews in person at a place that is most convenient for participants (e.g., at the clinic, work place) or by phone if more practical (choice of participants). BETTER 2 team members will facilitate focus groups and interviews. To structure the conversations, the BETTER 2 team will use two guides to explore the perspectives and experiences of participants involved in BETTER 2: One for focus groups and one for key informant interviews. As it is characteristic for qualitative research, questions may be changed depending on the informants’ perspectives and emerging themes. However, the questions in the guide provide examples what kind of questions may be asked.

The research team will audio record and transcribe the conversations with health care providers, administrators and the BETTER 2 team. If anybody prefers not to be audio recorded, the team will take notes instead. A time that works for those who agree to participate will be arranged. The research team are also interested in the perspectives of patients involved in BETTER 2. To be considerate of patients’ time and to protect patients’ privacy, the prevention practitioner will give a feedback form to the patient at the end of their prevention visit.

Data analysis
The research team will use the framework approach to analyze the data. The framework approach is a systematic and analytical method that was developed by Ritchie and Spencer (2002) for applied policy research. Since the framework approach is based on participants’ perspectives and experiences, it will be useful to identify key areas of the BETTER 2 implementation and adaptations. The team will use latent content analysis to identify themes and patterns. Passages will be read and re-read and initially coded, that is, each idea will be given a code name (a word or phrase summarizing the main idea). Initially, codes will be managed manually and, later organized with the use of software such as N-VIVO. The BETTER 2 team will initially code each document independently of the others. The research team will then meet and discuss the interpretations to develop consensus on the coding. The codes will then be grouped according to their properties and types; codes will be grouped into categories; and these in turn may be grouped into overarching themes. Relationships between different ideas will emerge and be written as memos (ideas and thoughts during analysis). Identifying key areas will be useful for communities involved in BETTER 2 and communities interested in becoming involved in BETTER 2 or a similar approach.

The aim of BETTER is to improve chronic disease prevention and screening for chronic diseases such as diabetes, heart disease, and cancer, including their associated lifestyle factors, in patients aged 40-65. BETTER introduces a new role to primary care settings: The Prevention Practitioner (PP). The Prevention Practitioner is a member of the health care team who meets with the patient for a prevention visit. During that visit, the PP and the patient review together the patient’s risk for diabetes, heart disease and cancer based on the patient’s history and lifestyle. Then, they collaboratively develop a “prevention prescription”, a document that outlines specific goals and actions, including eligible screening tests, for the patient. The approach is in its second iteration, called BETTER 2. Currently, Fort Smith, Tulita, and Fort Resolution have started to adapt and implement BETTER 2 to their particular settings. Another potential participating community is Yellowknife, dependent on availability of electronic based BETTER tools. All communities in the Northwest Territories who are interested in BETTER 2 can become involved in this program. The BETTER tools and resources are freely available to health care providers, administrators, policy makers, and patients through the BETTER website at or through the Northwest Territories government website at
BETTER 2 is a community driven approach that can be adapted to the specific needs of a community. Community leaders, such as community health representatives or health care providers can decide how to implement BETTER 2 in their community. Furthermore, BETTER 2 encourages patients to build relationships and support each other to achieve their health goals (e.g., informing each other about existing resources, starting a walking group, etc.). In communities that participate in the qualitative program evaluation of BETTER 2, participants in the interview and focus groups will receive summaries of the conversations that took place with the BETTER 2 team.

In communities that participate in the qualitative program evaluation of BETTER 2, participants in the interview and focus groups will receive summaries of the conversations that took place with the BETTER 2 team.

The fieldwork for this study will be conducted from July 18, 2014 to December 31, 2014.