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Element 7: Implementing the Plan

The most common definition of program implementation is “how well a proposed program or intervention is put into practice.” [1] The detailed work plan should guide the implementation of the program in terms of timing, content, strategies, monitoring and evaluation. The plan developed should be based on the needs and interests of the workforce as well as “best practices,” which include committing to evaluating both the processes undertaken and the impacts achieved. There is a commitment from senior levels to proceed so now it is time for the “rubber to hit the road” and implement the planned programs.

Whenever possible, get employees involved in the decision making, as this can improve employee interest in the program. Also, when implementing the plan, tell all employees about the plan is, how it was developed, how they can be involved and that the program needs feedback.

Aspects of implementation[2]
  • Program adherence or fidelity – the degree to which core program components were delivered as planned
  • Exposure – the frequency and duration of the program
  • Quality of program delivery – the skill and style of delivery
  • Participant responsiveness – engagement with and reaction to the program
  • Program differentiation – verifying the conditions of the study design
When implementation is documented, it is clear that the level and quality of implementation influences program effectiveness and that higher quality implementation is associated with stronger, more positive outcomes[3].

The research into how to implement health promotion programs in general is fairly limited, with that geared to mental health promotion and/or the workplace setting being even scarcer.  Therefore, what is presented here is a combination of what is known and what can be readily extrapolated from other applications.

When implementing a health promotion program, there are several recommended generic principles:

Theoretical basis – The content, structure and implementation of successful interventions is founded on sound scientific theory and research.

Clarifying goals and objectives – The development of a shared mission and clear goals and objectives for a given intervention are critical to its success.

Program provider training and support – Effective programs build capacity through adequate resources and comprehensive professional development for program providers.

Evaluation and high quality research methods – High quality, systematic rigorous evaluation and ongoing monitoring procedures are essential to successful intervention programming.

Infrastructural support from management – The degree of administrative or infrastructural support for a program can have a critical influence on its success or failure.

Program fidelity versus reinvention – Programs should be implemented with high quality which includes, among others, the fidelity of the program implementation.[4]

In addition, there are two principles that apply specifically to the workplace as a setting for implementing mental health promotion programs:

Participatory

A participative approach engages employees, employers and management in communication and joint participation, appears to be an important success factor for the development and implementation of interventions for mental health promotion in the workplace.

Advocacy

There is an especially strong case for demonstrating the cost-benefit of implementing mental health promotion programs in the workplace. Work stress interventions that actually reduce health care costs for employers or improve productivity are much more likely to be adopted and implemented (Briner and Reynolds, 1999). Advocacy efforts underlying the costs and benefits of intervening at the workplace, including social and other welfare benefits, will enhance the likelihood of management support for intervention implementation and ownership.

With these implementation principles in mind, there are a few barriers to keep in mind as well. An organization may want to develop a contingency plan.

Implementation barriers[5]

  • Failure to commit time and resources
  • Engaging implementers who lack the appropriate skills to deliver the program
  • Insufficient organizational and key leader support
  • Poor motivation and buy-in of implementing staff
  • Failure to provide ongoing support and technical assistance
  • Lack of program monitoring

RE-AIM is a framework for evaluating health behaviour interventions. It can be used to estimate the potential impact of interventions on public health. RE-AIM Framework identifies five aspects by which an intervention can be maximized: Reach, Efficacy/Effectiveness, Adoption, Implementation, Maintenance. RE-AIM[6] suggests the following ways to improve implementation of an intervention and to have a greater positive impact:

  • Be sure that intervention protocols are clear and easy to follow.
    Choose an intervention that fits well with the target audience, the setting, and the amount of resources. Automate part(s) of the program when useful or necessary.
    If the initiative does not have enough staff members to deliver it or has more participants than can be accommodated the healthy workplace committee might have to find creative delivery options. If possible, alternate methods of delivery with little or no assistance could be used, such as an interactive CD, a multimedia presentation on a computer, or a video.
  • Monitor and provide staff with feedback and recognition for successful implementation.
    Implementation is assessed by reporting on what percentage of process objectives was achieved (e.g., what proportion of pamphlets were distributed, how many class hours were taught, or prescribed phone calls completed). Information is often very important for predicting if others will try a program.
  • Maintenance - The extent to which a program or policy becomes part of the routine organizational practices and policies.  See sustaining the program below for more information on maintenance.

Sustaining the program: 

  • After the CWHP has been developed and implemented, the healthy workplace committee should think about devising a sustainability strategy. Ask, “What is trying to be sustained over time?”
  • How do we keep mental health in the workplace as an important issue to the organization?
    • Keep the issue on a variety of agendas, some or all stakeholders – including the employee groups, senior management, partners and decision makers
    • Raising/maintaining awareness about and support for individual and organizational changes.
    • Providing effective messages so that policy-makers know that mental health issues are important
  • What behaviour changes have employees made or have started to make?
    • involves building skills and creating/modifying the physical and social environment so that the changes are supporting mentally healthy behaviours
    • involves creating programs that address the important elements of behaviour change
    • helps support individuals in maintaining their behaviour changes
  • Tips to help employees implement the changes:
    • Organize booster sessions within six weeks of the original program offered to reinforce key concepts and help manage challenges.
    • Set long-term goals but emphasizes the smaller steps. That way, successes can be seen, recognized and celebrated.
    • Provide supports – mental health promotion policies within the workplace will help reinforce the expected behaviours, social supports, such as support groups or buddy systems or a place to ask questions, when the going gets tough and physical supports such as access to online or hard copy resources.
    • Monitor the changes and shift the intervention as required to make adaptations easier.
  • What effective programs are still needed?
    • Sustaining mental health promotion programs involves integrating one or more related activities, such as an awareness campaign, a support group or an educational session into the existing organization.
  • What partnership do we need to form and sustain?
    • This involves creating and maintaining productive working relationships and maximizing the benefits of addressing mental health issues with a group of stakeholders.
    • Who agrees to take responsibility for the program over the long-term?

CMHA Ontario and THCU can support workplace mental health promotion efforts in various ways. Both organizations have a collection of tools and resources that can help. For more information on work being done at CMHA Ontario, visit www.ontario.cmha.ca/workswell or www.mentalhealthworks.ca. For information about workplace projects that are being done at THCU visit http://www.thcu.ca/workplace/workplace.html.

In conclusion, research shows that the most successful companies spend 90 percent of their workplace wellness resources developing strategy and getting people on board. They spend just 10 percent on implementation.  For this reason, it is important to maximize the impact of these usually scarce implementation resources.

Information:
Tools:
  • Sustainability at a Glance is a workbook by THCU that provides additional information on the concept of sustainability; suggestions and tools regarding approaches that will increase the likelihood of sustainability; and examples of sustained health promotion activities. See http://www.thcu.ca/infoandresources/resource_display.cfm?resourceID=784. 
  • RE-AIM Framework identifies five aspects by which an intervention can be maximized: Reach, Efficacy/Effectiveness, Adoption, Implementation, Maintenance. To view this resource go to www.re-aim.org 

[1] J.A. Durlak, “Why program implementation is important,” Journal of Prevention and Intervention in the Community 17 (1998): 5-18.

[2] International Union for Health Promotion and Education, “The implementation of mental health promotion programmes” Promotion & Education Supplement, International Journal of Health Promotion and Education (2005): 31.

[3] International Union for Health Promotion and Education, “The implementation of mental health promotion programmes” Promotion & Education Supplement, International Journal of Health Promotion and Education (2005): 30.

[4] International Union for Health Promotion and Education, “What makes mental health promotion effective?” Promotion & Education Supplement, International Journal of Health Promotion and Education (2005): 49.

[5] International Union for Health Promotion and Education, “The implementation of mental health promotion programmes” Promotion & Education Supplement, International Journal of Health Promotion and Education (2005): 31.

[6] RE-AIM, “Framework: Implementation of Health Behavior Interventions,” http://re-aim.org/about-re-aim/what-is-re-aim/implementation.aspx (accessed February 16, 2010).