Identifying barriers and facilitators to implementing equitable health care services at Norwegian hospitals

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Identifying barriers and facilitators to

implementing equitable health care services at Norwegian hospitals

A qualitative study employing the COM-B model and Behavior Change Wheel framework

Cecilia Karlsen Gnaly

Master Thesis

Department of Health Management and Health Economics, Faculty of Medicine

University of Oslo

Thesis submitted as part of the Master of Philosophy Degree in Health Economics, Policy and Management

Date: 15.05.2018

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2 Copyright  Cecilia Karlsen Gnaly

Year: 2018

Title: Identifying barriers and facilitators to implementing equitable health care services at Norwegian hospitals. A qualitative study employing the COM-B model and the Behavior Change Wheel framework

Author: Cecilia Karlsen Gnaly

http://www.duo.uio.no

Print: Reprosentralen, University of Oslo

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Abstract

Background: Knowledge and research related to immigrant’s health status, health inequities and barriers to secondary care are recognized by various stakeholders. Suggested causes and solutions to these issues are increasing. This is the case for Norway as well. The right to equitable health care services are stated in multiple sources of legislation, governmental reports and several of the public hospital’s strategic documents and actions plans. The next step will be the successful implementation of research, strategies and legislation into good quality interventions and practices for secondary care and the health care sector in general.

Objectives: This study sought to identify perceived barriers and facilitators to

implementation of equitable health care services experienced by health personnel, working mainly administratively with the provision of equitable health care services at six hospitals, located in the four regional hospital thrusts in Norway. Secondly, the study has tried to explore the variation in barriers and shared barriers between the hospitals. Thirdly, the study has investigated the types of interventions and supporting policies expected to be effective in modifying the identified barriers to implementation.

Methods: Qualitative methods of data collection was conducted: two focus groups, three phone interviews and four face-to-face interviews using a semi-structured interview guide.

The interviews were conducted with 13 informants, working with the provision of equitable health care administratively and/or practically. They represented various job positions e.g.

hospital priest, cultural advisor, advisor/consultant/coordinator for equitable health care services. Interviews were transcribed, coded and analyzed. Implementation theory, more specifically the COM-B (Capability, Opportunity, Motivation, Behavior) system together with the TDF (Theoretical Domains Framework) and BCW (Behavior Change Wheel)

frameworks, were used for understanding actor’s behavior and describe barriers and facilitators of implementation. In compliance with Norwegian legislation on ethics in research, the study was regarded as health service research and was approved by the

Norwegian Data Ethical Approval: Data Protection Official for Research, Norwegian Social Science Data Service (Project no 58418). Each participant provided consent to participate.

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4 Results: The findings revealed perceived barriers of implementation in need of change within the COM-B components of physical and psychological capability, physical and social

opportunity and reflective motivation. Variations between hospitals were identified in factors related to: strategical documents and plans and how hospitals work towards the specified goals and objectives within these documents, economic and material resources, interpretation services, organizational location and attitudes. The mutual factors identified are knowledge of task environment (psychological capability), time and staff resources, user involvement, structural and systematic conditions, national tools and guidelines (physical opportunity), and beliefs about capabilities (reflective motivation). Suggestions for potential types of

interventions and supporting policies are provided.

Conclusion: The study shows that there are factors influencing implementation of equitable health care services for immigrant patients on individual-, organizational- and systemic level.

By using the COM-B model and BCW framework, mutual factors related to physical

opportunity was identified as most appropriate and effective to target for future interventions.

These perceived factors are consultation time with patients, number of staff working

specifically with equitable health care, user evaluations, immigrant user involvement in User Councils (Brukerutvalg), adaptable structures taking care of diversified patient group,

integration of practices promoting equitable health care into standard work routines of health care professionals, registration of patients according to country/ethnicity, collective templates provided at national level for letter and documents distributed to patients, and innovative tools and instruments for utilization in service provision. Interventions focused on training,

restriction, environmental restructuring and enablement have been recognized as effective and appropriate for bringing about behavior change.

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Acknowledgements

The process of writing this master thesis has been challenging and exciting. I have met some great people, and also learned a lot about myself working independently.

I will first and foremost like to give thanks to my informants for their participation in this study. I would like to thank my supervisor Eli Feiring for giving me valuable feedback, discussions and guidance throughout the process, and to Ragnhild Storstein Spilker at NAKMI for all your support and inspiration.

A special thanks to Simo for your comments, positivity and perseverance through all of the ups and downs. I am sincerely grateful. And to my friends and family, for always being there and always believing in me.

Cecilia Karlsen Gnaly Oslo, May 2018

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1.0 Introduction

1.1 Study objective and research questions

This study will examine the implementation processes at Norwegian hospitals, focused on implementation of equitable health care services for the immigrant population. In other words, the process of putting new practices, measures and interventions concerned with making health care services at hospitals accessible, adaptable and good quality for all immigrant patients regardless of social, economic and cultural background, into use. The study aims to identify what kind of barriers and facilitators to implementation health personnel working with the provision of equitable health care services experience in their work. Secondly, it will also try to explore whether there exists variation in implementation barriers between

hospitals. Thirdly, the study will try to shed light on what type of interventions and supporting policies that might be expected to be effective in this context.

This type of study is important because lack of equity in health care within a country can lead to reduced quality of care and patient safety for vulnerable groups in the population, which again can contribute to larger health inequities in society (Norwegian Institute of Public Health, 2014). There are increasing knowledge and research on the causes of health inequity and the barriers vulnerable groups like immigrants might be exposed to in secondary care, and for the most part consensus exists amongst stakeholders on causes for inequities in health, and the issues health care organizations need to address in order to provide solutions to the issues (Seeleman, Essink-Bot, Stronks, & Ingleby, 2015). The next step will then be to successfully translate this knowledge and evidence-based research into good quality interventions and practices. Thus, this study might contribute to improved understanding of health care personnel's role and influence in the implementation processes, what kind of external and internal factors are restricting or enhancing the performance of their work and make suggestions on how the restricting barriers might be targeted for effective change.

The research questions chosen to shed light on this topic are:

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10 - What kind of barriers are perceived to influence health care personnel working

with equity in health care’s effort in implementing equitable health care services throughout their organization?

- What is the differences, if any, in experienced barriers between the different hospital organizations?

- What type of interventions and policies should be initiated in order to make health care services more equitable?

This paper begins by describing the concept of equity in health care, the Norwegian health care system and a brief description of the immigrant population. Chapter three describes the theoretical framework including implementation theory, more specifically the COM-B model, (capability, opportunity, motivation, behavior) Theoretical Domains Framework (TDF) and behavior change wheel (BCW) framework. Chapter four explains how the study was carried out methodologically. The fifth chapter presents the results extracted from the qualitative interviews conducted with informants and starts to analyze these results through the COM-B model. Lastly, in chapter six the findings are discussed further within the COM-B model, focusing on variation and shared factors between hospitals and how the different parts of the model are interconnected. It will then go on making future suggestions for interventions and policies recommended to be in place, based on the application of the BCW framework.

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2.0 Background

2.1 Equity in health care

A frequently used definition of equity in health care is the one developed by Whitehead (1992, s. 434) “equal access to available care for equal need; equal utilization for equal need;

equal quality of care for all”. Equity in health care and equality in health care are two dissimilar concepts with different meanings. The former takes into consideration patient diversity in needs and presuppositions (Le, 2013). Equity in health care does not necessarily mean that every individual should have the same treatment for equal need, equal outcome, or consume the same amount of health care services irrespective of need (Whitehead, 1992). It is rather to create equal opportunities for accessing the available health care services for those with equal need; everyone has the equal possibility of utilizing health care services when wanted and equally needed, independent of economic, geographical and social disadvantages;

and finally, that every individual has an equal opportunity of receiving good quality care based on the criteria of need. In order to achieve this, individuals with unequal needs have suitably unequal opportunities for utilization (Oliver & Mossialos, 2004).

To provide equitable health care services health personnel needs the ability to relate to, recognize and respond to the characteristics of the individual patient. Examples of

characteristics are culture, religion, gender, ethnicity, language barriers and socio-economic background. Standards and measures aimed at tackling differences in quality and access to health care often focus on specific target groups, like immigrants, women or people with disabilities (Cattacin, Chiarenza, & Domenig, 2013). In doing so, one might create inequalities, stereotyping of some of these groups or ignore other vulnerable groups. For health care organizations, like hospitals, to be able to handle diversity effectively and give patients proper treatment, they need to focus on all of the often-overlapping factors of vulnerability and treat patients more on an individualized and case-by-case assessment basis (Cattacin et al., 2013; The Task Force on Migrant-Friendly and Culturally Competent Health Care, 2014).

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2.2 Characterizations of the Norwegian health care system and the immigrant population

The Norwegian health care services are divided into primary- and secondary health care services. Primary health care consists of the general practitioners (GPs), emergency medical services, nursing home, physiotherapists and their services (Elstad, Finnvold, & Texmon, 2015). They are the first line of services, functioning as gate-keepers for secondary health care, and are mostly organized by the municipalities. This study focuses on secondary health care services. Secondary health care services are currently organized into four public owned regional health care thrusts, and are comprised of somatic and psychiatric hospitals;

policlinics; treatment centers; institutions for rehabilitation (Elstad et al., 2015).

A well-known characterization of the Norwegian health care system is the emphasis on universal health care and equity in access, use and outcomes of health care services. Multiple national health legislations (Helse- og omsorgstjenesteloven, 2011; Pasient- og

brukerrettighetsloven, 1999; Spesialisthelsetjenesteloven, 1999), reports to the Storting, and other political documents states the fundamental rights of all patients to equitable health care services and the health care organizations right to provide them. For example, Report 47 (2008-2009) to the Storting, The Coordination Reform (Samhandlingsreformen), sees equal access to good quality and equitable health care services, independent of economy, ethnicity or place of residence, as an important foundation of the Norwegian welfare state (The Norwegian Ministry of Health and Care Services, 2009). Report 11 (2015-2016) to the Storting reinforces this by acknowledging the political consensus on the issue of providing equitable health care for all, when needed, independent of age, sex, geographical location, economical resources and ethnic background (The Norwegian Ministry of Health and Care Services, 2015). This is underlined as a central objective for Norwegian hospitals.

The demographic composition of the Norwegian population is changing in many ways.

Especially relevant for this study is the changes related to migration, which includes cultural differences in perceptions of health, different health problems compared to Norwegian population, and language barriers (The Norwegian Ministry of Health and Care Services, 2013). This means that today’s health care organizations are confronted with a more varied patient group with diverse expectations of services (Cattacin et al., 2013). This puts pressure

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13 on hospitals and other health care organizations to adapt their structures and behaviors in accordance with the changes in the general population (Cattacin et al., 2013; Seeleman et al., 2015).

The immigrant population is a heterogeneous group consisting of individuals with various cultural, social, national and religious backgrounds. Their perceptions of health and use of the health care system are largely diverse (Elstad et al., 2015; Sandnes, 2017). I will use Statistics Norway definition which defines an immigrant as an individual born in another country by two foreign-born parents and four foreign-born grandparents (Statistics Norway, 2018b).

Every sixth person in Norway has immigrant background, and the total number at the start of 2018 was 746 661 individuals, equivalent to 14,1 % of the total Norwegian population (Statistics Norway, 2018a).

Focusing on providing equitable health care services is a major key to improving quality care and reducing health disparities for all vulnerable groups, including immigrants. According to The Coordination Reform, it is a rising need for health personnel's competencies in

identifying the distinctiveness of every patient and provide adapted and adequate treatment, especially with regards to minority and vulnerable groups (The Norwegian Ministry of Health and Care Services, 2009). There has also been initiated several measures in order to meet the health challenges of immigrant patients, and the following challenges this puts on the

Norwegian health care system (The Norwegian Ministry of Health and Care Services, 2013).

Several measures have also been initiated internally at many hospitals in Norway (The Norwegian Ministry of Health and Care Services, 2015). Despite this, lines of evidence suggest that there are significant health differences within the Norwegian population dependent on ethnicity or socioeconomic variables (Norwegian Institute of Public Health, 2014). Thus, judicial rights, political conduct and strategic documents are not enough to grant rights to health care for all. These rights also need to be guaranteed through adapting

organizational structures, processes, measures, culture, and services so that access to equitable, evidence-based quality care becomes a reality (Seeleman et al., 2015). There is a need for increased knowledge about the implementation processes of equitable health care services. In other words, how agents’ deliberately initiated processes are translated into actions, interventions, measures or practices concerned with the provision of accessible, adaptable and good quality services for patients regardless of social, economic and cultural background.

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3.0 Theoretical framework

3.1 Implementation theory

In general, implementation studies explore any aspects of implementation: the factors

affecting implementation, the implementation process, or the outcomes of implementation. It is valuable because implementation studies can shed light on what can be achieved in theory and what actually happens in practice (Peters, Tran, & Adam, 2013)

Implementation is a process where new practices are put to use in an environment (Nilsen, 2015). In this study, implementation is perceived as a continuous social process where individuals make things happen through their actions (May, 2013). The objects implemented are called complex interventions. The implementation of these interventions is done in

interaction with other processes, constrained and enabled by the environment. Implementation is defined as:

“(…) a deliberately initiated process, in which agents intend to bring into operation new or modified practices that are institutionally sanctioned, and are performed by themselves and other agents” (May, 2013, s. 4).

There exist several theories, models and frameworks on implementation. Which theory, model or framework to choose are dependent on the assumptions, aims and other characteristics of the specific study. Nilsen (2015) proposes three overarching aims

in implementation science, and five categories of theories, models and frameworks. I have chosen the category implementation theory for this study, more specifically the COM-B and BCW framework. Implementation theories have been developed by implementation

researchers. It enables researchers to get an enhanced understanding of certain aspects of the implementation process perceived as the most crucial to analyze (Nilsen, 2015). These types of theories concern themselves with understanding or explaining what influences

implementation outcomes. They can also seek to do both. These types of theories and frameworks are mainly used to describe the implementation processes rather than predicting the type of factors influencing outcomes. But there exists some intersecting between the five

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16 categories of implementation theories, models and frameworks. Hence, implementation theories might also identify preventing or promoting factors (Nilsen, 2015).

3.2 Complex adaptive systems

Mintzberg’s (1983) book Structure in fives: designing effective organizations concerns itself with the activity, functioning and design of organizations. His description of professional bureaucracy describes the structure of the hospital organization at large, its functions, division of labor and coordination of work tasks. The coordinating mechanisms, the basic

organizational diagram, and various types of functional flows describe the activity and functioning of organizations. It is important to remember that this is a theory and therefore a simplification of organizational realities, but it can still be used to understand parts of reality, as comprehensible simplifications enabling us to analyze and categorize data and experiences (Mintzberg, 1983).

The structure of an organization can be defined as the sum of ways in which its labor is divided into distinctive tasks and the coordination achieved among these tasks (Mintzberg, 1983). Five coordinating mechanisms seek to explain the ways in which organizations can coordinate their work. These five are as follows: mutual adjustment, direct supervision, standardization of work processes, standardization of work outputs and standardization of worker skills. Under specific conditions, an organization will favor one coordinating mechanism over the others. The preferred coordinating mechanism changes with shifts in complexity of work. In very complex work, the outputs often cannot be standardized so the organization must settle for standardization of skills, if possible. If this is difficult it may be forced to return to the simplest yet most adaptable coordinating mechanism – mutual adjustment. Formal and informal structures are interdependent and, in some cases, hard to separate from each other. Most organizations mix all five of the coordinating mechanism. For all organizations, a certain amount of direct supervision (leadership) and mutual adjustment (informal communication) is always required.

The five organizational types described by (Mintzberg, 1983) consist of five basic parts: the operating core, support staff, technostructure, middle line and strategic apex. The operating core consists of the employees in the organization that performs the basic work related

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17 directly to production of services to clients. In this study the operating core refers to the health care professionals e.g. nurses, physicians etc. The support staff encompasses the employees and units of an organization that provides support outside its operating work flow e.g. hospital cafeteria, mailroom, security department. This means that they only provide indirect support outside the main task of a hospital. These support staff units can be perceived as small self- contained organizations in themselves.

The technostructure defines the part of the organization where we find the analysts. They are not part of the operating work flow themselves, but they assist the organization by influencing the work of operating core, middle line and strategic apex. The ways in which they influence work can be by designing, planning, changing or training the people working in the operating work flow. Mintzberg (1983) focuses his attention on the control analysts concerned with standardization, but analysts can also concern themselves with changing the organization to meet environmental and societal changes. My unit of analysis fit into this category.

The middle line refers to the middle level managers linking the operating core together with the strategic apex. These managers have a closer relation with health care professionals in the operating core, and they have direct authority and supervision of their work. The middle-level manager is the one passing feedback from the operating core to the strategic apex, and

delegating resources, rules and plans from the strategic apex down to the operating core.

Furthermore, in the strategic apex we find the top-level managers, board, chief executive etc.

In other words, they are the individuals with the overall responsibility for the organization.

Their main tasks are to have an overall view of the organization, communicate with the external environment, make sure that the organization serves its mission effectively and formulating the organization’s strategy.

When an organization grows in size and complexity, a manager sitting at the strategic apex is appointed. Further growth calls for more managers, thus a middle line is created between the strategic apex and the operating core. These jobs are administrative types, thus distinguished from those who do the basic work in the operating core. With the call for standardization there is a need for analysts taken on that responsibility. They are located in in the

technostructure, outside the hierarchical line of authority. As the organization grows even more it tends to add staff units. These provide indirect services and are called support

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18 staff. Middle management refers to all staff not at the strategic apex or operating core. The technostructure and support staff have become increased in size within many organizations.

The five organizational types are not mutually exclusive. Hospital organizations for example are highly complex, and there might exist different types of organizational configurations within. Such constellations are called hybrids (Mintzberg, 1983). One kind of hybrid is the one that uses different configurations in different parts of the organization. Most hospitals are best described by the overall structure of the professional bureaucracy. Overall, professional bureaucracy is the best fit for the clinical units, but closer looks might reveal greater

variations in design, work flows and structure. Although the professional bureaucracy is going to be used as theoretical framework in this study, the argument above needs to be accentuated.

An organization that resembles the professional bureaucracy is standardized and at the same time also decentralized (Mintzberg, 1983). The work behavior of the operating core is predictable due to a stable environment, and the work tasks are standardized. But the work is also highly complex. Hence, it is controlled directly by the health care professionals in the operating core themselves. The only coordination mechanism that can provide for

standardization and decentralization simultaneously is the standardization of skills. Most hospital organizations resemble this design; a highly complex but stable environment;

horizontal and vertical decentralized structure; health care professionals inhabit skills and knowledge that are crucial for the functioning of a hospital organization, and they produce standard services. Other characterizations suitable to the professional bureaucracy are the way in which training and indoctrination of health care professionals in the operating core mainly takes place outside their organization (universities, special institutions etc.). When hired, health care professionals are given great autonomy in their work. They work quite

independently of their colleagues and closely with their patients, compared to for example industry workers.

The organization itself is highly bureaucratic, but its source of power lies not so much with hierarchal power but more with the power of professional expertise (influence by virtue of one’s knowledge and skills) (Mintzberg, 1983). The technostructure and middle line-

management are not highly elaborated in these types of structures. Their ability to coordinate and supervise the work of the operating core is minimal due to the complexity of their work and the limited standardization of tasks. Hence, according to Mintzberg, it is a limited amount

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19 of planning and formalization needed. Consequently, their main tasks as coordinators,

changers and/or standardizers have limited necessity. Due to this autonomy and expert power of the operating core, two parallel but separated administrative hierarchies emerge. One being democratic and bottom-up for the health professionals, and the other bureaucratic and top- down for the support staff. This does not imply that administrators and directors at hospitals are powerless. But compared to other types of organizations they have less direct control and authority but possesses a considerable amount of indirect power. The health care professional is in most cases reliant on an effective administrator or he would have had to do the

administrative work himself.

Strategies have limited significance in the professional bureaucracy. This is because outputs are not easily measured, and goals are not easily agreed upon. Hence, it is difficult to create one single integrated organizational strategy. Due to the structure and design of this type of organizations personal strategies or strategies linked to health care professional’s professional associations are perceived as more logical than to think in collective organizational terms.

Hospital organizations are also highly concerned with safety. Thus, some degree of standardization and stability are sought for.

The health professionals working in these types of organizations have both the attachment to an organization and all its advantages. They are also free to serve clients in their own way, only constrained by the established standards of his or her profession. For this reason,

healthcare professional tends to be highly motivated and dedicated to their work. On the other hand, these characteristics of the organization also provide problems of coordination between health professionals and other personnel, and additionally between the professionals

themselves. Secondly, it is difficult to detect and deal with unconscientious or unprincipled employees, or concerns related to how an employee does his or her work. Thirdly, there can be problems of innovation because innovation depends on cooperation, thus it calls for interdisciplinary efforts. There is a logical need for cooperation but also a logical resistance towards it. New problems are often forced into old “labels and boxes” which makes perfect sense in a stable and predictive environment, but not in an unpredictable and volatile one.

This in combination with professional autonomy means that change is often time-consuming and obscurely diffused.

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3.3 The COM-B system and the behavior change wheel

The COM-B and BCW framework was selected due to the model being developed from combining multiple behavioral frameworks, with the aim of developing a framework overcoming their limitations while combining their strengths. Furthermore, COM-B and BCW seeks to understand and explain individual’s behavior, changing of behavior and individual, relational and environmental barriers and facilitators to behavioral change.

Consequently, successful implementation depends on the understanding of these factors and how behavior is changed in numerous individuals within an organization, making the implemented interventions and practices internalized (Atkins et al., 2017). Several studies have used TDF in relation to the COM-B framework for analyzing issues related to different topics in health care and secondary care (Alexander, Brijnath, & Mazza, 2014; Atkins et al., 2016; Mangurian et al., 2017; Templeton et al., 2016). The benefit of this approach is that TDF can be perceived as an elaboration of COM-B, where each domain can be connected to one of the COM-B components (Atkins et al., 2017; Cane, O’Connor, & Michie, 2012;

Michie, Atkins, & West, 2014). The TDF was also specifically developed for analyzing health professional’s behavior in relation to implementation processes of evidence-based

recommendations (Atkins et al., 2017).

The COM-B system together with the TDF and BCW are chosen as a theoretical framework and are applied to understand and analyze actors in implementation processes. It is a dynamic and systematic model of behavior change and can be useful to describe facilitators and

barriers influencing actor’s behavior, and why an intervention strategy is or is not succeeding (Michie et al., 2014; Michie, van Stralen, & West, 2011). Secondly, it is also useful in

designing behavioral change interventions. Thirdly, understanding behavior in context is also part of its utility. The framework was developed in order to bring together individual, inter- relational and structural factors affecting behavior and behavioral change (Michie et al., 2014). The need for a coherent, comprehensive and broad framework was identified because according to the developers, this did not exist. A strength with the COM-B system and BCW are that they have been constructed from multiple behavioral frameworks, with the aim of overcoming the limitations identified in these pre-existing frameworks (Michie et al., 2011).

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21 In this study, the theoretical aim is to utilize COM-B, TDF and BCW retrospectively. This means that COM-B, TDF and BCW will be analyzing tools used to identify the current barriers and facilitators of implementation. The intervention functions and policy categories will seek to identify what kind of interventions and policies are lacking and should be developed, according to the framework. Furthermore, some illustrative suggestions will be made about future policy and intervention designs, but this is mainly beyond the objectives of this study.

3.4 COM-B system

COM-B consists of three mechanisms: capability, opportunity and motivation, and these three interact and influence each other to generate behavior (Figure 1). Apart from capability, opportunity and motivation affecting behavior, both capability and opportunity can influence motivation (Michie et al., 2011). In addition, a performed behavior can also influence

capability, opportunity and motivation. But motivation cannot influence capability and opportunity because motivation alone is not enough. The individual needs to also act on this motivation, employing his or her physical or psychological capacities (capability), or

exploiting the enabling environment (opportunity) (Michie et al., 2014). Another important aspect of this system is that different behaviors might be affected to a lesser or greater degree by the three mechanisms. Thus, changing individual, group or population behavior means changing one or more of the three mechanisms so that the system are reconfigured, making sure that the new behavior persists (Michie et al., 2014). It is important to recognize that individual behavior exists within a social context, together with other behaviors of the same or other individuals. In the final part of this section these three mechanisms will be defined and explained in more detail.

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Figure 1 The COM-B system – a framework for understanding behavior Source: (Michie et al., 2011).

3.4.1 Capability

The capability mechanism is defined as “the individual’s psychological and physical capacity to engage in the activity concerned” (Michie, Stralen, & West, 2011, s. 4). This means that for any behavior to occur, an individual must have the capability to perform it (Michie et al., 2014). A distinction is made between psychological and physical capability. Psychological capability refers to individual’s capacity of knowledge, understanding, mental skills, and stamina to engage in mental thought processes e.g. comprehension and focus (Michie, Atkins,

& West, 2018; Michie et al., 2011). Physical capability means the physical skill, strength or stamina to perform a task or process, e.g. having the necessary technological skills to create a website.

3.4.2 Opportunity

Opportunity is defined as “all the factors that lie outside the individual that make the behavior possible or prompt it” (Michie, Stralen, & West, 2011, s. 4). This means that there must exist a conducive physical and social environment, enabling the behavior. In other words, it evaluates whether the target behavior is affordable, socially acceptable, physically accessible and accomplishable within reasonable time (Mangurian et al., 2017). Opportunity is divided into physical and social opportunity. The former refers to the opportunities permitted by the environment, like time, triggers, equipment, locations and resources. Social opportunity on the other hand, refers to the opportunities permitted by interpersonal relations and influences, social cues and cultural norms (Michie et al., 2018). These processes influence how

individuals think about subjects, e.g. social pressure to sign a petition.

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23 3.4.3 Motivation

Motivation was the starting point for the COM-B model. It identified it as an energizing process directing behavior (Nilsen, 2015). Capability and opportunity were added at a later stage as essential conditions, together with sufficient motivation, for individual volitional behavior. Motivation is defined by Michie et al (2011, s. 4) as “all those brain processes that energize and direct behavior”. Individuals must be more motivated to perform the behavior at the specific time than not to perform it, or to engage in a contesting behavior. A distinction is made between reflective and automatic processes (Michie et al., 2014). Reflective motivation comprises of self-conscious intentions, planning, evaluations and moral beliefs, e.g. valuing user involvement as the highest prioritized goal (Michie et al., 2018). Automatic motivation involves emotional reactions, wants and needs, desires, impulses and reflex responses arising from learning and/or inherent dispositions (Michie et al., 2014, 2011), e.g. feeling pleasure of working at the maternity clinic.

These three mechanisms encompass the COM-B model. They also form the inner circle of the behavior change wheel (BCW) which will be described in the next section.

3.5 Behaviour change wheel

The BCW is a dynamic model. The components of the model are linked to each other (Figure 2). The different components can also be seen as interacting. This could happen across the three layers of the wheel and within the single layers (Michie et al., 2011). The BCW acknowledges that the targeted behavior one seeks to analyze or change, can emerge from combinations of any of the components in the model. Some components can be more important than others dependent on the context, processes and actors studied. Furthermore, the BCW helps to identify relevant interventions and policies based on the understanding of target behaviors. Target behavior means the behavior chosen or targeted for change (Michie et al., 2014).

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Figure 2 the behavior change wheel put together with TDF domains (yellow) Source: (Michie, n.d.).

3.5.1 Sources of behavior (COM-B)

With regards to the BCW, capability, opportunity and motivation are the mechanisms that cause and maintain behavior or prevent it from changing. Thus, hindering or enabling implementation of interventions. The inner circle defines the factors and processes affecting the implementation problem and specifies what needs to change in order to handle the issue of implementation (Michie et al., 2011).

3.5.2 Intervention functions

Nine intervention functions make up the middle layer of the BCW. The definition of an intervention used in this study is the one proposed by Michie et al (2011, s. 1): “coordinated set of activities designed to change specified behavior patterns”. This layer of the model seeks to identify the appropriate intervention function(s) likely to be effective in changing the targeted behavior (Michie et al., 2011). The kind of intervention that will be appropriate, is dependent on the outcome of the COM-B analysis.

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25 3.5.3 Policy categories

The outer layer of the BCW consists of seven policy categories. They represent population- level strategies that can support and enable the delivery of the intervention functions found in the middle layer (Michie et al., 2011). In most cases, these policies are created on national, regional or local state level and not by the hospital organization themselves.

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4.0 Methodology

“The purpose of research is to discover answers to questions through the application of systematic procedures” (Berg, 2009, p. 8). This chapter explains how the study was carried out methodologically through the application of selected methodological procedures. It explains what types of methods has been chosen and why I chose these methods. It also illustrates the problems which occurred throughout the process of conducting and writing the study. In compliance with Norwegian legislation on ethics in research, the study was regarded as health service research and was approved by the Norwegian Data Ethical Approval: Data Protection Official for Research, Norwegian Social Science Data Service (Project no 58418).

Each participant provided consent to participate.

4.1 Study design

4.1.1 Qualitative methods

The aim of this study is to understand and analyze health care personnel’s interpreted experiences, meanings and motivations, and to get an in-depth understanding of the implementation processes. Thus, for this study, qualitative methods would be the most suitable methodological approach. When collecting data on human actors and social settings, qualitative studies can be useful in understanding social phenomena (Thagaard, 1998). I chose to conduct semi-structured interviews and focus groups. Because of the small number of health personnel working directly with equity in health care, focus groups were conducted at the hospitals with three or more informants, and interviews were used as a method at the hospitals with less than three informants. Relevant advantages and disadvantages with using these two methods will be described in a later section.

Interviews is the best way to collect rich and descriptive information about health care personnel’s personal experiences, meanings and understandings of their lived realities (Thagaard, 1998). As mentioned by Brinkmann and Kvale (2015), qualitative research

interviews can be a medium for individuals, expressing their opinions, meanings and concerns around the research topic.The extent of the acquired information depends on the

phenomenon, the background of the researcher and the accessibility of informants (Dalen,

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28 2004). Seven semi-structured interviews were conducted using an interview guide laying out certain topics of discussion and questions that was perceived as important to be answered for the study. Because of the geographical location of two hospitals, phone-interviews was

selected. Semi-structured interviews are not strictly structured or unstructured, but somewhere in between those two extremes (Brinkmann & Kvale, 2015). The interviewer does the task of leading the interview by asking specific open-ended questions written beforehand to the interviewee. These questions were not standard, and the interview guide was not followed like a recipe from start to finish. When conducting the interviews, I chose instead to follow the story line of the informants, making room for unplanned responses, asking follow-up questions, and posed the pre-written questions when it was natural in the ongoing conversation. This flexibility in research design is an advantage with qualitative studies, because it makes it possible for the researcher to adjust the data collection method

continuously, reflect and elaborate further on findings explored early in the research process (Thagaard, 1998). Qualitative research can be described as a cyclic process, where different stages of the research process are not clearly defined from each other, but more specifically defined as overlapping phases.

Two focus group interviews consisting of three participants were also conducted. The focus group is a research technique where a number of informants interacts around a specific research topic (Frey & Fontana, 1991). Its main advantage as an interview technique is the gathering of informants expressing multiple viewpoints on the topic of discussion and additionally, the possibility of observing group dynamics and interpersonal relations (Brinkmann & Kvale, 2015). Similarly, to qualitative interviewing, focus groups provide information expressed in the informant’s own words and understanding (Stewart &

Shamdasani, 2015). The degree of directedness can vary from little interchange between the participants of the group, only between interviewer and individual informants, to the other extreme where the interviewer participates at the start of the discussion, and to keep the discussion on topic (Stewart & Shamdasani, 2015). In this study, the participating informants were asked semi-structured questions on pre-defined topics, while the ‘interviewer’ or

‘moderator’ made sure that the participant’s discussion stayed focused on the purpose and objective of the research, by directing the topic of discussion (Frey & Fontana, 1991).

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29 4.1.2 Case study

This study is a descriptive and exploratory case study. The aim is to explore perceptions of barriers and facilitators to implementation, and understand the factors identified from the data as perceived barriers and facilitators. Case-studies analyzes a lot of information about few units or cases. These units or cases can be people, events, structures, groups or organizations (Kumar, 2014). The case-study design is very useful when studying issues where little

knowledge is available, where how and why research questions are asked, when the aim of the study is to explore and understand the issue, and when the explored issue is a complex present time phenomenon within a real-life context (Kumar, 2014; Yin, 2014). Having the

opportunity to use multiple sources of data as evidence are regarded as a strength of case- study research (Yin, 2014). This is also called data triangulation. Hospital strategies and plans, focus groups and semi-structured interviews are the sources of evidence supporting the findings of this study. The study conclusions are possibly perceived as more accurate if multiple sources of information support the findings (Yin, 2014). Hence, strengthening the construct validity of the study. The defined case- or unit of analysis in this study are health personnel’s experiences and views around their work and issues affecting the implementation of equitable health care.

4.2 Selection of informants

When selecting informants, the most central factor was that they had a job position in a Norwegian hospital where they worked administratively and/or practically with the facilitation and provision of equitable health care services. It was important that my informants had extensive information about the topic of interest. My informants were all working at Norwegian hospitals with the provision of equitable health care services. It is fully or partly a part of their job description. The informants can be considered as key informants on this topic. The group of individuals fitting the description are relatively small in number, hence a small study population. In qualitative studies the main purpose is to investigate one or a few cases more in depth, in order to identify the spread of diversity, and not the scope of an issue or topic (Kumar, 2014). Consequently, having a large sample size might defeat these purposes. At the same time, it becomes difficult to generalize and draw conclusions on population level. Hence large representative sample sizes and generalizations do not inhabit

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30 the same importance in qualitative studies as in quantitative studies. For these reasons, I will argue that the number of interviews conducted is sufficient in order to shed light on the research questions and provide valuable information about the subject.

The informants are employed at six different hospitals in Norway. Hospital organization 1 and 2 are university hospitals situated in the eastern part of southern Norway. Hospital

organization 3 is a university hospital situated in the Northern part of Southern Norway.

Hospital organization 4 is located in the eastern part of southern Norway, and hospital organization 5 is a university hospital in northern Norway. Lastly, hospital organization 6 is located in western Norway.

Due to the organizational differences between hospitals, my informants have a variety of job titles and were subject to different departments (table 1). Three of my informants were males and 10 were females. The hospitals and informants were selected by purposive sampling, which is a commonly used sampling method for qualitative research studies (Kumar, 2014).

Purposive sampling relies on the judgement of the researcher, where the informants are selected based on their ability to provide rich and extensive information on the subject of study, so that the researcher can answer the research questions and fulfill the study objectives (Kumar, 2014). In my study, all the informants had extensive information on the subject at their respective hospitals.

These six hospitals were selected in order to encompass all of the four Norwegian regional hospital thrusts. Furthermore, five out of six of the hospitals are the only Norwegian hospitals that have created separate positions for one or more employees working mainly with equitable health care services. They were also willing to participate in the study. The sample was

collected as follows: during my internship at The Norwegian Centre for Migration and Minority Health (NAKMI) during the spring 2017, I got interested in equity in health care.

NAKMI gave me advice on whom to contact at the selected hospitals. Firstly, I sent out e- mails to three of the hospitals. Not long after the e-mails were sent, NAKMI invited me to observe and introduce my study in one of their meetings for the network of migrant-friendly hospitals (NONEMI). At the meeting I received positive feedback about my choice of topic.

At this time, there was only one of the hospitals that had agreed to participate in the study.

The meeting gave me an opportunity to meet some of the informants. After the meeting I came in contact with the rest of the hospitals. All of the selected hospitals were present at the

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31 meeting except two. After some time, I got all the informant’s consent in conducting the study and confirmed date and time of the interviews. The first interview was conducted February 21^st, and the last on April 30^th. I contacted only one informant at every hospital. Some of these informants then suggested other individuals at their hospital that could provide relevant and extensive information and that was available to participate in a focus group or interview.

Table 1 Overview of informant’s job titles/positions (Norwegian)

Job title/position Number of informants

Diabetessykepleier 1

Hovedprest/seksjonsleder for prestetjenesten 1

Koordinator lærings- og mestringssenteret 1

Koordinator for tolketjenesten 1

Kulturkonsulent/kulturrådgiver 2

Prosjektleder 1

Rådgiver/koordinator/konsulent i likeverdig helsetjeneste 5

Seniorrådgiver for mangfold, likeverd og migrasjonshelse 1

4.3 Data collection: conducting interviews and focus groups

For this study, I have chosen to utilize the semi-structured interview and focus group as data collection methods. These methods were chosen based on the purpose of the study and the type of research questions it seeks to answer. The health personnel working administratively or practically with the provision and implementation of equitable health care are my unit of analysis, and I am interested in analyzing their shared experiences, meanings and attitudes concerning these processes. Additionally, their challenges in implementing equitable health care services at their respective hospitals. Thus, observation as data collection method have also been considered, and this method might have been valuable in order to gain an

understanding of work practices, actors’ unaware behaviors, and their communication in everyday work setting (Morse & Richards, 2002). Due to time and resource constraints as well as the difficulty of gaining access, observation was not chosen as data collection method for this study. But using observation in further research on implementation of equitable health care could provide valuable insight on the topic and everyday practices and work processes.

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32 4.3.1 The interviews

An interview can be broadly defined as a conversation that has a certain structure and purpose (Brinkmann & Kvale, 2015). It is the interviewer who asks the questions, defines the main topics of the conversation, and ends the conversation. It is a one-way dialogue, where the interviewer asks and the interviewee answers. For this reason, the qualitative research

interview is not an everyday conversation between two equally powerful parts. The interview has certain power relations and a certain instrumental purpose for taking place (Brinkmann &

Kvale, 2015). The knowledge obtained from the interview is created and affected by the interpersonal dynamics between the interviewer and the interviewee. Thus, the interview is therefore an interpersonal situation. Furthermore, the interviewer is a coauthor of the

produced interaction, not merely a collector of statements. For this reason, different forms of interviewing with different individuals will produce diverse data and knowledge (Brinkmann

& Kvale, 2015).

4.3.2 Focus groups

Focus groups normally consists of between 4 to 12 informants discussing a topic chosen by the researcher (Tong, Sainsbury, & Craig, 2007). As discussed earlier, its main advantage as an interview technique is the gathering of various individual and shared viewpoints and observing group dynamics and interpersonal relations between the participants. Similarly, to qualitative interviewing, the focus point is the informant’s own words and understandings, and the meanings accredited to them. In the majority of cases, focus groups are utilized for the purpose of exploring a specific little-known topic or identifying specific issues

and opportunities (Stewart & Shamdasani, 2015). In the health sciences, focus groups are more specifically used to explore for example concepts and roles of health personnel or patient-health personnel relationships.

4.3.3 The two methods compared

A strength with using focus groups instead of individual interviewing, is the opportunity to observe interpersonal dynamics, group interaction, culture and experiences, by

accommodating a group discussion. Another advantage is the collection of data from a group of people at lesser cost and time compared to individual interviews with each individual (Stewart & Shamdasani, 2015). Furthermore, in contrast to individual interviews, it allows participants to respond to and build on other group members responses, thus

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33 the participants stimulate and trigger each other. On the other hand, a difficulty with using focus groups as research technique, is the required awareness of group dynamics which requires an experienced researcher (Frey & Fontana, 1991). Compared to

individual interviews, focus groups can reduce the interviewer's control over the direction of the interaction, making the interaction more divergent, and unstructured (Brinkmann & Kvale, 2015). This can also mean an enhancement of complexity with regards to interpreting

the interview transcripts.

4.3.4 Interview guide

Before starting the interviews, a pilot interview was conducted with an acquaintance. A weakness with the pilot interview was that the person interviewed did not meet the criteria for the study group. Due to time constraints this was not manageable. The semi-structured

interview guide consisted of five parts. The first part asked the informants about background information, while the four others concerned the research topic. After the first two interviews, some of the questions were modified to be more appropriate for the research questions and study objective.

4.3.5 Conducting interviews and focus groups

Because of their busy work schedule and the short time-frame to conduct the data collection, I let the informants choose time and place. All the interviews and focus groups occurred at their workplace during work hours. The individual interviews lasted between 34 and 65 minutes, and the focus groups lasted for 50 and 70 minutes. After posing the questions about the

informants background the conversation moved on to general questions about equitable health care and how their work was organized. From there, more direct questions on implementation, kind of measures and actions, challenges to implementation and their motivations were

discussed. In some cases, I found it a bit difficult to stimulate group discussions in focus groups, as well as directing the conversation. My focus was to have the informants talk freely about the relevant topics they mentioned but made sure they discussed the main topics

involved in the interview guide. Some of the informants spoke very freely around the topics and came with information about the issues often before I asked the questions. In those cases, it was simpler to ask follow-up questions, and I adjusted the posing of questions to their line of narrative. Others needed more direct questions in order to talk. In those cases, the interview guide was followed more strictly.

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4.4 Data analysis

As mentioned earlier, I used interviews as data collection method. The interviews were recorded and transcribed in Norwegian. At a later stage in the analysis process, I translated the illustrative citations used in the thesis to English. Transcriptions are translations from oral to written language, and once they have been completed, they can be regarded as solid

empirical data descending from the interviews (Brinkmann & Kvale, 2015). After the interviews were transcribed, all text which might be identified as informant’s barriers and facilitators to implementation was extracted from the transcripts and categorized by

informant. This could be considered as the ‘description phase’, organizing and making sense of the data material (Thagaard, 1998). Thereafter, the data material was coded into relevant COM-B components. In this ‘interpretation phase’ the objective is to get a deeper

understanding of the data, and develop relevant concepts and theories (Thagaard, 1998). After this first round of coding, three more rounds of checking the initial coding and re-coding were conducted. At this stage citations were also categorized into relevant TDF domains and sub- constructs within each COM-B component. The citations were translated from Norwegian to English during the last round of coding. Coding is a process that should be revisited and reviewed to allow oneself to reflect upon the data, and this strengthens its robustness (Morse

& Richards, 2002).

4.5 Ethical considerations

Ethical issues will arise throughout the research process when applying qualitative research and interviews as data collection methods. In the design stage and interview situation, this might include obtaining informed consent, obtaining confidentiality, the role of the researcher and being aware of the consequences of participation for the informants (Brinkmann & Kvale, 2015). With regard to the process of transcription, data analysis and reporting of findings, it is especially the issue of confidentiality that needs to be taken into consideration.

Informed consent from the participating informants implies informing them of the purpose of the research and relevant information concerning their participation (Dalen, 2004). The informants are also given the right to withdraw from the study at any time, and the research

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35 should not be started before informants have given their voluntary and knowing informed consent to participate. In this case, a written or oral agreement can function as a protection for the informant and the interviewer.

Confidentiality refers to the agreement with the informant about actively making sure that he or she is not identifiable in the study, and that personal data and sensitive information are secured and not disclosed (Brinkmann & Kvale, 2015). This also implies that the research material is anonymized (De nasjonale forskningsetiske komiteene, 2016). The researcher shall guarantee that the risk of harm for the informants and the larger group they represent, is as minimal as possible (Brinkmann & Kvale, 2015). This stems from the informants right to privacy. In qualitative research this can pose a conflictual situation between the demand for an informant's confidentiality, and the demand for credibility and study replication in scientific research studies (Brinkmann & Kvale, 2015). Furthermore, there can also arise a dilemma between confidentiality and loss of important details and information due to

anonymization of e.g. biographical information, organizations or places (Dalen, 2004). With regards to this study, the anonymization of hospitals meant that hospital strategies could not easily be referred to in the text in connection with informant’s citations, because the

information extracted from the strategies could point out which hospital it stems from, and therefore also the informant’s hospital. For this reason, hospital strategies and plans were used as a contextual source of information.

When conducting interviews, the interviewer is with his or her presence and participation in the conversation, influencing the process. Thus, the role and moral integrity of the researcher is of central importance when discussing ethics (Brinkmann & Kvale, 2015). It is important that the interviewer strives to be as objective as possible, keeping a professional distance from the informants. The researcher should also reflect upon the consequences of participation for the informants. According to ethical principles, informants should not be exposed to risk of physical or mental harm or strain because of their participation in the research (De nasjonale forskningsetiske komiteene, 2016).

My informants were contacted through e-mail asking for their participation in the research project. The inquiry of participation was added as an attachment. It outlined the purpose of the study, the conduct of the interview, explanation of the processing of personal data and a statement of their participation. It was also made clear that the project was approved by

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36 Norwegian Centre for Research Data (NSD). Before starting the interviews, I handed out the inquiry and statement of participation and made sure the informants had read and understood its content, their voluntary participation and their right to withdraw from the study at any time. Their written informed consent was also collected at this point. With regards to two of the phone interviews, the informants gave their oral consent. After the interviews, I gave the informants my e-mail and phone number in case they had any questions, inquiries or wanted to withdraw from the project. By doing these procedures, I have made sure that the ethical guidelines for research which includes informed consent, informing participants about the project and confidentiality has been followed (De nasjonale forskningsetiske komiteene, 2016).

4.6 Validity, reliability, generalization and flexibility

It is contested whether validity, reliability and generalization have relevance in qualitative studies due to its interpretation in quantitative studies, and some qualitative researchers have ignored or dismissed these concepts altogether (Brinkmann & Kvale, 2015). Nevertheless, Brinkmann and Kvale (2015) have decided to use and reconceptualize these concepts, making them more relevant to qualitative methods.

4.6.1 Validity

The concept of validity refers to: “the ability of an instrument to measure what it is designed to measure” (Kumar, 2014, p. 213). In other words, does our observations reflect the issue of interest to the researcher? Thus, validity makes a claim for inferences being appropriately derived from its premises (Brinkmann & Kvale, 2015). In addition, the statements put forward by the informant should reflect his or her understandings and experiences as good as possible (Dalen, 2004). The interpretative skills of the researcher and his or her role in the interview situation influences validity. Furthermore, the data collection methods should

comprehensively comply with the research objectives, research questions and theoretical framework.

4.6.2 Reliability

The concept of reliability raises the question of whether the research instrument and findings are sufficiently consistent and trustworthy (Brinkmann & Kvale, 2015). As Yin (2014, p. 49)

Identifying barriers and facilitators to implementing equitable health care services at Norwegian hospitals