Social and Behavioral Variables in the Electronic Health Record: A Path Forward to Increase Data Quality and Utility

Background Normalization Process Theory (NPT) identifies, characterises and explains key mechanisms that promote and inhibit the implementation, embedding and integration of new health techniques, technologies and other complex interventions. A large body of literature that employs NPT to inform feasibility studies and process evaluations of complex healthcare interventions has now emerged. The aims of this review were to review this literature; to identify and characterise the uses and limits of NPT in research on the implementation and integration of healthcare interventions; and to explore NPT’s contribution to understanding the dynamics of these processes. Methods A qualitative systematic review was conducted. We searched Web of Science, Scopus and Google Scholar for articles with empirical data in peer-reviewed journals that cited either key papers presenting and developing NPT, or the NPT Online Toolkit (www.normalizationprocess.org). We included in the review only articles that used NPT as the primary approach to collection, analysis or reporting of data in studies of the implementation of healthcare techniques, technologies or other interventions. A structured data extraction instrument was used, and data were analysed qualitatively. Results Searches revealed 3322 citations. We show that after eliminating 2337 duplicates and broken or junk URLs, 985 were screened as titles and abstracts. Of these, 101 were excluded because they did not fit the inclusion criteria for the review. This left 884 articles for full-text screening. Of these, 754 did not fit the inclusion criteria for the review. This left 130 papers presenting results from 108 identifiable studies to be included in the review. NPT appears to provide researchers and practitioners with a conceptual vocabulary for rigorous studies of implementation processes. It identifies, characterises and explains empirically identifiable mechanisms that motivate and shape implementation processes. Taken together, these mean that analyses using NPT can effectively assist in the explanation of the success or failure of specific implementation projects. Ten percent of papers included critiques of some aspect of NPT, with those that did mainly focusing on its terminology. However, two studies critiqued NPT emphasis on agency, and one study critiqued NPT for its normative focus. Conclusions This review demonstrates that researchers found NPT useful and applied it across a wide range of interventions. It has been effectively used to aid intervention development and implementation planning as well as evaluating and understanding implementation processes themselves. In particular, NPT appears to have offered a valuable set of conceptual tools to aid understanding of implementation as a dynamic process. Electronic supplementary material The online version of this article (10.1186/s13012-018-0758-1) contains supplementary material, which is available to authorized users.

This article investigates the relationship among objectively assessed neighborhood socio-economic status (SES), subjective perceptions of neighborhood environment, individual SES and psychosocial factors, and self-rated health among middle-aged and older adults. Analysis of data from a representative sample of adults, aged 50-67 years in Cook County, Illinois, shows a significant association between objective neighborhood SES and self-rated health after controlling for age, gender, and race/ethnicity, but the effect is substantially explained by individual SES and neighborhood perceptions. By contrast, perceived neighborhood quality (i.e., subjective ratings of neighborhood physical, social, and service environments) exhibits a significant effect after controlling for individual socio-demographic factors as well as neighborhood SES. In turn, the effects of perceived neighborhood environment on health are partially explained by the psychosocial factors of loneliness, depression, hostility, and stress, but not by perceived social support or social networks. In sum, the research supports a model in which the effects of neighborhood SES on self-rated health act through sequential pathways of individual SES, perceptions of neighborhood quality, and psychosocial status.