We observed three main findings. Overall, organizational readiness for referring SUS users to the EducaDor program was low in most of the Family Health teams. Second, organizational readiness for implementing change was higher in Family Health teams that had a multidisciplinary team; that is, nine (64.9%) of fourteen Family Health teams with multidisciplinary team were ready for the innovation. Third, the commitment and efficacy components varied according to occupation. Dieticians had higher commitment and efficacy than community health agents, oral health teams and general practitioners, and both domains were higher in community health teams compared to oral health teams. Physical education professionals and physical therapists had higher score for change commitment compared to oral health teams.
The organizational readiness for implementing change in Family Health teams with multidisciplinary team could be explained by the increase in the number of professionals working in the primary healthcare unit. The largest number of primary healthcare providers could reduce workload and allow the team to take care of other SUS user demands. In this case, become aware of SUS users chronic pain condition and refer them to the EducaDor program. Other point is that all primary healthcare providers of multidisciplinary team have access to the digital medical records system, and some primary healthcare providers of Family Health have not. The lack of access to the digital medical records system can impact the workflow of primary healthcare providers. It can difficult referring SUS users to the EducaDor program, and another primary healthcare provider with access to the digital medical records system should be contacted to do the referral.
Another possible barrier of organizational readiness for referring SUS users to the EducaDor program may be that, although pain education is essential to optimizing chronic musculoskeletal management, it is also a new science(27, 28). Then, it is not well known how much primary healthcare providers have acknowledgement about pain education and agree with its importance in referring it to SUS users with chronic musculoskeletal pain. Organization training has shown a central role in enhancing the success of digital health strategies(29). To improve acknowledgement, we realize 1-hour of pain education training in each Family Health team, including how to refer SUS users to the EducaDor program using the digital medical records system. Although not all primary healthcare providers have access to digital medical records system, in this 1-hour training was discussed how primary healthcare providers could improve collaboration and coordination workflow among each other and refer SUS users to the EducaDor program. Well-planned coordination of services can increase adoption, especially when several teams are involved(29, 30).
Conversely, increasing the possibilities to coordinate and communicate with other staff members can be challenging, sometimes resulting in lack of trust or conflicting opinions(29). Also, interprofessional collaboration have been reported that this can result in more pressure on professionals, adding to their already high workload(29). Despite the workload, women have showed to be more confident in their ability to work on a team and creating positive interpersonal relationships(31). Also, women spend more time with individual patients, which influences the number of patient encounters, patient adherence to preventive and treatment regimes, patient satisfaction and patient outcomes(31, 32). Thus, the high prevalence of women in our study (87.7%; n = 136) can increase the success rate in referring users to the EducaDor program. The rapid feminization of the primary healthcare workforce over the past half-century is a significant demographic change that has the potential to influence service availability(32, 33).
Also, it is possible that the use of soft technologies, also known as relationship technologies, such as welcoming, bonding, autonomy, accountability and management as a work process may interfere in the user’s care(34). It could explain why neither the territorial area size of Family Health team nor the number of SUS users per primary healthcare providers probably were not related to the organizational readiness for implementing change. For example, Adão Kaminski team and Paz e Bem team were not ready for implementing change and had small territorial area and low number of users per primary healthcare providers. In contrast, Colibri team and Campo Velho team, which had a large territorial area and high number of SUS users per primary healthcare providers, were ready for implementing change. It seems that the lack of soft technologies, resistance among professionals to adopt new work processes in their professional routine, in addition to the lack of knowledge, personal and academic profile of some professionals could be related with organizational readiness for implementing change(34, 35).
A further aspect warranting investigation concerns the impact of online pain education on organizational readiness. While digital platforms offer promising avenues for integrating pain knowledge into clinical practice, there is a need to explore their effectiveness in fostering interdisciplinary treatment approaches for patients with chronic pain(36, 37). It is important to highlight that digital health is a recent national policy in Brazil(38) and began to be part of municipal health policy in Guarapuava city in 2022, including the implementation of digital health services for SUS users(39). Therefore, before implementing the EducaDor program at the secondary level of care, we met with municipal health managers to adapt the program considering the characteristics and preferences of the end-users, based on others municipal digital health strategies previously implemented. We have made language adjustments to the end-users (simple communication, using images, videos, audios, and short texts) and chose a familiar application (WhatsApp®) and friendly videoconferencing platform (Whereby® - with EducaDor program layout, without the need for login and password to access). Furthermore, it is estimated that more than 80% of the Brazilian population has access to the internet and a smartphone, which would enable access to digital health(40). Fowe et al(41) highlighted some recommendations that implies a high level of organizational readiness for implementing a digital intervention, such as intervention characteristics (design quality, cost and complexity). Sufficient consideration of the end-user and the technical infrastructure will lead to the design of an intervention that is incongruent with the implementing end-user population(29, 41).
In our study, we did not directly analyze contextual factors of the SUS users (e.g. digital literacy) nor problems faced by Family Health teams in their respective territorial areas (extreme poverty, drug addiction, or other priority health conditions). These contextual factors could explain the low organizational readiness observed in some Family Health teams (n = 17) and help redesign the EducaDor program to meet local demands. In primary healthcare services, the worker’s close link with the user’s territory can mean a greater vulnerability of the health care provider himself by experiencing with greater intensity the feeling of impotence in face of the magnitude of the health problems to be treated(42). Also, primary healthcare providers face the fear by threats to the moral and physical integrity by working in open environments or in the users’ own residence(42). These are some factors that can contribute to higher levels of occupational stress and lower work engagement(33). Other studies, including qualitative studies, could identify contextual factors related with organizational readiness to refer SUS users with chronic musculoskeletal pain to EducaDor program. It could help improve strategies for increase organizational readiness for referring SUS users to EducaDor program.
Assessing readiness for change adds an important component to the evaluation of the EducaDor program. In the future, these data will be useful for analyzing implementation outcomes related to the implementation of the EducaDor program, especially adoption, based on the rate of SUS users referred to the EducaDor program by Family Health teams. The evidence for whether readiness for change predicts change adoption is an area of great interest and the ORIC instrument has been noted as a scale with promising psychometric properties but has yet to be tested for predictive validity(43). One of the premises of organizational readiness theory is that it can be changeable over time(44). And that, throughout this period of implementing a change, it is possible to promote a shared sense of readiness with consistent leadership messages and actions, information sharing through social interaction and experiences, including experiences with changes in previous efforts(44, 45). All of this could promote a good shared mental state in the organization and members' perceptions of readiness(45).
The strengths of our study include the appropriate timing of the data collection, right before the implementation of the EducaDor program, and the targeting of the survey to all primary healthcare providers. We distributed the survey concurrently with the dissemination of the EducaDor program implementation in the digital medical records system and immediately before the possibility for primary healthcare providers to refer users to the program. When considering the implementation of this program in public health healthcare, caution is advised in interpreting organizational readiness results. It is essential to refine pre-implementation strategies, like continuous education for providers and monitoring of key indicators. This caution stems from the fact that some organizations, while generally open to change, may not be prepared for specific changes at certain times(41). The willingness and readiness of primary healthcare providers to embrace new changes are crucial for implementation; this has been described as a critical precursor to successful implementation(12).
The limitations of this study include a low response rate from the first invitation of primary healthcare providers (n = 155; 28.2%). However, most of it was due to fewer responses from primary healthcare providers working in the Family Health team, especially the nurse team and community health agents, who would be less affected than the primary healthcare providers from multidisciplinary team. This lower response rate may be attributed to their lower involvement compared to providers in multidisciplinary teams who frequently use digital medical records to refer for interventions to treat chronic musculoskeletal pain.