Sustainable practice change: Professionals’experiences with a multisectoral child healthpromotion programme in SwedenKristina Edvardsson1*, Rickard Garvare2, Anneli Ivarsson1, Eva Eurenius1, Ingrid Mogren3 and Monica E Nyström4
Abstract
Background: New methods for prevention and health promotion and are constantly evolving; however, positiveoutcomes will only emerge if these methods are fully adopted and sustainable in practice. To date, limitedattention has been given to sustainability of health promotion efforts. This study aimed to explore facilitators,barriers, and requirements for sustainability as experienced by professionals two years after finalizing thedevelopment and implementation of a multisectoral child health promotion programme in Sweden (the Salutprogramme). Initiated in 2005, the programme uses a ‘Salutogenesis’ approach to support health-promotingactivities in health care, social services, and schools.
Methods: All professionals involved in the Salut Programme’s pilot areas were interviewed between May andSeptember 2009, approximately two years after the intervention package was established and implemented.Participants (n = 23) were midwives, child health nurses, dental hygienists/dental nurses, and pre-school teachers.Transcribed data underwent qualitative content analysis to illuminate perceived facilitators, barriers, andrequirements for programme sustainability.
Results: The programme was described as sustainable at most sites, except in child health care. The perception offacilitators, barriers, and requirements were largely shared across sectors. Facilitators included being activelyinvolved in intervention development and small-scale testing, personal values corresponding to programmeintentions, regular meetings, working close with collaborators, using manuals and a clear programme branding.Existing or potential barriers included insufficient managerial involvement and support and perceived constraintsregarding time and resources. In dental health care, barriers also included conflicting incentives for performance.Many facilitators and barriers identified by participants also reflected their perceptions of more general andforthcoming requirements for programme sustainability.
Conclusions: These results contribute to the knowledge of processes involved in achieving sustainability in healthpromotion initiatives. Facilitating factors include involving front-line professionals in intervention development andusing small scale testing; however, the success of a programme requires paying attention to the role of managerialsupport and an overall supportive system. In summary, these results emphasise the importance for bothpractitioners and researchers to pay attention to parallel processes at different levels in multidisciplinaryimprovement efforts intended to ensure sustainable practice change.
* Correspondence: [email protected] of Public Health and Clinical Medicine, Epidemiology andGlobal Health, Umeå University, SE 901 87 Umeå, SwedenFull list of author information is available at the end of the article
Edvardsson et al. BMC Health Services Research 2011, 11:61http://www.biomedcentral.com/1472-6963/11/61
BackgroundVast evidence shows that conditions during the foetalperiod, infancy, and childhood can affect physical andmental health throughout life [1-4]. Although chains ofrisk factors for physical and mental problems can beinterrupted by preventive and health promoting inter-ventions [5], current research shows that the rate ofadoption, implementation, and sustainability of suchinterventions often is low, indicating that many potentialhealth benefits are never achieved [6-11]. For example, arecent Swedish child health care intervention project inUppsala County aimed to broaden the psychosocial sup-port to families; however, the intervention resulted inonly a few families taking part in the originally plannedinterventions, and professionals were more likely to dis-tribute books and brochures instead of changing theirworking routines [12].Precisely why changes do or do not occur in multi-
faceted preventive programs can be difficult to explain[13]. A number of factors are important - indepen-dently or in interaction with others [14] - and barriersthat may impede change of perceptions, attitudes, andbehaviours among professionals can be found at dif-ferent levels of health care [15,16]. To improve qualityand outcomes of care, one needs to take into accountfactors specific to the levels of the individual, groupor team, organization, and the larger environment[15].Implementation research deals with questions such as
“what is happening and why"? [17], and theories onimplementation of change can be used to explain underwhat circumstances change most likely will be achieved[18]. Sustainability is a key to programme success andcan be defined as ‘the degree to which an innovationcontinues to be used after initial efforts to secure adop-tion is completed’ [19]. However, it is well known thatcompliance rates often drop and return to pre-interven-tion levels when specific implementation efforts haveended [6,20], and one question still remains unan-swered: What are the crucial components that lead tosustainability of innovations in health care [21,22]?Quantitative studies have dominated this field ofresearch, but more qualitative studies are needed [14].Qualitative methods can further the understanding ofwhy or why not sustainability can be reached, for exam-ple, by exploring reasons behind certain behavioursamong professionals [23]. To contribute to a deeperunderstanding of these processes, we explored facilita-tors, barriers, and requirements for programme sustain-ability as experienced by involved professionals twoyears after finalizing the development and implementa-tion of a multisectoral child health promotion pro-gramme in Sweden.
MethodsStudy contextThe study was conducted in Västerbotten County, Swe-den (260,000 residents). In 2005, Västerbotten CountyCouncil launched the Salut Programme - a multisectoralchild health programme developed to support the provi-sion of health promoting activities in health care, socialservices, and school settings. The programme has a ‘Salu-togenesis’ approach, which implies focusing on factorsthat support human health and well-being rather thanfactors that cause disease [24]. Starting with the pregnantwoman and her partner, the programme continues to fol-low the child, partly by involving parents, up to 18 yearsof age through age specific modules. The programmealso includes an epidemiological surveillance component.This study covers the first two modules that target par-ents and their children from foetal life to 1½ years of age.
Description of involved sectorsIn Sweden, nearly all health care is provided through anational social insurance system, mainly financed throughtaxes levied by county councils and municipalities [25].The maternal and child health services, which are part ofthis system, are free and reach nearly all expectant womenand children aged 0 - 6 years in the country.Antenatal care with registered midwives responsible
for activities provides women with counselling andinterventions regarding sexual and reproductive healthand maternal and foetal surveillance during pregnancy.Pregnant women are offered seven to nine visits fromthe first trimester to childbirth, additional counsellingby physicians if required, and a follow-up visit6-12 weeks post partum [26]. Child health care staffedby registered nurses with qualification in child healthprovide families with support, advice, and informationregarding issues such as child health and development,immunization, breast feeding, nutrition, child safety, andparenting. Visits to child health care centres are recom-mended at approximately 11 key ages during the child’sfirst 18 months and subsequently at 3, 4, and 5 years ofage. Examination by physicians are included in five ofthese visits [27].In Sweden, dental care can be provided by the Public
Dental Services or by private care providers. The CountyCouncils responsibility is to ensure that dental care isavailable to everyone and free comprehensive dentalcare is provided for children up to the age of 19 [28].Open pre-schools offer pedagogical group activities ledby preschool teachers and serve as alternatives to theregular pre-school for children with parents on parentalleave or non-working. These services are free, childrenare not registered, and they are not obliged to attendregularly [29].
Edvardsson et al. BMC Health Services Research 2011, 11:61http://www.biomedcentral.com/1472-6963/11/61
Page 2 of 12
Salut programme development and implementationprocessHealth-promoting interventions targeting children (foe-tal life to 1½ years of age) and their parents were devel-oped and implemented in each sector in the four pilotareas between 2005 and 2007. A modified version of theInstitute for Health Care Improvement’s BreakthroughSeries Model guided the intervention development pro-cess [30], supported by the County Council change pro-cess consultants and led by the Salut Programmemanagement. Professionals in the pilot areas attendedfive learning seminars and conducted small-scale testingof interventions between seminars for one year, guidedby the principles of the Plan-Do-Study-Act (PDSA)cycle of learning [31]. Then the intervention packagewas decided upon jointly by the professionals, Salut Pro-gramme managers, and experts in the field of maternal,child, and dental health. The year of intervention devel-opment was followed by a one-year implementation per-iod that provided another five learning seminars to helpthe participants improve their skills, adjust their inter-ventions, and evaluate the feasibility of the programme.All seminars during the first and second year includedlectures on topics related to relevant health issues anddiscussions in small groups on the progress of the pro-gramme using the following questions: What has hap-pened since the last seminar? How do we proceed?What is our plan for small-scale testing? The seminarsalso provided the participants with tools such as man-uals and some practical training. Two outreach visits toeach group were performed by the Salut programmemanagers during the intervention development andimplementation periods. The ‘salutogenetic’ approachwas not new to the Swedish health care system, as pre-ventive measures such as counselling on healthy lifehabits previously had been part of the service in mostsectors investigated. The majority of the participantshad a short education in ‘Motivational interviewing’[32]. However, further development of the professional’sknowledge and skills were facilitated by the combinationof lectures, group discussions, and small-scale testing ofinterventions. The resulting intervention package, whichwas summarized in work manuals and included struc-tured protocols and questionnaires, is presented inTable 1. The timeline for intervention development,implementation, and follow up on sustainability of mod-ules targeting parents and their children from foetal lifeto 1½ years of age is presented in Figure 1.
ParticipantsAll of the professionals (n = 23) involved in the pilotareas of the Salut Programme gave their consent to par-ticipate in the study after an invitation via telephone bythe first author. Hence, the study included the whole
eligible population. Participants’ characteristics are pre-sented in Table 2.
Data collection proceduresSemi-structured face-to-face interviews [23] were con-ducted at each working site from May to September2009 - approximately two years after that the interven-tion package was established and the implementationphase had ended. Two participants requested to beinterviewed simultaneously; all others were interviewedindividually. The interviews lasted between 25 and55 minutes (mean 33 minutes). Participants were askedto describe and reflect on the following experiences: i)participating in the development process of the pro-gramme; ii) the current situation in their work place inrelation to programme activities; iii) facilitators and bar-riers for compliance to the programme; iv) general viewson important requirements for continuous developmentand programme sustainability; and v) other thoughts orreflections in relation to these themes that they wantedto include. All interviews were digitally recorded.
Data analysisVerbatim-transcribed data underwent qualitative contentanalysis through a systematic classification process, andcoding into categories provided information on thelatent and manifest content [33,34]. First, the interviewswere read several times to get a holistic sense of thecontent. By this, the individual participants’ perceivedsustainability of the programme also became known.Second, data was coded to capture key thoughts andconcepts related to facilitators, barriers, and require-ments for sustainability. Third, codes with shared con-ceptual content were sorted into broad content areasand subsequently abstracted into categories. Fourth, thecontent of all categories were validated against the ver-batim-transcribed data. Finally, a model inspired by Groland Wensing was used to sort categories into a theoreti-cal scheme [16]. This multi-level model proposes factorsto be identified at the levels of the innovation, the indi-vidual professional, the patient, the social context, theorganizational context, and the economic and politicalcontext. The software Open Code 3.4 was used as a toolfor coding and categorizing all data [35]. In the resultsection, we use the following concepts to describe pro-portions of participants contributing to a specific cate-gory: Few refer to 1-4, some to 5-9, half to 10-14, mostto 15-19, and all to 20-23 participants. Quotations areprovided to illustrate how the interpretations aregrounded in data.
TrustworthinessThe first author conducted the interviews and com-pleted the primary analysis and developed codes and
Edvardsson et al. BMC Health Services Research 2011, 11:61http://www.biomedcentral.com/1472-6963/11/61
Page 3 of 12
preliminary categories, which then were reviewedagainst the original interview transcripts by two co-authors independently. To strengthen the credibility anddependability of the analysis, several interviews werealso independently read by the other researchers [33].The authors were largely in agreement about the con-ceptualization. Nevertheless, during the course of analy-sis, uncertainties in coding and interpretation wereregularly and thoroughly discussed by all authors toreach consistent findings. The first author, who is aregistered nurse with work experience in child healthcare was familiar with the study context but did notoccupy dual roles. The co-authors’ various backgrounds -paediatrics, epidemiology, public health, work andorganizational psychology, engineering and qualitymanagement, physiotherapy, and obstetrics and gynae-cology - provided complementing perspectives that
enriched the analysis process and interpretation of theresults.
Ethics approvalAll participation was based on informed consent. Ethicsapproval was obtained from the Regional Ethical ReviewBoard in Umeå, Sweden (08-168Ö).
ResultsPerceived programme sustainabilityThe programme was described as sustainable at most siteswith the exception of child health care where few partici-pants reported complete or high sustainability of the pro-gramme. The following two quotations are examples ofhow participants described high versus low level of pro-gramme sustainability.
Table 1 The intervention package within the Salut Programme targeting parents and their children from foetal life to1½ years of age
Intervention Antenatalcare
Childhealth care
Dentalservice
Open pre-school
Motivational interviewing [32] * * *
Collaboration between involved sectors * * ** **
Parent meetings * * ** **
Health counselling focusing on life habits, mental health, domestic violence1, parent-childattachment, psychosocial health and parent relationships
“Mothers visit” at child age 8 months including screening for domestic violence **
“Fathers visit” at child age 10 months with focus on fathers experiences of change in lifesituation
**
Questionnaires for health surveillance ** ** **
Free dental health care visit for the pregnant woman and her partner **
Activities to enhance early parent-child attachment, children’s physical activity and linguisticdevelopment
* *
Activities supporting parents to establish contacts with each other *
Activities to promote healthy snacks/food and drinks *
* Strengthening or restructuring of existing interventions.
** Newly developed interventions within the Salut Programme.1 Pregnant women and women recently given birth.
0 - 1½ y
Foetus
2005 2006 2007 2008 2009 Intervention development Implementation Follow up
Figure 1 Timeline for intervention development, implementation, and follow up on sustainability of modules targeting parents andtheir children from foetal life to 1½ years of age.
Edvardsson et al. BMC Health Services Research 2011, 11:61http://www.biomedcentral.com/1472-6963/11/61
Page 4 of 12
This way of working is so well established so I knowwhat to do.... I don’t have to read the manuals fre-quently. (Dental hygienist)It [the programme] does not work; for me it’s notworking at all right now. I feel that I’m back in myold routines because that’s the easiest and fastestway. (Child health nurse)
Several factors of importance for programme sustain-ability were identified during analysis. Table 3 gives anoverview of perceived facilitators, barriers, and require-ments nested in the theoretical scheme inspired by Grolet al. [16] with one level added, the development pro-cess. Main findings at each of the included levels aresummarized below.
Perceived facilitators, barriers, and requirements forprogramme sustainabilityThe innovation development processDuring the analysis, several facilitators related to theprocess when the interventions were developed andtested discerned. Most participants experienced learningseminars followed by small-scale testing to be an effi-cient way to translate sweeping visions and challenginggoals to small and feasible interventions. This facilitatedprogramme sustainability and an overall understandingof the programme.
At first, we had enormously high goals set that wereunrealistic. They have been adjusted into smallergoals by us. I think, that is why we are here today.(Dental hygienist)
However, some participants experienced the involve-ment in the development process as demanding and highlytime consuming, especially since they also felt that theydid not move forward. This led to lowered motivation.
We were so tired of all those questions, about currentstatus and how to proceed. At the same time we feltthat we did not move forward, we were stuck atsquare one. (Open pre-school teacher)
The County Council change process consultants’ sup-port was seen as highly valuable in the developmentprocess as it facilitated structured and goal-orientedwork and feedback on performance. Some participantsdescribed how their motivation increased as a result ofbeing given power to influence the development processand programme content. A few stated that the pro-gramme was their ‘own’ product, something that theyclaimed had facilitated sustainability.
We have built this on our own. It had empty spaces,lacked a basic programme, had nothing like this. It isours, definitely ours. (Open pre-school teacher)
The importance of being given time to practice newways of working and thus speed up the learning curveduring the start-up period was experienced as facilitat-ing programme sustainability by half of the participants.
If you can learn to do a good job, then I think thatwill lead to success.... if you for a while have time todevelop a good routine, then I think it will be sus-tainable. (Child health nurse)It does not take much more time if you have time topractice and introduce it as a part of your workingmethods. (Midwife)
The innovation contentAll participants described the programme’s relevance forpromoting the health of expectant parents, children, andtheir parents as an important facilitator, although a fewexpressed a decrease of motivation and interest in theprogramme since components of the intervention wereperceived as being similar to approaches that werealready present at the workplace. The content of theintervention was seen as being up to date, enhancingthe ability of viewing the family as a unit, and in linewith values, working methods, and goals of the partici-pants. This relevance was described as facilitating theintegration of programme activities in daily work.
It fits my way of thinking. In that way it has beeneasy. (Child health nurse)
Most of the participants viewed the manuals, includ-ing protocols and questionnaires, as facilitating discus-sions on sensitive topics and as a key to a standardizedway of working. They were also seen as an importantrequirement for programme sustainability, for example,by serving as support during periods of staff turnover.
Well-documented work manuals are important; it isessential that new employees, regardless of the placeand profession, easily can get information on how wework. (Dental hygienist)
Table 2 Characteristics of the participants in the study(n = 23)
Sexfemale,n (%)
Agemean,years(range)
Workexperiencemean, years
(range)
Midwives 5 (100) 53 (41-64) 24 (16-32)
Child health nurses 7 (100) 57 (52-63) 26 (13-38)
Dental hygienists/dentalnurses
7 (100) 39 (26-47) 14 (05-29)
Pre-school teachers 4 (100) 54 (48-58) 31 (26-35)
Edvardsson et al. BMC Health Services Research 2011, 11:61http://www.biomedcentral.com/1472-6963/11/61
Page 5 of 12
Table 3 Factors influencing the Salut Programme sustainability, nested in a theoretical scheme inspired by Grol andWensing [16]*
FACTORS INFLUENCING SUSTAINABILITY
LEVEL REQUIREMENTS FACILITATORS BARRIERS
Innovation
Developmentprocess
Involvement in developmentand small scale testing 1-4
Support from processconsultants 1-4
Having time to developstrategies 1-4
Time consuming andineffective 1-4
Content Carefully designed workmanuals 3
Perceived as important 1-4
Easily integrated 1-4
Manuals essential tools 1-4
Clear programme branding 1-4
Time consuming 1-4
Not suiting specific needs ofimmigrants 1,2,4
Difficulty with social andpsychological problems 1,2
Found similar to approachesalready present at the workplace 1,2,4
Individual
Professionals Own commitment andinterest 1-4
Own values coherent withprogramme’s purpose andgoals 1-4
Lack of motivation 2,3,4
Programme goals foundunrealistic 2
Parents(Patients)
Positive attitudes tointerventions 3,4
New topics and questionnairesintrusive and extensive 1-3
Content of parent meetingsunpopular 1,3
Context
Social Regular meetings 1-4
Permanent programmeorganization 1-3
Information to new employees 1,3
Managerial responsibilityand commitment1-4
Regular meetings 1-4
Active managerial support 1-4
Lack of managerialinvolvement or support 1-4
Lack of involvement orsupport from physicians orother colleagues 1-3
Further establishment andspread of the programme 1-4
Geographical proximity forcollaborators 1-4
Lack of time and resources 1-4
Lack of communication andagreement betweenprogramme management andlocal managers 2,3
Economicaland political
Incentives in line withprogramme intentions 3
Conflicting incentives forperformance 3
Threat of cutbacks 1-3
1 Represent the views of midwives, 2 child health nurses, 3 dental hygienists/dental nurses, 4 open pre-school teachers.
* With an added level; development process.
Edvardsson et al. BMC Health Services Research 2011, 11:61http://www.biomedcentral.com/1472-6963/11/61
Page 6 of 12
One concern shared by most participants was thatusing the established intervention package was timeconsuming. The comprehensive interventions in childhealth care (Table 1) were experienced as a major bar-rier for sustainability, as these required extra time froman already resource-constrained sector. Some partici-pants also emphasised that the programme was not suf-ficiently tailored to meet the needs of immigrants.A few mentioned psychosocial aspects as difficult orchallenging to deal with, such as defining good psycho-social health, raising questions about it, or handlingexisting problems.
There are a lot of things that comes up to the sur-face. The hard thing is to know how to deal with itin a good way. (Midwife)
Some participants mentioned that parents often recog-nized the Salut Programme brand in different settingsafter the initial introduction in antenatal care; this expo-sure helped them recognize what the programme repre-sented. One nurse described how she experienced Salutas self-selling, since parents were asking to also involvetheir residential area in the programme. The brandname was also experienced as a facilitator for carryingout the interventions, for example, when professionalsreferred to the programme when raising uncomfortablequestions. It also meant that professionals could identifythemselves as being part of a team and a larger effort.
You just have to mention Salut when you call, theneverybody knows why you are calling. Because every-one has heard of it. (Dental hygienist)
The individual professionalsHalf of the participants expressed that their personalvalues corresponded to the programme’s purpose andgoals and experienced this as a strongly supporting fac-tor for integrating and continuously carrying out theSalut activities, while a few experienced these goals asunrealistic. Some participants mentioned that beingcommitted and interested in the programme wereimportant requirements for programme sustainability.However, a few participants noted barriers related tolack of motivation that, for example, was a result of notbeing able to participate at meetings and thus ‘losingthe thread’ of the discussion, or just being tired of therecurring introductions of new working methods.
I cannot say that it has been difficult... it has notbeen like that, but... I mean everything that is new. Ifyou’ve been working as long as I have, you sometimesfeel that, oh no, please, no more.... Do you under-stand? You know, something more to be put on yourshoulders. (Child health nurse)
Another barrier was experiencing competing healthmessages in other contexts, resulting in perceptions ofinterventions as redundant.The Parents (Patients)Some participants stated that parents that were positivetowards and embraced the interventions facilitated pro-gramme sustainability, while some experienced problemswith parents that perceived the new topics of question-naires and discussions as extensive and intrusive. A fewalso stated that the new topics developed within theSalut programme for parents’ meetings were not popularamong parents. This sometimes led to cancellation ofmeetings.
The clients experiences that there are too many ques-tionnaires. Many questions and forms, they obviouslyget tired of it, which is understandable. (Dentalhygienist)
The social contextRegular meetings with involved professionals from dif-ferent sectors within the Salut programme were by mostseen as strongly valuable and stimulating. Continuouslearning was facilitated by sharing knowledge, advice,and ideas, and by giving and getting feedback. Themeetings also facilitated insight in the different profes-sions’ activities and ideas on how synergies could be cre-ated by collaboration. Half of the participants stated thatregular meetings were a crucial component for the pro-gramme’s survival; a few specifically mentioned the needof a permanent programme organization to supportcontinuing networking activities.
When the programme is disseminated, I believe thatcoordinators are needed in all areas.... you reallyhave to have some unifying persons, otherwise it willdisappear. (Dental hygienist)It is always like, it is always a lot of enthusiasm inthe beginning of a project, and then, you will fallback into old routines. I think it’s necessary to stopand think, and come together in meetings and thingslike that. (Midwife)I thought it was fantastic to be there, and to benefitfrom other’s knowledge, to learn new things I can usein my work. And, of course, I share my knowledge aswell, and in that way I am part of the decision pro-cess. (Pre-school teacher)
Lack of support and involvement from managers aswell as lack of formal mandate to drive change were byhalf of the participants experienced as existing or poten-tial barriers. Both active and passive managerial supportwas discussed. Participants who described a high level ofprogramme sustainability also experienced active leader-ship. However, some participants described managers
Edvardsson et al. BMC Health Services Research 2011, 11:61http://www.biomedcentral.com/1472-6963/11/61
Page 7 of 12
who expressed the importance of the programme, butdid not actively support its progress and the profes-sionals themselves felt full responsibility for programmecontinuation. For example, some participants had to askfor sanctions to carry out programme activities andmanagers failed to give priority to the programme andhad to be ‘reminded’ to ensure the basic conditions forthe interventions. A few experienced their managers tobe dissatisfied with the programme since they thought itwas too time consuming and did not give enough inreturn to the clinic. Managerial commitment andresponsibility were declared as important requirementsfor sustainability. A few participants also emphasizedthe need to integrate the programme with organizationalaction plans.
It is important to have support from our leaders.... Ithink it is important to remind them in some way,for example to go to their meetings and to remindthem now and then in between. I think that is impor-tant to keep the flame burning. (Midwife).The managers have a great responsibility in leading[leadership]. If they stop talking Salut, then I thinkSalut will die, actually, I think that’s the fact. (Den-tal hygienist)The managers have not been present. They have notgiven the priority to this programme as they perhapsshould have done, partly perhaps or because theyrelied on the project coordinator. They saw her asthe spider of the web and the one who should spreadthe information. So they could withdraw themselvesa bit. (Open pre-school teacher)
Another barrier, experienced by half of the partici-pants, was the difficulty finding support among collea-gues and/or involvement from physicians within thework place or support from colleagues outside the pilotareas.The organizational contextGeographical proximity (i.e., working in the same buildingor in the same neighbourhood) was by most participantsexperienced as a strong facilitator, but also as a require-ment for multisectoral collaboration, one of the pro-gramme’s cornerstones. Synergies were created byspontaneous contact or interaction when sharing premises.
If you have a query it is so easy just to walk overthere [to collaborators in other sectors] because weare so close. It’s essential that it is easy. (Dentalhygienist)
The sub-group of participants reporting low compli-ance to the programme described the organizationallevel barriers as the main reasons for not carrying out
the Salut interventions, with lack of time and resourcesfrequently mentioned as barriers. Time restraintsresulted not only in prioritizing ‘ordinary’ tasks prior totasks related to the Salut programme, but also hinderedthe participants from finding their own strategies toincorporate the programme activities into daily work.A few also expressed that the lack of communicationand agreement between the Salut programme manage-ment and local managers resulted in a gap betweenresources and the programmes’ intention.
This extra work has been forced into our regularactivities and working hours, and that is never good.You need extra time during the start up period inorder to find your own solutions.... You basicallyneed time to develop this. And this extra time wasnever given us. (Child health nurse)
Further establishment and spread of the programmewere by some seen as an important requirement for sus-tainability; one participant characteristically questionedif it was worth the effort working with the programme ifnot all areas in the county would be involved in the nearfuture.The economic and political contextBarriers at this level largely concerned dental healthcare, where professionals felt the pressure of generatingmoney from their clinics by treating adults, while in theSalut programme expectant parents were offered a freevisit. Even though most participants from dental careclaimed high compliance with the programme two yearsafter its implementation, these conflicts between differ-ent incentives were described as a threat for long-termsustainability.
We are doing this now because we think it’s fun andinteresting. However, it will be difficult to involveothers, because it is more important to have patientsthat generate money. This generates no money. (Den-tal hygienist)
Threats of cutbacks were also experienced by some asreducing motivation and leading to prioritizing othertasks before programme interventions.
This [The Salut programme] is unfortunately nothingthat is given priority right now because of the threatsof cutbacks.... These things are given the lowest prior-ity under such circumstances, that’s the way it is.(Child health nurse)
DiscussionTo our knowledge, this is the first study that exploresfactors of importance for sustainability of a multisectoral
Edvardsson et al. BMC Health Services Research 2011, 11:61http://www.biomedcentral.com/1472-6963/11/61
Page 8 of 12
child health promotion programme in a Swedish con-text. The programme was described as sustainable atmost sites, except in child health care. The perceptionof facilitators, barriers, and requirements were largelyshared across sectors. Facilitators included being activelyinvolved in intervention development and small-scaletesting, personal values corresponding to programmeintentions, regular meetings, working close with colla-borators, using manuals, and a clear programme brand-ing. Existing or potential barriers included insufficientmanagerial involvement and support and perceived con-straints regarding time and resources. In dental healthcare, barriers also included conflicting incentives forperformance. Many facilitators and barriers identified byparticipants also reflected their perceptions of more gen-eral and forthcoming requirements for programme sus-tainability. From our point of view, this strengthens theimportance of these factors.The theoretical framework proposed by Grol and
Wensing [16] was found to be feasible in structuringresults of this study, findings that support its usefulnessas a multilevel approach to examine factors of impor-tance for sustainability of innovations. This frameworkhas been used in previous studies to identify facilitatorsand barriers for change [36,37]. However, our resultscontribute to extend the framework by also includingthe level of the development process, as several facilitat-ing factors were found at this level. Other theoreticalframeworks (for example, as proposed by Cabana et al.)might also have been applicable [38].Professionals’ participation early in the process of pro-
gramme development and the use of small-scale testingwere described as strongly contributing to programmesustainability. During that process, interventions becamecontext adapted and a sense of ownership of the pro-gramme was fostered on behalf of the professionals.These results are consistent with previous research find-ings regarding positive aspects of involving front-lineprofessionals in intervention development [19,39-41].The risk of low awareness and limited practical use ofguidelines that mainly were developed at manageriallevels has previously been recognized [42].The difficulties of sustaining long-term compliance
rates are well known [6,20]. Therefore, the relativelyhigh level of perceived programme sustainability amongprofessionals in this study is an interesting finding, espe-cially since well-recognized barriers in terms of insuffi-cient support from managers and peers as well asunderstaffing and time constraints were reported fromall sectors [43]. These factors mainly affected profes-sionals in child health care, and lack of sustainability inthis sector might be attributable to a more comprehen-sive intervention package and a more pressed worksituation. The relatively high age of the involved child
health nurses could be a contributing factor, as olderand experienced professionals tend to use guidelines toa lesser extent compared to their younger and lessexperienced peers [43].Most participants viewed the use of manuals, includ-
ing protocols and questionnaires, as highly valuable inachieving sustainability by facilitating a standardized wayof working and by serving as supporting tools whenraising sensitive questions. The use of growth charts haspreviously shown to facilitate raising issues about over-weight in child health care [44], and structured proto-cols for screening has shown to raise awareness andimprove documentation of child abuse among emer-gency department staff [45]. However, previous qualita-tive research regarding the role of manuals as tools insimilar health promotion initiatives is scarce and furtherstudies are needed.The perceived attributes of the innovation, including
relative advantage, compatibility, complexity, trialability,and observability can, according to Rogers, explainbetween 49% to 87% of the variance in the rate of adop-tion [19]. Furthermore, interventions that can easily betried out in practice and that do not need additionalresources are more likely to be implemented [43]. Pro-fessionals’ training has also been found to be a crucialfactor in achieving sustainability of health educationprogrammes in schools [46]. These factors were alsofacilitated because of the chosen strategy to involvefront-line professionals in programme development.However, there are conflicting messages concerning
whether guidelines developed by involved professionalsthemselves are used more often or not [43]. There isalso criticism of the ‘participation model’ concerning therisk of not introducing the best care possible and therisk of not paying attention to structural factors that areimportant for successful implementation [20]. Some fac-tors were found to serve as both facilitators and barriersfor sustainability. One example is the experience ofbeing motivated by involvement, but at the same timefacing lack of managerial support when given authorityto participate in programme development. This phe-nomenon has previously been examined [47,48]. In thisstudy, the advantages of the participation model werechallenged by the perceived difficulties at the organisa-tional level. Results indicate that there might be risksfor less programme sustainability if managerial levels arenot involved and if an organizational structure for conti-nuing support and development is not sustained [49,50].Furthermore, conflicting incentives for performance, asdescribed by professionals in dental health care, mightalso pose a threat to long-term programme sustainabil-ity; clearly, these conflicts should be taken into account.Hence, this study highlights the importance of planningfor sustainability at an early stage in programme
Edvardsson et al. BMC Health Services Research 2011, 11:61http://www.biomedcentral.com/1472-6963/11/61
Page 9 of 12
development [51] and of analysing both target contextsand target groups before intervention and implementa-tion designs are set [52-54].Multidisciplinary collaboration is often aimed for in
health services, but it is rarely achieved with ease. Ourresults indicate that teamwork can be enhanced andsynergies created by regular meetings and by sharingpremises or having geographical proximity. This mightbe important to consider for those who have mandateto decide on the organization of services for expectantparents and young children that depend on multisec-toral collaboration. These results also appear consistentwith previous results regarding facilitators and barriersto such collaboration [55]. Stability in the work forcefrom programme initiation until the time when thestudy was undertaken likely contributed to programmesustainability. Otherwise, high rates of professionals’turnover can undermine existing collaboration as keypersons leave their positions [56,57].The role of the programme’s brand name in facilitat-
ing for professionals to raise uncomfortable questionswith clients was a somewhat unexpected finding. Thus,not only is a brand name important in relation to theadoption of health behaviour of individuals [58]. Theright branding might also serve as a facilitator for clari-fying the programme’s mission and goal, encouragingbehavioural change among professionals working in thefield of health promotion. Interestingly, this seems to bean often overlooked factor in previous discussions offacilitating factors for behavioural change among thisdiversity of professionals, even though the importance ofcommunicating visions and goals has been recognised.
Methodological discussionA qualitative approach with inductive coding and cate-gorizing [34,53] was considered appropriate since stu-dies of barriers and facilitators in similar contexts aswell as implementation studies involving other profes-sionals than physicians are sparse [48]. Rich data wereobtained as all professionals in the pilot areas con-sented to take part in the study [59,60]. The impor-tance of having an open-ended approach was confirmedsince an existing framework used for organizing find-ings was expanded. In addition, the similarity of issuesraised by participants regardless of profession indicatesthat our findings might also be transferable to otherprofessions and settings. As the study covered thewhole eligible population, we decided to specify somequantities in the results section. However, the quantifi-cation of data should be interpreted with caution, andour results cannot be considered as exhausting thearea of barriers and facilitators due to their sensitivityto the intervention, target group, and context. A limita-tion of this study is that it reflects the views of the
programme’s front-line professionals. Perspectives ofpeople at the managerial levels and of the receivers ofinterventions (i.e., expectant parents and parents) wouldadd value and provide a more comprehensive picture ofimportant factors of sustainability. A more objectiveassessment of sustainability is also warranted. Further-more, the study reflects the perceptions of female parti-cipants of similar age. Nevertheless, the proportion ofwomen in this study mirrors the general female predo-minance in these sectors in Sweden. A re-organizationinto family centres during the start-up phase of theSalut Programme might have influenced our results asit led to closer proximity and opportunities for colla-boration between maternal health care, child healthcare, open pre-school, and social services. Due to this,it might be possible that the importance of having col-laborators nearby were raised to a greater extent.Finally, because of the recent launch of the programmeinterventions, their effectiveness has not yet been evalu-ated or reported, something that otherwise would havestrengthened this study.
ConclusionsThese results contribute to the knowledge of processesinvolved in achieving sustainability in health promotioninitiatives. Facilitating factors include involving front-line professionals in intervention development and usingsmall-scale testing; however, the success of a pro-gramme clearly requires paying attention to the role ofmanagerial support and an overall supportive system. Insummary, these results emphasise the importance forboth practitioners and researchers to pay attention toparallel processes at different levels in multidisciplinaryimprovement efforts intended to ensure sustainablepractice change.
AcknowledgementsWe are grateful to the participants for sharing their time and experiencesand to J C Kempe Memorial Fund for financial support. The study wasundertaken within the Centre for Global Health research at the MedicalFaculty of Umeå University and in cooperation with the Vinnvård researchprogramme - From evidence to practice.
Author details1Department of Public Health and Clinical Medicine, Epidemiology andGlobal Health, Umeå University, SE 901 87 Umeå, Sweden. 2Division ofQuality Management, Luleå University of Technology, SE 971 87 Luleå,Sweden. 3Department of Clinical Science, Obstetrics, Umeå University, SE 90187 Umeå, Sweden. 4Medical Management Centre, Department of Learning,Informatics, Management and Ethics, Karolinska Institutet, SE 171 77Stockholm, Sweden.
Authors’ contributionsKE, MN, RG, and AI designed the study. KE performed the interviews,conducted the initial analysis, and wrote the manuscript. All authorsreviewed, edited, and approved the final manuscript.
Competing interestsThe authors declare that they have no competing interests.
Edvardsson et al. BMC Health Services Research 2011, 11:61http://www.biomedcentral.com/1472-6963/11/61
Page 10 of 12
Received: 5 August 2010 Accepted: 22 March 2011Published: 22 March 2011
References1. Forsdahl A: Are poor living conditions in childhood and adolescence an
important risk factor for arteriosclerotic heart disease? Br J Prev Soc Med1977, 31:91-95.
2. Lau C, Rogers JM: Embryonic and fetal programming of physiologicaldisorders in adulthood. Birth Defects Res C Embryo Today 2004, 72:300-312.
3. Kuh D, Ben-Shlomo Y: A life course approach to chronic diseaseepidemiology. Oxford: Oxford University Press; 2004.
4. Gluckman PD, Hanson MA: Living with the past: evolution, development,and patterns of disease. Science 2004, 305:1733-1736.
5. Ben-Shlomo Y, Kuh D: A life course approach to chronic diseaseepidemiology: conceptual models, empirical challenges andinterdisciplinary perspectives. Int J Epidemiol 2002, 31:285-293.
6. Bauer MS: A review of quantitative studies of adherence to mentalhealth clinical practice guidelines. Harv Rev Psychiatry 2002, 10:138-153.
7. Mangione-Smith R, DeCristofaro AH, Setodji CM, Keesey J, Klein DJ,Adams JL, Schuster MA, McGlynn EA: The quality of ambulatory caredelivered to children in the United States. N Engl J Med 2007,357:1515-1523.
8. Bhutta ZA, Darmstadt GL, Hasan BS, Haws RA: Community-basedinterventions for improving perinatal and neonatal health outcomes indeveloping countries: a review of the evidence. Pediatrics 2005,115:519-617.
9. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS: How many childdeaths can we prevent this year? Lancet 2003, 362:65-71.
10. McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA:The quality of health care delivered to adults in the United States. NEngl J Med 2003, 348:2635-2645.
11. Asch SM, Kerr EA, Keesey J, Adams JL, Setodji CM, Malik S, McGlynn EA:Who is at greatest risk for receiving poor-quality health care? N Engl JMed 2006, 354:1147-1156.
12. Lagerberg D, Magnusson M, Sundelin C: Barnhälsovård i förändring.Resultatet av ett interventionsförsök. Stockholm: Gothia; 2008.
13. Lobo CM, Frijling BD, Hulscher ME, Braspenning JC, Grol RP, Prins A, van derWouden JC: Organizing cardiovascular preventive care in generalpractice: determinants of a successful intervention. Prev Med 2002,35:430-436.
14. Cochrane LJ, Olson CA, Murray S, Dupuis M, Tooman T, Hayes S: Gapsbetween knowing and doing: understanding and assessing the barriersto optimal health care. J Contin Educ Health Prof 2007, 27:94-102.
15. Ferlie EB, Shortell SM: Improving the quality of health care in the UnitedKingdom and the United States: a framework for change. Milbank Q2001, 79:281-315.
16. Grol R, Wensing M: What drives change? Barriers to and incentives forachieving evidence-based practice. Med J Aust 2004, 180:57-60.
17. A guide to implementation research. Chapter one. [http://www.urban.org/pubs/implementationresearch/chapter1.html].
18. Grol RP, Bosch MC, Hulscher ME, Eccles MP, Wensing M: Planning andstudying improvement in patient care: the use of theoreticalperspectives. Milbank Q 2007, 85:93-138.
19. Rogers E: Diffusions of innovations. New York, NY: Free Press;, 5 2003.20. Grol R, Wensing M, Eccles M: Improving patient care. The implementation
of change in clinical practice. Oxford: Elsevier; 2005.21. Wensing M, Bosch M, Grol R: Developing and selecting interventions for
translating knowledge to action. CMAJ 2010, 182:E85-88.22. Greenhalgh T, Donaldson L: Diffusion of innovations in health service
organisations: a systematic literature review. London: BMJ; 2005.23. Pope C, van Royen P, Baker R: Qualitative methods in research on
healthcare quality. Qual Saf Health Care 2002, 11:148-152.24. Antonovsky A: Unraveling The Mystery of Health. How People Manage
Stress and Stay Well. San Francisco: Jossey-Bass Publishers; 1987.25. Dentistry in Sweden. [http://www.whocollab.od.mah.se/euro/sweden/data/
dentistry_03.pdf].26. Swedish Association of Obstetrics and Gynecology: Maternal health care,
sexual and reproductive health. Report no. 59. Stockholm; 2008.27. Hagelin E, Magnusson M, Sundelin C: Barnhälsovård. Stockholm: Liber AB; 2007.28. Responsibility, costs and dental health. [http://www.regeringen.se/sb/d/
11943/a/143018].
29. Skolverket: Child Care in Sweden. Kalmar: Leanders Tryckeri AB; 2000.30. The Breakthrough Series: IHI’s Collaborative Model for Achieving
31. Deming WE: The new economics: for industry, government, education.Cambridge, Mass.: MIT Press;, 2 2000.
32. Miller WR, Rollnick S: Motivational interviewing: preparing people forchange. New York: Guilford Press;, 2 2002.
33. Graneheim UH, Lundman B: Qualitative content analysis in nursingresearch: concepts, procedures and measures to achievetrustworthiness. Nurse Educ Today 2004, 24:105-112.
34. Hsieh HF, Shannon SE: Three approaches to qualitative content analysis.Qual Health Res 2005, 15:1277-1288.
35. Open Code 3.4. [http://www.phmed.umu.se/enheter/epidemiologi/forskning/open-code/].
36. Koh SS, Manias E, Hutchinson AM, Donath S, Johnston L: Nurses’perceived barriers to the implementation of a Fall Prevention ClinicalPractice Guideline in Singapore hospitals. BMC Health Serv Res 2008,8:105.
37. Peters MAJ, Harmsen M, Laurant MGH, Wensing M: Ruimte voorverandering? Knelpunten en mogelijkheden voor verandering in depatientenzorg [Room for improvement? Barriers to and facilitators forimprovement of patient care]. Nijmegen: Centre for Quality of Care Research(WOK), Radboud University Nijmegen Medical Centre 2002.
38. Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR:Why don’t physicians follow clinical practice guidelines? A frameworkfor improvement. JAMA 1999, 282:1458-1465.
39. Ritchie D, Parry O, Gnich W, Platt S: Issues of participation, ownership andempowerment in a community development programme: tacklingsmoking in a low-income area in Scotland. Health Promot Int 2004,19:51-59.
40. Harrison MB, Legare F, Graham ID, Fervers B: Adapting clinical practiceguidelines to local context and assessing barriers to their use. CMAJ2010, 182:78-84.
41. Sachs M: [Successful strategies and methods of nursing standardsimplementation]. Pflege 2006, 19:33-44.
42. Appleton JV, Cowley S: The guideline contradiction: health visitors’ use offormal guidelines for identifying and assessing families in need. Int JNurs Stud 2004, 41:785-797.
43. Francke AL, Smit MC, de Veer AJ, Mistiaen P: Factors influencing theimplementation of clinical guidelines for health care professionals: asystematic meta-review. BMC Med Inform Decis Mak 2008, 8:38.
44. Edvardsson K, Edvardsson D, Hornsten A: Raising issues about children’soverweight–maternal and child health nurses’ experiences. J Adv Nurs2009, 65:2542-2551.
45. Louwers EC, Affourtit MJ, Moll HA, Koning HJ, Korfage IJ: Screening forchild abuse at emergency departments: a systematic review. Arch DisChild 2010, 95:214-218.
46. Hoelscher DM, Feldman HA, Johnson CC, Lytle LA, Osganian SK, Parcel GS,Kelder SH, Stone EJ, Nader PR: School-based health education programscan be maintained over time: results from the CATCH Institutionalizationstudy. Prev Med 2004, 38:594-606.
47. Kennedy T, Regehr G, Rosenfield J, Roberts SW, Lingard L: Exploring thegap between knowledge and behavior: a qualitative study of clinicianaction following an educational intervention. Acad Med 2004, 79:386-393.
48. Gravel K, Legare F, Graham ID: Barriers and facilitators to implementingshared decision-making in clinical practice: a systematic review of healthprofessionals’ perceptions. Implement Sci 2006, 1:16.
49. Nystrom M: Characteristics of health care organizations associated withlearning and development: lessons from a pilot study. Qual ManagHealth Care 2009, 18:285-294.
50. Aarons GA, Sommerfeld DH, Walrath-Greene CM: Evidence-based practiceimplementation: the impact of public versus private sector organizationtype on organizational support, provider attitudes, and adoption ofevidence-based practice. Implement Sci 2009, 4:83.
51. Sridharan S, Go S, Zinzow H, Gray A, Barrett MG: Analysis of strategic plansto assess planning for sustainability of comprehensive communityinitiatives. Eval Program Plann 2007, 30:105-113.
52. Stetler CB, Ritchie JA, Rycroft-Malone J, Schultz AA, Charns MP:Institutionalizing evidence-based practice: an organizational case studyusing a model of strategic change. Implement Sci 2009, 4:78.
Edvardsson et al. BMC Health Services Research 2011, 11:61http://www.biomedcentral.com/1472-6963/11/61
53. Campbell NC, Murray E, Darbyshire J, Emery J, Farmer A, Griffiths F,Guthrie B, Lester H, Wilson P, Kinmonth AL: Designing and evaluatingcomplex interventions to improve health care. BMJ 2007, 334:455-459.
54. Solberg LI: Guideline implementation: what the literature doesn’t tell us.Jt Comm J Qual Improv 2000, 26:525-537.
55. Xyrichis A, Lowton K: What fosters or prevents interprofessionalteamworking in primary and community care? A literature review. Int JNurs Stud 2008, 45:140-153.
56. Ritchie D, Gnich W, Parry O, Platt S: ’People pull the rug from under yourfeet’: barriers to successful public health programmes. BMC Public Health2008, 8:173.
57. Woltmann EM, Whitley R, McHugo GJ, Brunette M, Torrey WC, Coots L,Lynde D, Drake RE: The role of staff turnover in the implementation ofevidence-based practices in mental health care. Psychiatr Serv 2008,59:732-737.
59. Daly J, Willis K, Small R, Green J, Welch N, Kealy M, Hughes E: A hierarchyof evidence for assessing qualitative health research. J Clin Epidemiol2007, 60:43-49.
60. Morse JM, Barrett M, Mayan M, Olson K, Spiers J: Verification strategies forestablishing reliability and validity in qualitative research. IJQM 2002,1:1-19.
61. Hewitt C, Gilbody S, Brealey S, Paulden M, Palmer S, Mann R, Green J,Morrell J, Barkham M, Light K, Richards D: Methods to identify postnataldepression in primary care: an integrated evidence synthesis and valueof information analysis. Health Technol Assess 2009, 13:1-145, 147-230.
Pre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/11/61/prepub
doi:10.1186/1472-6963-11-61Cite this article as: Edvardsson et al.: Sustainable practice change:Professionals’ experiences with a multisectoral child health promotionprogramme in Sweden. BMC Health Services Research 2011 11:61.
Submit your next manuscript to BioMed Centraland take full advantage of:
• Convenient online submission
• Thorough peer review
• No space constraints or color figure charges
• Immediate publication on acceptance
• Inclusion in PubMed, CAS, Scopus and Google Scholar
• Research which is freely available for redistribution
Submit your manuscript at www.biomedcentral.com/submit
Edvardsson et al. BMC Health Services Research 2011, 11:61http://www.biomedcentral.com/1472-6963/11/61
