Sustainable practice change: Professionals' experiences with a multisectoral child health promotion programme in Sweden
© Edvardsson et al; licensee BioMed Central Ltd. 2011
Received: 5 August 2010
Accepted: 22 March 2011
Published: 22 March 2011
New methods for prevention and health promotion and are constantly evolving; however, positive outcomes will only emerge if these methods are fully adopted and sustainable in practice. To date, limited attention 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 the development and implementation of a multisectoral child health promotion programme in Sweden (the Salut programme). Initiated in 2005, the programme uses a 'Salutogenesis' approach to support health-promoting activities in health care, social services, and schools.
All professionals involved in the Salut Programme's pilot areas were interviewed between May and September 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, and requirements for programme sustainability.
The programme was described as sustainable at most sites, except in child health care. The perception of facilitators, barriers, and requirements were largely shared across sectors. Facilitators included being actively involved in intervention development and small-scale testing, personal values corresponding to programme intentions, 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 constraints regarding 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 and forthcoming requirements for programme sustainability.
These results contribute to the knowledge of processes involved in achieving sustainability in health promotion initiatives. Facilitating factors include involving front-line professionals in intervention development and using small scale testing; however, the success of a programme requires paying attention to the role of managerial support and an overall supportive system. In summary, these results emphasise the importance for both practitioners and researchers to pay attention to parallel processes at different levels in multidisciplinary improvement efforts intended to ensure sustainable practice change.
Vast evidence shows that conditions during the foetal period, infancy, and childhood can affect physical and mental health throughout life [1–4]. Although chains of risk factors for physical and mental problems can be interrupted by preventive and health promoting interventions , current research shows that the rate of adoption, implementation, and sustainability of such interventions often is low, indicating that many potential health benefits are never achieved [6–11]. For example, a recent Swedish child health care intervention project in Uppsala County aimed to broaden the psychosocial support to families; however, the intervention resulted in only a few families taking part in the originally planned interventions, and professionals were more likely to distribute books and brochures instead of changing their working routines .
Precisely why changes do or do not occur in multifaceted preventive programs can be difficult to explain . A number of factors are important - independently or in interaction with others  - and barriers that may impede change of perceptions, attitudes, and behaviours among professionals can be found at different levels of health care [15, 16]. To improve quality and outcomes of care, one needs to take into account factors specific to the levels of the individual, group or team, organization, and the larger environment .
Implementation research deals with questions such as "what is happening and why"? , and theories on implementation of change can be used to explain under what circumstances change most likely will be achieved . Sustainability is a key to programme success and can be defined as 'the degree to which an innovation continues to be used after initial efforts to secure adoption is completed' . However, it is well known that compliance rates often drop and return to pre-intervention levels when specific implementation efforts have ended [6, 20], and one question still remains unanswered: What are the crucial components that lead to sustainability of innovations in health care [21, 22]? Quantitative studies have dominated this field of research, but more qualitative studies are needed . Qualitative methods can further the understanding of why or why not sustainability can be reached, for example, by exploring reasons behind certain behaviours among professionals . To contribute to a deeper understanding of these processes, we explored facilitators, barriers, and requirements for programme sustainability as experienced by involved professionals two years after finalizing the development and implementation of a multisectoral child health promotion programme in Sweden.
The study was conducted in Västerbotten County, Sweden (260,000 residents). In 2005, Västerbotten County Council launched the Salut Programme - a multisectoral child health programme developed to support the provision of health promoting activities in health care, social services, and school settings. The programme has a 'Salutogenesis' approach, which implies focusing on factors that support human health and well-being rather than factors that cause disease . Starting with the pregnant woman and her partner, the programme continues to follow the child, partly by involving parents, up to 18 years of age through age specific modules. The programme also includes an epidemiological surveillance component. This study covers the first two modules that target parents and their children from foetal life to 1½ years of age.
Description of involved sectors
In Sweden, nearly all health care is provided through a national social insurance system, mainly financed through taxes levied by county councils and municipalities . The maternal and child health services, which are part of this system, are free and reach nearly all expectant women and children aged 0 - 6 years in the country.
Antenatal care with registered midwives responsible for activities provides women with counselling and interventions regarding sexual and reproductive health and maternal and foetal surveillance during pregnancy. Pregnant women are offered seven to nine visits from the first trimester to childbirth, additional counselling by physicians if required, and a follow-up visit 6-12 weeks post partum . Child health care staffed by registered nurses with qualification in child health provide families with support, advice, and information regarding issues such as child health and development, immunization, breast feeding, nutrition, child safety, and parenting. Visits to child health care centres are recommended at approximately 11 key ages during the child's first 18 months and subsequently at 3, 4, and 5 years of age. Examination by physicians are included in five of these visits .
In Sweden, dental care can be provided by the Public Dental Services or by private care providers. The County Councils responsibility is to ensure that dental care is available to everyone and free comprehensive dental care is provided for children up to the age of 19 . Open pre-schools offer pedagogical group activities led by preschool teachers and serve as alternatives to the regular pre-school for children with parents on parental leave or non-working. These services are free, children are not registered, and they are not obliged to attend regularly .
Salut programme development and implementation process
The intervention package within the Salut Programme targeting parents and their children from foetal life to 1½ years of age
Child health care
Motivational interviewing 
Collaboration between involved sectors
Health counselling focusing on life habits, mental health, domestic violence1, parent-child attachment, psychosocial health and parent relationships
Edinburgh Postnatal Depression Scale (EPDS) screening 
Oral health screening at 12 months of age
"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 life situation
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 linguistic development
Activities supporting parents to establish contacts with each other
Activities to promote healthy snacks/food and drinks
Characteristics of the participants in the study (n = 23)
Child health nurses
Dental hygienists/dental nurses
Data collection procedures
Semi-structured face-to-face interviews  were conducted at each working site from May to September 2009 - approximately two years after that the intervention package was established and the implementation phase had ended. Two participants requested to be interviewed simultaneously; all others were interviewed individually. The interviews lasted between 25 and 55 minutes (mean 33 minutes). Participants were asked to describe and reflect on the following experiences: i) participating in the development process of the programme; ii) the current situation in their work place in relation to programme activities; iii) facilitators and barriers for compliance to the programme; iv) general views on important requirements for continuous development and programme sustainability; and v) other thoughts or reflections in relation to these themes that they wanted to include. All interviews were digitally recorded.
Verbatim-transcribed data underwent qualitative content analysis through a systematic classification process, and coding into categories provided information on the latent and manifest content [33, 34]. First, the interviews were read several times to get a holistic sense of the content. By this, the individual participants' perceived sustainability of the programme also became known. Second, data was coded to capture key thoughts and concepts related to facilitators, barriers, and requirements for sustainability. Third, codes with shared conceptual content were sorted into broad content areas and subsequently abstracted into categories. Fourth, the content of all categories were validated against the verbatim-transcribed data. Finally, a model inspired by Grol and Wensing was used to sort categories into a theoretical scheme . This multi-level model proposes factors to be identified at the levels of the innovation, the individual professional, the patient, the social context, the organizational context, and the economic and political context. The software Open Code 3.4 was used as a tool for coding and categorizing all data . In the result section, we use the following concepts to describe proportions of participants contributing to a specific category: Few refer to 1-4, some to 5-9, half to 10-14, most to 15-19, and all to 20-23 participants. Quotations are provided to illustrate how the interpretations are grounded in data.
The first author conducted the interviews and completed the primary analysis and developed codes and preliminary categories, which then were reviewed against the original interview transcripts by two co-authors independently. To strengthen the credibility and dependability of the analysis, several interviews were also independently read by the other researchers . The authors were largely in agreement about the conceptualization. Nevertheless, during the course of analysis, uncertainties in coding and interpretation were regularly and thoroughly discussed by all authors to reach consistent findings. The first author, who is a registered nurse with work experience in child health care was familiar with the study context but did not occupy dual roles. The co-authors' various backgrounds - paediatrics, epidemiology, public health, work and organizational psychology, engineering and quality management, physiotherapy, and obstetrics and gynaecology - provided complementing perspectives that enriched the analysis process and interpretation of the results.
All participation was based on informed consent. Ethics approval was obtained from the Regional Ethical Review Board in Umeå, Sweden (08-168Ö).
Perceived programme sustainability
This way of working is so well established so I know what to do.... I don't have to read the manuals frequently. (Dental hygienist)
It [the programme] does not work; for me it's not working at all right now. I feel that I'm back in my old routines because that's the easiest and fastest way. (Child health nurse)
Factors influencing the Salut Programme sustainability, nested in a theoretical scheme inspired by Grol and Wensing *
FACTORS INFLUENCING SUSTAINABILITY
Involvement in development
and small scale testing 1-4
Support from process
Having time to develop
Time consuming and
Carefully designed work
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 of
Difficulty with social and
psychological problems 1,2
Found similar to approaches
already present at the work
Own commitment and
Own values coherent with
programme's purpose and
Lack of motivation 2,3,4
Programme goals found
Positive attitudes to
New topics and questionnaires
intrusive and extensive 1-3
Content of parent meetings
Regular meetings 1-4
Information to new employees 1,3
Regular meetings 1-4
Active managerial support 1-4
Lack of managerial
involvement or support 1-4
Lack of involvement or
support from physicians or
other colleagues 1-3
Programme integrated in
action plans 1-3
Geographical proximity for
Sufficient time 1-3
Further establishment and
spread of the programme 1-4
Geographical proximity for
Lack of time and resources 1-4
Lack of communication and
programme management and
local managers 2,3
Incentives in line with
programme intentions 3
Conflicting incentives for
Threat of cutbacks 1-3
Perceived facilitators, barriers, and requirements for programme sustainability
The innovation development process
At first, we had enormously high goals set that were unrealistic. They have been adjusted into smaller goals by us. I think, that is why we are here today. (Dental hygienist)
We were so tired of all those questions, about current status and how to proceed. At the same time we felt that we did not move forward, we were stuck at square one. (Open pre-school teacher)
We have built this on our own. It had empty spaces, lacked a basic programme, had nothing like this. It is ours, definitely ours. (Open pre-school teacher)
If you can learn to do a good job, then I think that will lead to success.... if you for a while have time to develop a good routine, then I think it will be sustainable. (Child health nurse)
It does not take much more time if you have time to practice and introduce it as a part of your working methods. (Midwife)
The innovation content
It fits my way of thinking. In that way it has been easy. (Child health nurse)
Well-documented work manuals are important; it is essential that new employees, regardless of the place and profession, easily can get information on how we work. (Dental hygienist)
There are a lot of things that comes up to the surface. The hard thing is to know how to deal with it in a good way. (Midwife)
You just have to mention Salut when you call, then everybody knows why you are calling. Because everyone has heard of it. (Dental hygienist)
The individual professionals
I cannot say that it has been difficult... it has not been like that, but... I mean everything that is new. If you've been working as long as I have, you sometimes feel that, oh no, please, no more.... Do you understand? You know, something more to be put on your shoulders. (Child health nurse)
Another barrier was experiencing competing health messages in other contexts, resulting in perceptions of interventions as redundant.
The Parents (Patients)
The clients experiences that there are too many questionnaires. Many questions and forms, they obviously get tired of it, which is understandable. (Dental hygienist)
The social context
When the programme is disseminated, I believe that coordinators are needed in all areas.... you really have to have some unifying persons, otherwise it will disappear. (Dental hygienist)
It is always like, it is always a lot of enthusiasm in the beginning of a project, and then, you will fall back into old routines. I think it's necessary to stop and think, and come together in meetings and things like that. (Midwife)
I thought it was fantastic to be there, and to benefit from other's knowledge, to learn new things I can use in my work. And, of course, I share my knowledge as well, and in that way I am part of the decision process. (Pre-school teacher)
It is important to have support from our leaders.... I think it is important to remind them in some way, for example to go to their meetings and to remind them now and then in between. I think that is important to keep the flame burning. (Midwife).
The managers have a great responsibility in leading [leadership]. If they stop talking Salut, then I think Salut will die, actually, I think that's the fact. (Dental hygienist)
The managers have not been present. They have not given the priority to this programme as they perhaps should have done, partly perhaps or because they relied on the project coordinator. They saw her as the spider of the web and the one who should spread the information. So they could withdraw themselves a bit. (Open pre-school teacher)
Another barrier, experienced by half of the participants, was the difficulty finding support among colleagues and/or involvement from physicians within the work place or support from colleagues outside the pilot areas.
The organizational context
If you have a query it is so easy just to walk over there [to collaborators in other sectors] because we are so close. It's essential that it is easy. (Dental hygienist)
This extra work has been forced into our regular activities and working hours, and that is never good. You need extra time during the start up period in order to find your own solutions.... You basically need time to develop this. And this extra time was never given us. (Child health nurse)
Further establishment and spread of the programme were by some seen as an important requirement for sustainability; one participant characteristically questioned if it was worth the effort working with the programme if not all areas in the county would be involved in the near future.
The economic and political context
We are doing this now because we think it's fun and interesting. However, it will be difficult to involve others, because it is more important to have patients that generate money. This generates no money. (Dental hygienist)
This [The Salut programme] is unfortunately nothing that is given priority right now because of the threats of cutbacks.... These things are given the lowest priority under such circumstances, that's the way it is. (Child health nurse)
To our knowledge, this is the first study that explores factors of importance for sustainability of a multisectoral child health promotion programme in a Swedish context. The programme was described as sustainable at most sites, except in child health care. The perception of facilitators, barriers, and requirements were largely shared across sectors. Facilitators included being actively involved in intervention development and small-scale testing, personal values corresponding to programme intentions, 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 constraints regarding 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 and forthcoming requirements for programme sustainability. From our point of view, this strengthens the importance of these factors.
The theoretical framework proposed by Grol and Wensing  was found to be feasible in structuring results of this study, findings that support its usefulness as a multilevel approach to examine factors of importance for sustainability of innovations. This framework has been used in previous studies to identify facilitators and barriers for change [36, 37]. However, our results contribute to extend the framework by also including the level of the development process, as several facilitating factors were found at this level. Other theoretical frameworks (for example, as proposed by Cabana et al.) might also have been applicable .
Professionals' participation early in the process of programme development and the use of small-scale testing were described as strongly contributing to programme sustainability. During that process, interventions became context adapted and a sense of ownership of the programme was fostered on behalf of the professionals. These results are consistent with previous research findings regarding positive aspects of involving front-line professionals in intervention development [19, 39–41]. The risk of low awareness and limited practical use of guidelines that mainly were developed at managerial levels has previously been recognized .
The difficulties of sustaining long-term compliance rates are well known [6, 20]. Therefore, the relatively high level of perceived programme sustainability among professionals in this study is an interesting finding, especially since well-recognized barriers in terms of insufficient support from managers and peers as well as understaffing and time constraints were reported from all sectors . These factors mainly affected professionals in child health care, and lack of sustainability in this sector might be attributable to a more comprehensive intervention package and a more pressed work situation. The relatively high age of the involved child health nurses could be a contributing factor, as older and experienced professionals tend to use guidelines to a lesser extent compared to their younger and less experienced peers .
Most participants viewed the use of manuals, including protocols and questionnaires, as highly valuable in achieving sustainability by facilitating a standardized way of working and by serving as supporting tools when raising sensitive questions. The use of growth charts has previously shown to facilitate raising issues about overweight in child health care , and structured protocols for screening has shown to raise awareness and improve documentation of child abuse among emergency department staff . However, previous qualitative research regarding the role of manuals as tools in similar health promotion initiatives is scarce and further studies are needed.
The perceived attributes of the innovation, including relative advantage, compatibility, complexity, trialability, and observability can, according to Rogers, explain between 49% to 87% of the variance in the rate of adoption . Furthermore, interventions that can easily be tried out in practice and that do not need additional resources are more likely to be implemented . Professionals' training has also been found to be a crucial factor in achieving sustainability of health education programmes in schools . These factors were also facilitated because of the chosen strategy to involve front-line professionals in programme development.
However, there are conflicting messages concerning whether guidelines developed by involved professionals themselves are used more often or not . There is also criticism of the 'participation model' concerning the risk of not introducing the best care possible and the risk of not paying attention to structural factors that are important for successful implementation . Some factors were found to serve as both facilitators and barriers for sustainability. One example is the experience of being motivated by involvement, but at the same time facing lack of managerial support when given authority to participate in programme development. This phenomenon has previously been examined [47, 48]. In this study, the advantages of the participation model were challenged by the perceived difficulties at the organisational level. Results indicate that there might be risks for less programme sustainability if managerial levels are not involved and if an organizational structure for continuing support and development is not sustained [49, 50]. Furthermore, conflicting incentives for performance, as described by professionals in dental health care, might also pose a threat to long-term programme sustainability; clearly, these conflicts should be taken into account. Hence, this study highlights the importance of planning for sustainability at an early stage in programme development  and of analysing both target contexts and target groups before intervention and implementation designs are set [52–54].
Multidisciplinary collaboration is often aimed for in health services, but it is rarely achieved with ease. Our results indicate that teamwork can be enhanced and synergies created by regular meetings and by sharing premises or having geographical proximity. This might be important to consider for those who have mandate to decide on the organization of services for expectant parents and young children that depend on multisectoral collaboration. These results also appear consistent with previous results regarding facilitators and barriers to such collaboration . Stability in the work force from programme initiation until the time when the study was undertaken likely contributed to programme sustainability. Otherwise, high rates of professionals' turnover can undermine existing collaboration as key persons leave their positions [56, 57].
The role of the programme's brand name in facilitating for professionals to raise uncomfortable questions with clients was a somewhat unexpected finding. Thus, not only is a brand name important in relation to the adoption of health behaviour of individuals . The right branding might also serve as a facilitator for clarifying the programme's mission and goal, encouraging behavioural change among professionals working in the field of health promotion. Interestingly, this seems to be an often overlooked factor in previous discussions of facilitating factors for behavioural change among this diversity of professionals, even though the importance of communicating visions and goals has been recognised.
A qualitative approach with inductive coding and categorizing [34, 53] was considered appropriate since studies of barriers and facilitators in similar contexts as well as implementation studies involving other professionals than physicians are sparse . Rich data were obtained as all professionals in the pilot areas consented to take part in the study [59, 60]. The importance of having an open-ended approach was confirmed since an existing framework used for organizing findings was expanded. In addition, the similarity of issues raised by participants regardless of profession indicates that our findings might also be transferable to other professions and settings. As the study covered the whole eligible population, we decided to specify some quantities in the results section. However, the quantification of data should be interpreted with caution, and our results cannot be considered as exhausting the area of barriers and facilitators due to their sensitivity to the intervention, target group, and context. A limitation of this study is that it reflects the views of the programme's front-line professionals. Perspectives of people at the managerial levels and of the receivers of interventions (i.e., expectant parents and parents) would add value and provide a more comprehensive picture of important factors of sustainability. A more objective assessment of sustainability is also warranted. Furthermore, the study reflects the perceptions of female participants of similar age. Nevertheless, the proportion of women in this study mirrors the general female predominance in these sectors in Sweden. A re-organization into family centres during the start-up phase of the Salut Programme might have influenced our results as it led to closer proximity and opportunities for collaboration between maternal health care, child health care, open pre-school, and social services. Due to this, it might be possible that the importance of having collaborators nearby were raised to a greater extent. Finally, because of the recent launch of the programme interventions, their effectiveness has not yet been evaluated or reported, something that otherwise would have strengthened this study.
These results contribute to the knowledge of processes involved in achieving sustainability in health promotion initiatives. Facilitating factors include involving front-line professionals in intervention development and using small-scale testing; however, the success of a programme clearly requires paying attention to the role of managerial support and an overall supportive system. In summary, these results emphasise the importance for both practitioners and researchers to pay attention to parallel processes at different levels in multidisciplinary improvement efforts intended to ensure sustainable practice change.
We are grateful to the participants for sharing their time and experiences and to J C Kempe Memorial Fund for financial support. The study was undertaken within the Centre for Global Health research at the Medical Faculty of Umeå University and in cooperation with the Vinnvård research programme - From evidence to practice.
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