Improving child health promotion practices in multiple sectors – outcomes of the Swedish Salut Programme

To improve health in the population, public health innovations must be successfully implemented within organisations, requiring behaviour change in health service providers as well as in the target population group. However, the literature to date indicates that such change is seldom easily achieved [1‐5]. Numerous theories on behaviour change have been developed over the years [6], but there are no easy to follow recipes on how to achieve uptake of new public health innovations. This is because a number of different factors, often in interaction, will affect how innovations are disseminated, implemented and sustained in practice, and the influence of each factor is highly context-dependent [7]. Furthermore, features of the innovation itself have been shown to play a crucial role in individuals’ decisions to adopt or reject it. Innovations characterised by high relative advantage, compatibility, trialability, observability, and less complexity are more likely to be adopted than other innovations [8]. Innovations in health promotion and disease prevention are often characterised by low relative advantage, as outcomes are often revealed, if at all, after a long period of time. This partly explains why such innovations generally diffuse more slowly than innovations in other fields [9].

Adapting innovations to the local context is described as essential to improve uptake, a process that also involves an assessment of factors that can facilitate or impede change [10, 11]. When planning for complex changes, Grol and Wensing emphasize the importance of considering factors at different levels, including features of the innovation; the professionals and patients; and the social, organisational, economic and political context [12]. Conceptual models, for example as developed by Greenhalgh et al., can also be used as tools to facilitate consideration of the situational complexity and the interaction of different factors [7]. Both quantitative and qualitative measures can contribute in illuminating factors that can facilitate or impede change. However, the use of qualitative methods in organisation and practice change trials has so far been relatively uncommon. This means that it is seldom known why an intervention was successful or not [13], hindering further learning, development and improvement [12, 14]. To date, there are few implementation studies of complex public health innovations that span different organizations and involve other professions than physicians [7, 15].

In 2005, the Västerbotten County Council in Sweden launched the Salut Programme with the aim to develop and strengthen health-promoting activities in health care, social services and school settings, and increase collaboration between these sectors [16, 17]. The programme starts with the pregnant woman and her partner and continues to follow the child up to the age of 18 via age-adapted interventions grouped into modules. Interventions in the programme’s first two modules (from pregnancy to 18 months of age) were developed and tested in four pilot areas from 2005 to 2007 [16]. From 2008 to 2010 they were implemented in the rest of the county in three sequences. This study investigated the early outcomes of this attempt to improve health promotion practices and collaboration between antenatal care (ANC), child health care (CHC), dental services and open pre-schools. A more detailed description of involved sectors and the Salut Programme development can be found elsewhere [5, 16, 17]. The second (coastal areas) and third (inland areas) implementation sequences, involving 13 out of 15 municipalities in Västerbotten, were monitored for the purpose of this study.

The overall aim was to examine outcomes of the Salut Programme on professionals’ self-reported health promotion practices and to investigate perceived facilitators and barriers for programme implementation. The research questions were:

This study aimed to examine outcomes of a Swedish child health promotion programme on professionals’ self-reported health promotion practices, and to investigate perceived facilitators and barriers for programme implementation. The results show that self-reported health promotion practices and collaboration were improved to some extent in all sectors at follow up. Main facilitators for programme implementation included cross-sectoral collaboration and sector-specific work manuals/questionnaires for use as support in everyday practice. Main barriers included high workload, and shortage of time and staff. A strength of this study is that it spanned multiple sectors and included both outcome measures and cross sectional data on implementation facilitators and barriers, allowing for a deeper understanding of the context in which changes occurred. It is acknowledged that the outcome data are self-reported and thus susceptible to bias, so due caution is needed in interpreting the results.

The most significant changes were reported in CHC and dental services, and the least in ANC, the sector that may have the greatest opportunity to influence the target group. The results indicated that the majority of Salut activities were already in place within ANC. Midwives normally encounter a pregnant woman seven to ten times during pregnancy. The partners also seem more inclined to be involved in healthcare during pregnancy than after the child’s birth [5, 23]. Thus, ANC might have needed more advanced interventions, especially since midwives have an excellent opportunity to involve both parents in health promotion activities. Interestingly, this was an issue raised by the midwives, as insufficient routines for involvement of fathers were reported as one of the barriers for programme implementation in ANC. A possible explanation for the relatively large change in dental services might be a novelty effect due to the introduction of new topics, or a simpler, less comprehensive intervention. The latter might explain why at the end of the implementation process (Seminar 4) fewer professionals in dental services reported support from structured work manuals as an important facilitator.

The framework used for analysing facilitators and barriers for change was valuable as it recognizes the importance of giving attention to different organisational levels [12]. During improvement efforts the focus is often on factors related to the individual professional [6] but as shown in this study, a number of factors can be involved and interact at multiple levels, many out of reach for the individual professional to influence.

Cross-sectoral collaboration emerged as one of the main facilitators for programme implementation. It is likely that the approach of gathering all sectors for seminars was successful in providing professionals with the opportunity to meet, interact and initiate or increase their collaboration, which in turn can create synergies and allow for a more integrated approach in provision of services [24, 25]. Among the main facilitators identified were also the sector specific and structured work manuals and questionnaires. These results are consistent with findings from a previous study where the development of patient education toolkits and brochures was found to be one crucial component in improving nursing care in hospital and community settings [4].

The Salut Programme interventions were originally developed and tested within each profession in pilot areas before countywide implementation [16]. Thus, contextual factors that could impede change were to some extent already adjusted and accounted for [10, 11, 26, 27]. A recent study of the implementation of a tool for lifestyle interventions in Swedish primary health care shows that a fixed implementation strategy (i.e. no tailoring of activities to meet professional needs) was not successful in terms of uptake of the intervention. Beliefs, values and behaviours linked to professional subcultures influenced the implementation, and most professional groups found the intervention more suitable for other professionals, contributing to a low level of adherence [28]. Thus, adapting approaches to different subgroups, preferably by involving end-users, is a strategy to enhance the likelihood of success [6, 8, 10, 22], which is consistent with our findings.

Another commonly mentioned facilitator across sectors was that interventions were perceived to be in line with existing work routines. This is also an indication that the interventions were well adapted to the target context. However, an alternative interpretation is that the interventions did not introduce any novel practices or activities, possibly just a more structured way of working due to detailed work manuals and questionnaires. This might be one reason for the few significant changes in antenatal care. Since health promotion has a long tradition of being central in the Swedish antenatal care programme [29], midwives were already addressing most issues included in the programme pre-implementation, leaving little room for improvement.

The main barriers for programme implementation, high workload and shortage of time, staff or resources, are among the most well recognized in the implementation literature, and our results are thus consistent with previous research [30, 31]. However, our findings suggest that improvements in health promotion practices and collaboration are possible to achieve, despite the presence of these common barriers. Even though positive outcomes were shown in this study, the characteristics of the barriers described indicate that there might have been a lack of overall organisational readiness for change, an important predictor of effective implementation, especially if changes are complex and the change process involves a great degree of interdependence [32]. It is plausible that outcomes in terms of health promotion practices and collaboration could have been further enhanced if attention had been given to readiness for change at the individual as well as the group and organisational levels. In addition, geographical distance was reported among the most important barriers in ANC, CHC and open pre-schools, a factor that should not be overlooked. Having shared premises has been shown to facilitate information transaction, communication and personal familiarity, while being located in separate buildings can constraint the team’s functioning and effectiveness [16, 31, 33]. Our results are consistent with these previous findings. As also indicated in the study, starting and maintaining new collaborative relations can be challenging, and this organisational network structure can be fragile due to a lack of shared management and due to demands both from both the teams and the organisations in which professionals are working [24]. Perceived barriers such as competing goals, demands and work tasks in ANC, CHC and dental services, or the conflicting financial incentives for performance in dental services were examples of such competing demands.

This multisectoral programme for health promotion, based on sector-specific intervention packages developed and tested by end users, and introduced via interactive multisectoral seminars, shows potential for improving health promotion practices and collaboration across sectors. Consideration of the key facilitators and barriers for programme implementation as highlighted in this study can inform future improvement efforts.