Perceived facilitators, barriers, and requirements for programme sustainability
The innovation development process
During the analysis, several facilitators related to the process when the interventions were developed and tested discerned. Most participants experienced learning seminars followed by small-scale testing to be an efficient way to translate sweeping visions and challenging goals to small and feasible interventions. This facilitated programme sustainability and an overall understanding of the programme.
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)
However, some participants experienced the involvement in the development process as demanding and highly time consuming, especially since they also felt that they did not move forward. This led to lowered motivation.
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)
The County Council change process consultants' support was seen as highly valuable in the development process as it facilitated structured and goal-oriented work and feedback on performance. Some participants described how their motivation increased as a result of being given power to influence the development process and programme content. A few stated that the programme was their 'own' product, something that they claimed had facilitated sustainability.
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)
The importance of being given time to practice new ways of working and thus speed up the learning curve during the start-up period was experienced as facilitating programme sustainability by half of the participants.
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
All participants described the programme's relevance for promoting the health of expectant parents, children, and their parents as an important facilitator, although a few expressed a decrease of motivation and interest in the programme since components of the intervention were perceived as being similar to approaches that were already present at the workplace. The content of the intervention was seen as being up to date, enhancing the ability of viewing the family as a unit, and in line with values, working methods, and goals of the participants. This relevance was described as facilitating the integration of programme activities in daily work.
It fits my way of thinking. In that way it has been easy. (Child health nurse)
Most of the participants viewed the manuals, including protocols and questionnaires, as facilitating discussions on sensitive topics and as a key to a standardized way of working. They were also seen as an important requirement for programme sustainability, for example, by serving as support during periods of staff turnover.
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)
One concern shared by most participants was that using the established intervention package was time consuming. The comprehensive interventions in child health care (Table ) were experienced as a major barrier for sustainability, as these required extra time from an already resource-constrained sector. Some participants also emphasised that the programme was not sufficiently tailored to meet the needs of immigrants. A few mentioned psychosocial aspects as difficult or challenging to deal with, such as defining good psychosocial health, raising questions about it, or handling existing problems.
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)
Some participants mentioned that parents often recognized the Salut Programme brand in different settings after the initial introduction in antenatal care; this exposure helped them recognize what the programme represented. One nurse described how she experienced Salut as self-selling, since parents were asking to also involve their residential area in the programme. The brand name was also experienced as a facilitator for carrying out the interventions, for example, when professionals referred to the programme when raising uncomfortable questions. It also meant that professionals could identify themselves as being part of a team and a larger effort.
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
Half of the participants expressed that their personal values corresponded to the programme's purpose and goals and experienced this as a strongly supporting factor for integrating and continuously carrying out the Salut activities, while a few experienced these goals as unrealistic. Some participants mentioned that being committed and interested in the programme were important requirements for programme sustainability. However, a few participants noted barriers related to lack of motivation that, for example, was a result of not being able to participate at meetings and thus 'losing the thread' of the discussion, or just being tired of the recurring introductions of new working methods.
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)
Some participants stated that parents that were positive towards and embraced the interventions facilitated programme sustainability, while some experienced problems with parents that perceived the new topics of questionnaires and discussions as extensive and intrusive. A few also stated that the new topics developed within the Salut programme for parents' meetings were not popular among parents. This sometimes led to cancellation of meetings.
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
Regular meetings with involved professionals from different sectors within the Salut programme were by most seen as strongly valuable and stimulating. Continuous learning was facilitated by sharing knowledge, advice, and ideas, and by giving and getting feedback. The meetings also facilitated insight in the different professions' activities and ideas on how synergies could be created by collaboration. Half of the participants stated that regular meetings were a crucial component for the programme's survival; a few specifically mentioned the need of a permanent programme organization to support continuing networking activities.
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)
Lack of support and involvement from managers as well as lack of formal mandate to drive change were by half of the participants experienced as existing or potential barriers. Both active and passive managerial support was discussed. Participants who described a high level of programme sustainability also experienced active leadership. However, some participants described managers who expressed the importance of the programme, but did not actively support its progress and the professionals themselves felt full responsibility for programme continuation. For example, some participants had to ask for sanctions to carry out programme activities and managers failed to give priority to the programme and had to be 'reminded' to ensure the basic conditions for the interventions. A few experienced their managers to be dissatisfied with the programme since they thought it was too time consuming and did not give enough in return to the clinic. Managerial commitment and responsibility were declared as important requirements for sustainability. A few participants also emphasized the need to integrate the programme with organizational action plans.
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
Geographical proximity (i.e., working in the same building or in the same neighbourhood) was by most participants experienced as a strong facilitator, but also as a requirement for multisectoral collaboration, one of the programme's cornerstones. Synergies were created by spontaneous contact or interaction when sharing premises.
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)
The sub-group of participants reporting low compliance to the programme described the organizational level barriers as the main reasons for not carrying out the Salut interventions, with lack of time and resources frequently mentioned as barriers. Time restraints resulted not only in prioritizing 'ordinary' tasks prior to tasks related to the Salut programme, but also hindered the participants from finding their own strategies to incorporate the programme activities into daily work. A few also expressed that the lack of communication and agreement between the Salut programme management and local managers resulted in a gap between resources and the programmes' intention.
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
Barriers at this level largely concerned dental health care, where professionals felt the pressure of generating money from their clinics by treating adults, while in the Salut programme expectant parents were offered a free visit. Even though most participants from dental care claimed high compliance with the programme two years after its implementation, these conflicts between different incentives were described as a threat for long-term sustainability.
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)
Threats of cutbacks were also experienced by some as reducing motivation and leading to prioritizing other tasks before programme interventions.
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)