EMPIRICAL STUDIES
12329
Managing the initiation and early implementation of health
promotion interventions: a study of a parental support
programme in primary care
Anna Westerlund MSc (PhD Student)1, Rickard Garvare PhD (Professor)2, Monica E. Nystro
1,3 1 1
(Senior Lecturer) , Eva Eurenius PhD (Researcher) , Marie Lindkvist PhD (Senior Lecturer) and Anneli
Ivarsson PhD (Assistant Professor)1
1
Department of Public Health and Clinical Medicine, Epidemiology and Global health, Ume
Business Administration, Technology and Social Sciences, Lule
a University of Technology, Lule
Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
Scand J Caring Sci; 2017; 31; 128–138
Managing the initiation and early implementation of
health promotion interventions: a study of a parental
support programme in primary care
Background: Mental health problems are increasing
among children and adolescents worldwide, and paren-
tal support programmes have been suggested as one
preventive intervention. However, the actual impact
and low rates of adoption and sustainability of preven-
tion programmes have proven to be a concern, and
thus, further studies on their implementation are
needed.
Aim: This study focused on the initial implementation of
the International Child Development Programme (ICDP)
in primary care. The aim was to investigate the involved
actors’ views on factors likely to affect implementation
and the strategies used to manage them.
Design: A case study design with a mixed-methods
approach combining quantitative and qualitative data
from questionnaires and interviews was used.
Methods: Eighty-two professionals at different positions in
the involved organisations participated. Directed content
analysis was used for analyses, focusing on perceived levels
of importance and the manifestation of implementation
factors.
Introduction
Social and emotional well-being is fundamental to child
development, and a healthy parent–child relationship
Correspondence to:
Anna Westerlund, Department of Public Health and Clinical
Medicine, Epidemiology and Global health, Ume
a University, SE
901 87 Ume a, Sweden.
E-mail: anna.westerlund@umu.se
128
doi: 10.1111/scs.
€ m PhD
a, Sweden, 2Department of
a University, Ume
a, Sweden and 3Department of Learning,
Findings: Interviews and questionnaires provided descrip-
tions of factors influencing the initial ICDP implementa-
tion. Uncertainty on how to manage important factors and
vague change strategies was reported. Discrepancies in the
perceived levels of importance versus manifestation were
found regarding several factors, including hands-on sup-
port, time and resources, communication and information,
a comprehensive plan of action, follow-ups, and external
and internal collaborations. Manifested factors were a need
for change, motivation and the ICDP’s compatibility with
existing norms, values and practices.
Conclusions: Implementing a parental support programme
in a complex setting will benefit from being preceded by
a thorough examination of the intervention and the tar-
get context and the development of clear implementation
strategies based on the results of that examination. This
study provides insights into how and by whom knowl-
edge on implementation is applied during the launch of a
health promotion programme, and these insights might
help increase the rate of adoption and the use of such
programmes and thereby increase their effectiveness.
Keywords: child health, health promotion, implementa-
tion, parental support programme, parent–child relation-
ship, primary care.
Submitted 17 February 2015, Accepted 11 December 2015
reduces the risk of numerous health problems for the
child and has positive effects that can carry over into
adulthood (1–3). Increasing rates of mental health prob-
lems are a major concern in many countries (4–7), and
parental support programmes have been suggested to be
cost-effective means to prevent these problems (8).
Studies have shown that programmes focusing on devel-
oping a positive interaction between parents and their
children have the greatest impact on children’s mental
health (9).
© 2016 Nordic College of Caring Science

Parental support programmes can be selective, that is
targeting specific groups based on an identified risk fac-
tor, or universal, that is targeting a total population (10).
In Sweden, the use of selective parental support pro-
grammes has been widely recognised, but lately it has
become more common to implement parental support
programmes on a universal level in order to promote
general mental health among children.
This study focuses on the International Child Develop-
ment Programme (ICDP) that is directed towards parents
and other caregivers. The programme is offered at a uni-
versal level and is based on the theories of developmental
and humanistic psychology with a focus on empathy and
sensitive adult adjustment (11). The ICDP is noninstruc-
tive and aims to guide caregivers’ interactions with chil-
dren. It is used in about 35 countries, but the evidence
supporting the programme’s effectiveness remains sparse.
A recent Norwegian study evaluating the impact of the
ICDP on parenting skills and parent–child relationships
reported an increase in positive attitudes towards child
management, improved parental strategies, better child
management and a reduced impact of childhood difficul-
ties (11). The authors suggested further studies to evalu-
ate community-wide implementations.
Previous studies have shown that both the rate of
adoption and the sustainability of health promotion and
preventive interventions are often low (12–17), and
many potential health benefits of such efforts are there-
fore never achieved. In a review of 500 studies of health
promotion and prevention programmes, it was found
that the implementation level affects the intended out-
comes, that is uncertainty regarding the implementation
level acts as a barrier to evaluating the programmes
(18). Evaluations of parental support programmes are
scarce, incomplete and mostly focused on selective pro-
grammes (10). The evidence base for universal pro-
grammes needs to be strengthened, as does the
knowledge on how to address any specific challenges
they encounter during implementation (19). In order to
evaluate a universal parental support programme, it is
crucial to know how and to what extent a programme
has been implemented.
In general, successful implementation of an interven-
tion depends on many factors (20–22). Walker et al.
elaborated on how factors found to be common to many
change efforts interact to influence change (23). The fac-
tors included change content, context, process and indi-
vidual differences, and the authors argued that more
knowledge in this area could aid decision-makers in
ensuring successful change and development. Greenhalgh
and her colleagues presented a review addressing factors
that influence the spread of innovations in health ser-
vices (24). Their findings were summarised in a model of
factors on the micro, meso and macro levels that must be
attended to during the implementation of interventions.
© 2016 Nordic College of Caring Science
Managing early implementation of parental support 129
Factors that might enhance the spread of innovations
were found in system-related categories (e.g. leadership
and strategic vision), adopter-related categories (e.g. ten-
sion for change and motivation), process-related cate-
gories (e.g. hands-on support and feedback on the
progress of the implementation) and categories related to
the innovation itself (e.g. innovation–system compatibil-
ity and perceived relative advantage). Most studies
included in the review focused only on a few of the fac-
tors depicted in the model, and the authors commented
on the small number of empirical studies that have
investigated the complexities of disseminating and sus-
taining innovations. Particularly rare is research that
evaluates changes in the impact that different factors
have at different stages of implementing an innovation
(25). Like Walker (23) and Greenhalgh (24), Fixsen and
colleagues (25) asserted that the understanding of the
components of the implementation and the factors that
promote its effectiveness must increase as a means to
bridge gaps between knowledge and practice. Based on
their review, Fixsen et al. divided the process of imple-
mentation into the following six stages: (1) Exploration
and Adoption, (2) Programme Installation, (3) Initial
Implementation, (4) Full Operation, (5) Innovation and
(6) Sustainability (25) in order to be able to better under-
stand the details of an implementation process.
Even though the body of literature on the implementa-
tion of interventions in health care is extensive, a gap
between knowledge and action remains, and the low rate
of adoption and sustainability of prevention programmes
is a concern. A recent review of implementation research
calls for more empirical research, both for inductive
approaches aimed at further construction of theory and
for deductive application of existing models and theories
to study how, to what extent and under what conditions
the use of implementation theories, models and frame-
works contributes to more effective implementation (26).
The shortage of studies looking at both the implementa-
tion and impact of parental programmes provides an
argument for more empirical studies of practical adher-
ence to knowledge on implementation when launching
parental programmes in different settings. Accordingly,
this study focuses on the early stages of a community-
wide implementation of the ICDP in primary care. The
overall aim was to investigate the involved actors’ views
on factors that are likely to affect implementation and if
and how these factors were managed during the pro-
gramme’s early stages. Our main research questions were
as follows: (1) how did different actors perceive the
impact of a variety of implementation factors during the
first stages of implementation of the ICDP, (2) what
strategies were used by the involved actors to manage
these factors in order to facilitate the implementation
process and (3) did the chosen strategies contribute to
more effective implementation in this case?
130 A. Westerlund et al.
Empirical setting
The study was conducted in one of the 21 County Coun-
cils that provide tax-funded healthcare services in Swe-
den (27). Maternal and child health services are free of
charge and reach nearly all parents during pregnancy
and all children aged 0–6 years in Sweden. The studied
County Council has about 40 health centres (HCs) where
HC practitioners, that is midwives and child health
nurses, work together in shared premises and sometimes
together with preschool teachers and social workers. A
central child health care (CHC) unit has the overall mis-
sion to support, supervise and develop child health care
in the county. In 2005, the Salut programme (hereafter
called Salut), a multisectorial child health promotion pro-
gramme aimed at children, adolescents and their parents
was initiated (28–32). A need to strengthen the psy-
chosocial support to parents and children offered by the
HCs in the county was identified, and this initiated the
idea to introduce the ICDP. The aim of implementing the
ICDP was to improve parental care competence, parent–
child interactions and attachment patterns. By participat-
ing in an ICDP training course, HC practitioners’ work
practices, including the provision of parental support
groups, were assumed to be improved. The ICDP imple-
mentation started with ten HCs located in different
municipalities within the county with the intention to
disseminate the ICDP throughout the rest of the county’s
HCs at a later date.
Methods
Study design
A case study design with a mixed-methods approach was
used (33); that is, both qualitative and quantitative data
were collected through questionnaires and semistruc-
tured interviews. Directed content analysis (34) was used
to analyse the interview data, meaning that the cate-
gories used were established beforehand by derivation
from the implementation theories outlined above. Factors
from Greenhalgh’s diffusion of innovation model (24)
were used to structure the questionnaires and interviews
and to aid in data analysis. The first three programme
stages according to Fixsen were investigated, including
Exploration and Adoption, Programme Installation and
Initial Implementation (25). Descriptive statistics and
bivariate analysis were used to summarise and interpret
the quantitative data.
The ICDP interventions
The ICDP course programme consists of three levels. The
aim of the first two levels is to inspire and train profes-
sionals to become certified ICDP counsellors, and the
third-level course is needed to become a certified advisor
of the ICDP and to teach at levels I and II. This study
concentrates on the period around the level I training
course, which consisted of two-two-day-long workshops
held 1 month apart for personnel at ten HCs in the
county. HC practitioners were divided into five groups
with each group starting the training course at different
times in a sequential manner between November 2010
and March 2011. Besides the HC practitioners who were
supposed to put the ICDP into practice, there were peo-
ple with more strategic or facilitating roles who were
involved in the implementation process, including HC
managers from the ten HCs, CHC managers (chief medical
officers and healthcare developers), CHC psychologists from
the CHC unit and Salut facilitators from the County Coun-
cil’s public health unit. Altogether 92 people were
directly or indirectly involved in the implementation pro-
cess. Fig. 1 provides an overview of the planned ICDP
implementation and the involved actors.
Informants
Out of the 92 actors involved in the ICDP intervention, 82
informants participated in the study by answering ques-
tionnaires, participating in interviews, or both. A question-
naire was distributed twice targeting all participating HC
practitioners (n = 66). The response rates were 100% for
the first questionnaire and 82% for the second.
Twenty-one informants were interviewed, including six
out of ten HC managers, both CHC managers, four out of
eight CHC psychologists and four out of six Salut facilita-
tors (two were excluded because they were part of the
research team). The HC practitioners were approached via
email, and the first seven who agreed to participate as
informants were interviewed (three open preschool teach-
ers, two child health nurses, one midwife and one social
worker). All professions were represented, and informants
came from six out of the ten HCs. After reaching all types
of professions during this first round, and when interviews
were found to provide similar answers, no more partici-
pants were recruited for interviews.
Procedures
Primary data were collected between November 2010
and May 2011 during the initial implementation stage
(stage three), and retrospective data were collected
regarding stages one and two. In the questionnaires, the
informants were encouraged to reflect upon the entire
period – from being introduced to the ICDP up to the
present day (stages 1–3).
Questionnaires. The first questionnaire was distributed in
the morning of the first day of each level I course. A sec-
ond identical questionnaire was sent out 6 weeks after
© 2016 Nordic College of Caring Science

Figure 1 Overview of the ICDP implementation
process over time, the number of involved actors
and their roles in the process.
each course had finished. The questionnaire was con-
structed by the research team and aimed to measure the
implementation factors’ degree of importance and degree
of manifestation. The 14 statements in the questionnaire
concerned factors that were system related (managerial
support, dedicated time for implementation, anchoring of
the ICDP implementation on relevant organisational
levels, the ICDP’s fit with other activities and workplace
attitudes towards learning new things), adopter related
(HC practitioners’ motivation to apply the ICDP and their
need to develop work practices), process related (a compre-
hensive plan of action for the ICDP implementation, the
presence of key change agents, hands-on support, forums
for sharing experiences and systematic follow-ups) and
innovation related (compatibility between the ICDP and
current workplace values and culture and the possibility
to adapt/reinvent the ICDP to current practice). Infor-
mants were instructed to indicate the degree of impor-
tance of a specific implementation factor and to what
degree the same factor was currently addressed or mani-
fested on a 5-point Likert scale (from ‘not at all’ to ‘a
very high degree’). The term ‘manifestation’ refers to
whether a factor was strategically managed and/or ‘put
in place’.
Interviews. Semistructured interviews were conducted to
provide information on the informants’ views on impor-
tant factors, as well as potential factors not covered by
the questionnaire, and to identify strategies used to man-
age these factors or to find other information of impor-
tance. The interviews were conducted during the later
stage of the course period (February–May 2011) and
lasted 8–75 minutes (mean 55 minutes).
The interview guide consisted of themes that
corresponded to the questionnaire (system-, adopter-,
© 2016 Nordic College of Caring Science
Managing early implementation of parental support 131
process- and innovation-related factors), and the ques-
tions were ordered to follow the implementation process
chronologically. The guide also provided the possibility to
add other factors of importance. The interviews were
adapted to fit the roles of different actors; for example,
the questions posed to HC practitioners focused on their
views on if and how the implementation process was
being, or had been, strategically managed and if so by
whom (i.e. if factors perceived as important were in fact
attended to by someone). Interviews with Salut facilita-
tors and HC and CHC managers sought to identify strate-
gies that were consciously used to enhance the
implementation process and to handle known implemen-
tation factors.
Data analysis
Questionnaire data were analysed by focusing on differ-
ences between the level of importance and the level of
manifestation and on differences between measurement
occasions. Paired differences between importance and
manifestation for each individual factor were analysed
using Wilcoxon’s signed-rank test. To quantify differences
between importance and manifestation, standardised
effect sizes were calculated (35). An effect size of 0.2 was
considered a small effect, 0.5 was considered an interme-
diate effect, and 0.8 was considered a large effect. Paired
differences between the two occasions were analysed
with Wilcoxon’s signed-rank test. The significance level
was defined as p < 0.05. IBM Statistics (version 20) was
used for the statistical analyses.
All interviews were audio-recorded and transcribed
verbatim. Qualitative content analysis, with a directed
approach (34), was performed in an iterative manner
using several steps (36–38). First, sentences or phrases
132 A. Westerlund et al.

Active code yes/no

that contained relevant information were structured into
meaningful utterances that included contextual informa-

(manifestation)
tion. These utterances were then condensed. Second,
each utterance was classified chronologically into one of
the three stages of Exploration, Programme Installation

Yes

Yes
No

No
and Initial Implementation based on the time period

Communication/information
referred to by the informant (25). In the third step, the
text units were classified into one of the four main factor

implementation factors
categories – system, adopter, process or innovation – and

Relative advantage
Themes/identified
factors/themes were identified and labelled. Finally, fac-

Comprehensive
plan of action
Compatibility
tors were marked with an ‘action code’ (yes/no/partly)
based on whether the factor had been described as mani-
fested (i.e. actively managed, not managed or partly
managed). An example of the analysis of the interviews
is given in Table 1.

Innovation factor

Innovation factor
Main category

Process factor

System factor
Ethical considerations
The informants received written and oral information
regarding the overarching national strategy for develop-

installation stage

Exploration stage
ing parental support and the study’s purpose. Before dis-

adoption stage

adoption stage
Exploration and

Exploration and
tributing the first questionnaire (which also included this

Programme
information), the attending researcher provided informa-

Stage
tion that participation was voluntary, how answers
would be processed, how data would be handled and
how the presentation of results would be done on the

Considerations regarding
innovation compatibility
Lack of communication

regarding the process

group level in such way that individuals could not be
Condensed utterance

A lack of planning
identified. Participation in the study was based on

and preparation
and information
informed consent. The study was approved by the Regio-
nal Ethics Committee at Ume a University (Dnr 2010-
€
306-32O).
Table 1 Examples of how qualitative data from interviews were coded and analysed

Results
‘When we looked into it, ICDPa seemed to be the method closest to the existing

The results of the study are reported according to the

we felt from the beginning that we had not received any information . . .

research questions. First, HC practitioners’ perceptions on

different implementation factors’ degree of importance
‘In an ideal world we would have had the time to plan this effort

and degree of manifestation as captured by the question-

‘From the very beginning, we could see the benefits with this’.
‘We really do not know what is going to happen next because

naires are presented. Secondly, more detailed results on

differently . . . and prepare for the implementation. If only

the informants’ perspectives on factors of importance, the

ICDP, the International Child Development Programme.
so we do not know what form this process will take’.

strategies used to manage these and the progress of the

approach and practice in child health care today’.

implementation are presented stage by stage. Finally, a

summary of the interview results structured by stages
and categories of implementation factors is provided,
including additional factors discussed in interviews and
not covered by the questionnaires.
we had not been in such a hurry’.

Questionnaire results regarding importance and manifestation

of implementation factors
Original utterance

The questionnaires focused on factors related to the inno-

vation or intervention being implemented, the imple-
mentation process and the adopter. Table 2 presents the
results of the statistical analysis comparing the perceived
importance and manifestation of the factors. The paired
a

© 2016 Nordic College of Caring Science

 Managing early implementation of parental support 133

Table 2 Health centre practitioners’ estimations of the degree of importance and manifestation of factors during early implementation of ICDPb

Questionnaire Questionnaire Difference between

1 (n = 66) 2 (n = 54) measurements

Median Median Effect

(Q1, Q3) (Q1, Q3) sizea
Effect Effect
Implementation factors Importance Manifested sizea Importance Manifested sizea Importance Manifested

System factors
Clear managerial support 4.5 (4,5) 4 (3,4) 0.36 5 (4,5) 3 (2,4) 0.51
Dedicated time for implementation 5 (4,5) 3 (1,3) 0.57 5 (4,5) 2 (2,3) 0.57
(all necessary activities included)
Anchoring of the ICDPb) implementation 4 (4,5) 2 (1,3) 0.56 5 (4,5) 2 (1,3) 0.54
on relevant organizational
levels and the ICDP’s fit with
other planned activities
Attitude towards learning 5 (4,5) 4 (3,5) 0.45 4.5 (4,5) 4 (3,4) 0.48
new things in the
workplace (a learning environment)
Adopter factors
Motivation 4 (4,5) 4 (3,4) 0.44 5 (4,5) 4 (4,4) 0.43 0.20 0.25
Need for change 5 (4,5) 3 (3,4) 0.47 5 (4,5) 3 (2,4) 0.54 0.31
Process factors
A comprehensive plan of action 5 (4,5) 1 (1,2) 0.58 4.5 (4,5) 2 (1,3) 0.58 0.25
(for the ICDP implementation)
The presence of key actors with 4 (4,5) 2 (1,3) 0.55 5 (4,5) 2 (1,3) 0.58
the responsibility for
driving the implementation forward
The possibility to get hands-on 4 (4,5) 1 (1,2) 0.57 5 (4,5) 1 (1,2) 0.59
process support
Forums for discussions and exchange 4 (4,5) 2 (1,3) 0.57 4.5 (4,5) 2 (1,3) 0.58
of experiences, knowledge, etc.
Systematic follow-ups 4 (4,5) 2 (1,3) 0.56 4 (3,5) 2 (1,3) 0.58
Innovation factors
Compatibility between the ICDP and current 4 (4,5) 3 (3,4) 0.49 5 (4,5) 4 (3,5) 0.43
workplace values and culture
Possibility to adapt the ICDP 4 (4,5) 3 (2,4) 0.54 5 (4,5) 3 (3,4) 0.54
to current practice

Effect size measures for Wilcoxon’s signed-rank test of paired differences for each individual between importance and manifestation and for dif-
ferences in importance and manifestation between measurement occasions.
a
Only effect sizes for significant tests are shown.
b
ICDP, the International Child Development Programme.

differences for each individual respondent between
importance and manifestation were considered significant
for all factors with p-values below 0.001. Effect size cal-
culations showed the largest differences between impor-
tance and manifestation for the process factors, where
importance was always rated higher than manifestation.
The smallest differences were found regarding adopter
factors and innovation factors. Few significant changes
between measurement occasions were found.
The vast majority of informants rated all process factors
as ‘not at all’ or ‘only slightly’ manifested, while the esti-
mated importance of the same factors was rated as being
‘relatively high’ or ‘very high’. Process factors showed
the highest degree of discrepancy between importance
and manifestation. The most common estimations were
‘very high’ for degree of importance and ‘not at all’ for
degree of manifestation. None of the individual process
factor results differed much from this pattern.
A majority of the informants viewed the importance of
system factors as ‘high’ or ‘very high’, while the estima-
tions of these factors’ manifestations were more varied.
The factor ‘learning environment in the workplace’
(based on the questionnaire statement: There is a positive
attitude towards learning new things to add to existing practice
at my workplace) stands out as being estimated more posi-
tively regarding manifestation than the other factors. If
this factor is excluded from the analysis, the overall pat-
tern becomes more negative because the discrepancy

© 2016 Nordic College of Caring Science

134 A. Westerlund et al.
between the importance and manifestation of the factors
widens.
For the adopter factors, both ‘motivation’ and ‘need for
change’ were viewed as ‘highly important’, and their
manifestations were also rated high. The same pattern
can be seen regarding the innovation factors. These
results show that both of these categories contain factors
that the informants stated are both important and
manifested.
Interviewees’ descriptions of early stages of the
implementation process
Stage 1 - Exploration and adoption. When referring to the
first stage, the Salut facilitators, CHC psychologists and
CHC managers all described how careful considerations,
with a focus on the intervention’s compatibility with
existing practice, had been made before deciding to
implement the ICDP. One CHC psychologist stated, ‘When
we looked into it, the ICDP seemed to be the method closest to
the existing practice in child health care today’. The CHC unit
had received requests from HC practitioners regarding
strengthening their competence and work practices con-
cerning parental support. The ICDP was considered by
Salut facilitators, CHC psychologists and CHC managers
as a promising way to promote children’s mental well-
being, which was presented as the main goal for imple-
menting the ICDP. However, all informants stated that
discussions across groups regarding visions and specific
goals, especially among HC managers, were insufficient.
Interviews with HC managers indicated that their
involvement and commitment regarding the ICDP were
limited, if not entirely absent, and this was exemplified
by statements like ‘What are you talking about? That we
have decided to engage in what? ICDP?’ The interviews pro-
vided no indications of a clear or commonly known divi-
sion of roles and responsibilities between involved actors.
No comprehensive plan of action seemed to have been
disseminated at this stage. The HC practitioners stated
that they had not received information regarding ICDP or
its implementation process before the first day of the
training course, and they provided statements like, ‘We
really do not know what is going to happen next because we
felt from the beginning that we had not received any informa-
tion. So we do not know what shape this process will take’.
They also confirmed the lack of managerial support and
considered this to be a problem. However, the vast
majority of the HC practitioners expressed a positive view
on the ICDP intervention, as exemplified by statements
like, ‘From the very beginning, we could see the benefits with
this!’
Stage 2 - Programme installation. The Salut facilitators
were described by all respondent categories as being
responsible for arrangements regarding the ICDP training
course. An informant from the CHC stated: ‘People from
Salut were involved in getting funding. They arranged for this
education, made all necessary contacts, and sort of did the job!
It is really good that they did!’ Other than this, no division
of roles and responsibilities among the groups of strategic
actors seemed to have been made. One statement pro-
vided by one of the Salut facilitators describes the situa-
tion: ‘We are still struggling with our role in relation to the
CHC unit in terms of how we should see ourselves and what
our mission is in relation to theirs. We wish that everything we
do will eventually be “owned” by them’. HC practitioners
expressed annoyance concerning the lack of information
about the ICDP and the lack of time to prepare for the
course: ‘We had not received proper materials before starting
the course. For example, we were supposed to have read the
main course book before day one of the course, but we did not
know about that book’. Besides HC practitioners’ participa-
tion in the first-level course, no activities specifically
directed to enhance the implementation and sustainabil-
ity of the ICDP were provided for in terms of dedicated
time and/or resources. No systematic follow-up of the
process had been planned, and none of the informants
were clear on how to follow up on potential results. HC
practitioners, as well as some Salut facilitators, pointed
this out as a deficiency: ‘If you never evaluate, you can never
know. How can someone put so much money, time, and effort
into something, an education or programme or whatever, and
not make sure they get what they expect out of it?’
Stage 3 - Initial implementation. When referring to the
third stage, HC practitioners expressed concerns that pro-
cess factors – such as ‘communication and information’,
‘hands-on support’ and ‘a comprehensive plan of action’
– were not manifested or managed by anyone. No clear
expectations on what actually should be done after the
training course were expressed. HC practitioners stated
that these deficiencies led to confusion and irritation.
Further, they did not perceive that there were any actors
responsible for enhancing the implementation, and they
expressed ambiguity regarding how they were supposed
to transfer what they learned from the course into their
work practice: ‘Is it up to us now to do what we want with
this new knowledge? Shall we offer parental groups according
to the ICDP now or should we just let what we’ve learned
inspire us in our daily meetings with parents and children?’
Among the strategic informants, views differed regard-
ing responsibilities for the process factors. Some Salut
facilitators viewed the CHC unit as responsible for pro-
viding hands-on support and structured feedback and for
arranging communication channels among the practition-
ers. Others from the Salut constellation claimed that HC
managers were the natural key actors and owners of the
implementation: ‘I would say that the manager at each
health centre should be responsible for “making things happen”
at his or her health centre’. For the direct question of
© 2016 Nordic College of Caring Science
 Managing early implementation of parental support 135

whether such opinions on division of responsibilities had
been communicated or discussed across different groups
of actors, all of the answers were ‘No’ or ‘I don’t know’.
There was no indication of a discussion on division of
responsibilities taking place. Some informants argued that
insufficiencies regarding the implementation process
were due to the short time frame for the implementation
– which was a restriction put in place by the external
funding agency – resulting in limited time for preparation
and anchoring activities: ‘In an ideal world we would have
had the time to plan this effort differently and prepare for the
implementation. If only we had not been in such a hurry’.
With the exception of the HC managers, the motivation
to implement the ICDP was stated by all informants to be
high at this stage, especially among the HC practitioners.
Several HC practitioners mentioned high compatibility
between the ICDP and the current approach at the HCs:
‘In many ways, this is what we have always done. Now this
has been confirmed, which has strengthened us in our work
with parents and children’.
Summary of interview findings
The interview findings were consistent with question-
naire results in terms of discrepancies between the differ-
ent factors’ importance and their manifestation. All HC
practitioners offered a consistent description of the early
stages of programme implementation. Overall, the inter-
view results showed a clear discrepancy between per-
ceived levels of importance and perceived levels of
manifestation, especially for the process-related and sys-
tem-related factors. Factors perceived to be well mani-
fested through all stages were motivation, relative
advantage of the intervention itself, need for change and
the intervention’s compatibility.
Interviews with informants at strategic levels mainly
confirmed the views of the HC practitioners. Table 3 pro-
vides an overview of all factors described in the inter-
views as being important by at least one respondent
when referring to the different stages of the programme
implementation (25). Whether these factors were per-
ceived to be manifested/managed or not (yes/no/partly)
based on the view of the majority of informants is also
presented. Factors are labelled in accordance with the
questionnaire (outlined in Table 3). Factors brought up
that were not included in the questionnaire are
highlighted.
In the interviews, four new factors not covered by the
questionnaire were brought up. Besides the HC man-
agers, all informants mentioned the innovation’s ‘relative
advantage’ (innovation factor), ‘communication/informa-
tion’ (process factor) and ‘visions and goals’ related to

Table 3 Overview of implementation factors stated as important by the 21 informants in interviews, structured by stages, categories and themes

Stages of implementation Categories Themes/identified implementation factors Managed or manifested

1. Exploration and Adoption System Clear vision and goals Partly (clear vision exists among
some groups of informants)
Clear management support No
Adopter Own perceived need for change Yes
Process Communication/information No
Division of roles and responsibilities No
Intervention Compatibility Yes
Relative advantage Yes
2. Programme Installation System Anchoring No
Dedicated time and resources Partly (for the course)
Comprehensive plan of action No
Adopter Motivation Yes
Process Communication/information No
3. Initial Implementation Adopter Motivation Yes
Process Communication/information No
Comprehensive plan of action No
Key actors responsible for implementation No
Division of roles and responsibilities No
Hands-on support No
Exchange of experiences No
Systematic follow-ups No
Intervention Compatibility Yes
Possibility to adapt ICDP to current practice Yes
Relative advantage Yes

New factors brought up in interviews are given in italics.

© 2016 Nordic College of Caring Science

136 A. Westerlund et al.
the innovation (system factor). The factor ‘division of
roles and responsibilities’ (process factor) was mentioned
by all Salut facilitators and by a majority of the infor-
mants from the CHC unit (managers and psychologists)
when referring to the exploration stage.
Discussion
A starting point of this study was the problem of low
adoption rates of health promotion programmes and the
possibility that this might partly be due to lack of aware-
ness or ignorance of existing knowledge on implementa-
tion and change in healthcare settings. In this case,
adherence to existing knowledge on implementation was
weak, that is mainly the factors in Greenhalgh et al.’s dif-
fusion of innovation model (24). The results reflect a
shortage of strategies for managing crucial aspects of the
ICDP implementation, meaning that time and effort put
into the initiative at its early stage (e.g. the training
course) might to some extent have been wasted. More
importantly, this could have threatened the ability to use
the ICDP as parental support and thereby not met the
aim of preventing mental illness among children and
adolescents. The question of whether chosen strategies
and ways of managing important factors enhanced the
implementation is not possible to answer based on these
results. Still, it can be concluded that despite the lack of
strategies and the confusion and irritation that arose as a
consequence, motivation was not missing in this case.
The ICDP was perceived by a large majority of informants
to be potentially beneficial, not only for parents and chil-
dren but also for all actors involved. This implies that if
innovation-related factors are manifested (i.e. the inno-
vation is wisely chosen), this could positively affect other
factors such as motivation. This finding is consistent with
results from a similar study on the dissemination of inno-
vations (39). Thus, it seems that careful considerations
made regarding the choice of intervention in this case
might somewhat have compensated for the lack of strate-
gies to manage other central factors.
Based on our findings, a question can be raised regard-
ing how to ensure an adequate level of implementation
when the ICDP is offered at a universal level and, as in
this case, is supposed to be adapted and merged into
existing work practices in HCs. In this case, the expecta-
tions on actions were vague and the direction of change
was not clarified or supported by managers or key strate-
gic actors during the early stages of the intervention’s
implementation. This in turn indicates that the use and
impact of the ICDP might vary among HCs regarding
both content and extent. If the intention is to merge new
approaches with current similar work practices, it
becomes difficult to monitor and evaluate the effects of
the intervention, especially for universal preventive pro-
grammes (18). In situations where selective parental
support programmes are offered over limited time periods
and under more stringent conditions, and with the pur-
pose of targeting specific groups based on identified risk
factors, this might be less of a challenge.
It can be argued that the multitude of actors with dif-
ferent accountabilities in combination with insufficient
communication contributed to the slow initial implemen-
tation of the ICDP. When many actors are involved, it is
likely more difficult to clarify roles and responsibilities
regarding different aspects of the implementation process.
The studied case provides a description of implementa-
tion factors and barriers to implementation that were not
addressed, even though they were perceived as important
by the actors involved. It also addresses some of the why’s
as stemming from the external context, such as the restric-
tions and time frames imposed by the external financer.
The latter also concerns the intervention itself, mainly
restrictions on the use of ICDP based on level of training,
and the lack of clarity regarding the intentions and expec-
tations on the adaptation of ICDP to current practice versus
the maintenance of fidelity to the original ICDP protocol.
Methodological considerations
As a case study, the possibility for generalisation lies in
its connection to building new or using existing theory
(40). In this study, we used previous research and models
on implementation factors to aid our interpretation of
the data, which makes the results comparable to other
similar studies but also limits the openness for new find-
ings. The value of combining quantitative (question-
naires) and qualitative (interviews) measurements, that is
the mixed-methods approach, in case studies was con-
firmed because the results from the questionnaires con-
structed on the basis of existing frameworks were
expanded by the interviews based on open-ended ques-
tions. However, our results did not exhaust the area of
potential implementation factors that can influence this
type of preventive programme. The interviews took place
between the two rounds of questionnaires, and there is a
possibility that the practitioners were affected by the con-
tent of the questionnaire. Thus, although the interview
data added new information, a limitation of a more
deductive approach is that other issues of relevance for
the implementation might have been unintentionally
excluded. The study largely reflects the perceptions of
female participants of similar age, but this proportion of
women mirrors the general female predominance in
these sectors in Sweden.
The similarity of issues raised by informants in differ-
ent data sources and regardless of profession or role in
the initiative strengthens the reliability and validity of
the results as a representation of the implementation pro-
cess. That all HC practitioners at the participating HCs
and a majority of the key programme actors took part in
© 2016 Nordic College of Caring Science
 Managing early implementation of parental support 137

the study ensures the representation of potentially differ-
ent perspectives. Interviews with HC managers were in
general very short. The fact that these managers had
sparse knowledge on the ICDP implementation was
unexpected and was an important result in itself, espe-
cially when considering the fact that a vast majority of
HC practitioners emphasised the importance of manage-
rial support. All managers had been informed about and
accepted the implementation of the ICDP at their HC.
Therefore, we did not exclude these from the study.
The strength of this study is that it reflects the views of
professionals at several organisational levels, including
front-line staff and perspectives of personnel at more
strategic levels. Unquestionably, perspectives from the
target group of the intervention (i.e. parents) as well as
measures regarding the ICDP’s effect on well-being of
both parents and their children would have strengthened
the study. Due to the recent launch of the initiative and
its somewhat hesitant start, no such data could be
obtained at the time of the study, but these perspectives
can be addressed in future follow-up studies.
and the use of health promotion interventions, thereby
increasing the probability of reaching the intended health
benefits. We suggest that further attention be paid to
issues of practical adherence (or nonadherence, as in this
case) to existing knowledge on implementation
when initiating health promotion and preventive
interventions.
Epilogue
Results from a follow-up study of the continuing ICDP
implementation indicate that the perceptions of several
factors have changed among all types of informants,
especially regarding the process-related factors, and that
the division of roles and responsibilities has been
clarified.
Acknowledgements
The authors would like to thank all respondents for their
time and effort.

Conclusion Author contributions

It can be concluded that if key actors and stakeholders
fail to clarify expectations, involve key individuals for
process support and develop strategies to manage known
implementation factors during initiation and early imple-
mentation, the aims of health promotion and preventive
programs like the ICDP might not be met.
Implementing the ICDP in a complex organisational
setting will benefit from being preceded by a thorough
examination of the intervention and the target context
and a development of implementation strategies based on
the results of such an examination. Agreeing on the divi-
sion of roles and responsibilities for different implementa-
tion factors can enhance the progress during the early
implementation stage.
A better understanding of how ‘if, how and by whom’
knowledge on implementation and change is applied in
empirical cases could help increase the rates of adoption
AW, RG, AI, EE and MN designed the study; AW col-
lected the data; AW, RG and ML conducted the analyses;
and AW, RG and MN drafted the manuscript. All authors
read, contributed to and approved the final manuscript.
Ethical approval
The study was approved by the regional Ethics Commit-
tee at Ume €
a University, Sweden (Dnr 2010-306-32O).
Funding
This work was financially supported by the Swedish
National Institute of Public Health through the ‘Swedish
national strategy for developed parental support’ and was
undertaken within the Ume a Centre for Global Health
Research, a Forte-supported Centre of Excellence.

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