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Exploring experiences among adopters during the diffusion of a novel dance intervention in Sweden

Exploring experiences among adopters during the diffusion of a novel dance intervention in Sweden INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 2018, VOL. 13, 1438697 https://doi.org/10.1080/17482631.2018.1438697 Exploring experiences among adopters during the diffusion of a novel dance intervention in Sweden a b a a c Noomi Carlsson , Agneta Kullberg , Ida-Klara Johansson , Paula Bergman , Janna Skagerström and Agneta Andersson a b Public Health & Healthcare, Regional Executive Office, Jönköping, Sweden; Division of Community Medicine, Social Medicine and Public Health Science, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden; Research & Development Unit in Local Health Care, and Department of Medicine and Health Sciences, Linköping University, Linköping, Sweden ABSTRACT ARTICLE HISTORY Accepted 5 February 2018 There is a demand for interventions aimed at adolescent girls with psychosomatic problems. In 2013, positive results were reported from a dance intervention programme addressing girls KEYWORDS with internalizing problems. The research team behind the intervention immediately received Implementation; requests from municipalities and county councils interested in using the intervention. From psychosomatic; diffusion; an implementation point of view it is unclear what made the intervention spread without an innovation; dance active plan. The aim of this study was to explore adopters’ experiences about the diffusion intervention and initiation of a public health intervention targeting adolescent girls with internalizing problems. Interviews were conducted with 12 people who were engaged in initiating the intervention in different settings. Data were analysed using conventional content analysis, yielding three categories: perceived appeal and trustworthiness, convenient information, and contextual factors. The results reflected that the participants found that there was a need for an intervention and found the dance intervention to be evidence based and not too complex to perform. Further, there was available information on the project which could easily be distributed to decision makers and others. When initiating the intervention, factors related to economy, possibility for collaboration and recruitment were of importance. rated health at 12 and 20 month follow-up (mean Introduction difference 0.62 and 0.40) and was a positive experi- Psychosomatic symptoms and mental health pro- ence (Duberg et al., 2013). In a qualitative study, girls blems among adolescents have increased rapidly who had participated in the dance intervention worldwide in recent years (Bor, Dean, Najman, & expressed that the intervention had given them a Hayatbakhsh, 2014). According to the World Health feeling of being free, and increased self-trust and Organization (2012, 2016), Sweden has seen a parti- confidence (Duberg, Möller, & Sunvisson, 2016). The cularly large increase in mental health problems. The dance intervention, organized as a complement to the prevalence of self-rated psychosomatic problems school health services, was demonstrated to be cost- among Swedish adolescents has increased in the effective compared with usual school health services past few decades, as has the number of contacts alone (Philipsson, Duberg, Möller, & Hagberg, 2013). with inpatient, outpatient and primary care due to Despite the relatively limited scientific evidence at psychosomatic illness (Folkhälsomyndigheten, 2016). the time, the intervention received widespread media All health care in Sweden is publicly funded by taxes coverage and the research team immediately received and mainly organized by two authorities: county requests to educate dance instructors and instruct councils and local municipalities. Throughout them how to set up the intervention in other loca- Sweden, these authorities are trying to tackle this tions across Sweden. In conjunction with the research complex public health issue and the political pressure process, the research team at Örebro University on decision makers is considerable. offered courses for dance instructors according to A dance intervention programme for adolescent the dance intervention programme. Although the girls with internalizing problems, i.e., with stress and intervention has spread to several municipalities, it is psychosomatic symptoms, was developed and a ran- still unclear what characteristics of the intervention domized controlled trial was performed by a Swedish made it spread without an active dissemination plan. research team and published in JAMA Pediatrics in The gap between research and practice has been 2013 (Duberg, Hagberg, Sunvisson, & Möller, 2013). widely reported and discussed. Traditionally, the pub- Evaluations show that the intervention improved self- lic health impact of intervention studies has not been CONTACT Noomi Carlsson [email protected] Folkhälsa och sjukvård, Region Jönköpings län, Box 1024, Jönköping 551 11, Sweden © 2018 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 2 N. CARLSSON ET AL. the concern of health researchers (Bauer, The dance instructors were asked to provide contact Damschroder, Hagedorn, Smith, & Kilbourne, 2015). information for their stakeholders in decision making However, interest in implementation science has and/or collaboration partners in the dance interven- grown in the past few decades to study what influ- tion. Among 27 potential informants provided by the ences the implementation of new practices (including dance instructors, 18 were strategically selected and interventions, programmes and services) and what asked to participate in the study. Most of the selected strategies might be effective to support implementa- informants had a directorship. The nine potential tion. Numerous so-called determinant frameworks informants who were not asked to participate were have been developed to describe barriers and facil- on sick leave, had a new job or had a peripheral itators that influence the implementation and use of position in relation to the dance project. To generate new practices (Nilsen, 2015). Most of these frame- a variety of experiences of the intervention process, works describe three types of determinants that influ- selection was based on the organizational role of the ence implementation: perceived attributes of the respondents. Further, heterogeneity regarding the practice (e.g., complexity and relative advantage in municipality or counties where the respondents relation to the current practice); individual character- worked was sought to capture the diffusion of the istics of the users of the new practice (e.g., attitudes, intervention in different settings. The potential infor- beliefs and motivation concerning the new practice); mants were informed about the study design and and contextual factors (e.g., organizational support purpose via e-mail in November 2014 and a reminder and support from colleagues and time constraints) was sent in December 2014. (Cochrane, Olson, Murray, Dupuis, Tooman, Hayes., Twelve of the 18 potential informants agreed to be 2007; Damschroder et al., 2009; Grol, Wensing, & interviewed and were contacted by telephone to Eccles, 2005; Rycroft-Malone & Bucknall., 2010). The schedule a semi-structured telephone interview. The frameworks also address various strategies that sup- informants represented four different regions in port implementation, ideally accounting for as many southern Sweden and were all employed in munici- determinants as possible to achieve successful imple- palities or county councils. Most were employed mentation of a new practice (Bauer et al., 2015). either in public health departments or in children Despite the fact that implementation science has and education or culture departments. The infor- identified many implementation barriers, new prac- mants’ professions included public health planner, tices sometimes spread by themselves, without the physiotherapist, and manager or coordinator in school use of any conscious strategies. Rogers’ diffusion of health, public health or health care. Eleven of the 12 innovations theory (Rogers, 2003) deals with the respondents were women. Most of the informants spontaneous spread of new practices, i.e., innovations. were community officials, decision makers and/or pro- The theory posits that diffusion of new practices in a moters of the dance project. Three of them had also social context, e.g., health care, is influenced by a participated in the course to become a dance instruc- number of factors, including the setting, the users, tor. Five people did not answer our e-mail or declined the perceived need for the intervention and external to participate. influences. Several implementation frameworks are influenced by the work of Rogers and have identified Procedure similar factors as being important (Damschroder et al., 2009; Greenhalgh, Robert, Bate, Macfarlane, & The interview guide was based on Rogers’ attributes Kyriakidou, 2005; Gurses et al., 2010). However, more of innovations, relative advantage, compatibility, com- research is needed to understand how public health plexity, trialability and observability (Rogers, 2003). interventions are perceived and spread within politi- For example, the question “How do you view the cally controlled organizations outside the health-care dance intervention in relation to how you have sector. worked before?” was intended to capture relative The aim of the present study was to explore adop- advantage, “Did introduction of the dance interven- ters’ experiences of the diffusion and initiation of a tion meet your expectations to intervene with the public health intervention targeting adolescent girls target group?” to capture compatibility and with internalizing problems, i.e., stress and psychoso- “Describe your experiences of initializing the dance matic symptoms. intervention” to capture complexity. The guide contained questions on initial contact with the dance intervention, reasons for considering Methods the intervention, response to the intervention, initia- tion process and goals of the intervention. Twelve Recruitment and informants telephone interviews were conducted by N.C. and A. Individuals who participated in the courses to become K., six by each author. The interviews were recorded a dance instructor during 2013–2014 were contacted. and lasted on average 27 minutes (range 19– INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 3 43 minutes). All interviews were performed in Swedish Perceived appeal and trustworthiness and transcribed by a professional transcriptionist, and The dance intervention filled a clear and pent-up selected quotations were then translated into English demand for a solution to a public health problem. In by a professional translator. addition, the intervention was perceived as trust- worthy by the fact that positive results were pub- lished in a scientific journal, and it also endorsed the Analysis informants’ own beliefs and expectations. The data were analysed using conventional content Pent-up demand analysis according to Hsieh and Shannon (2005). The Enhanced pressure from the political leadership about interviews were transcribed verbatim and read by all handling the increasing prevalence of psychological authors several times to obtain a sense of the whole. health problems among adolescents was described by Initially, the transcribed text was coded by N.C. and A. the participants. This was seen as a challenge within their K. separately. The data material was structured into professional assignment as they perceived a paucity of meaning-bearing units and then condensed, and sub- options. The informants expressed that, at the time when categories and main categories were constructed. they first heard about the dance intervention, they had Throughout the analysis process, all the main cate- limited or no interventions to offer the target group. gories and codes were discussed among all the authors until consensus was reached. Verbatim quota- Yes, well the issue was actually raised in political forums because mental ill health is a major problem with us, so it tions are provided to illustrate each subcategory. has actually been a prioritized area for a number of Selected citations were translated by a professional years. (IP1) translator. The respondents recognized the dance project as an intervention that, from several aspects, was realistic to achieve and thus offered a possible solution to face the Ethics challenge described above. Described advantages of the The study was approved by the Regional Ethical Board dance intervention were the focus on a distinct health- in Uppsala, Sweden (Dnr 2014/090). The participants promoting activity and the possibilities to perform the were informed that the material from the interviews intervention within a reasonable budget and training would be presented in a way that guaranteed con- initiative. fidentiality. Informed consent was obtained by the participants’ positive replies to the e-mail. Verbal con- Perceived as evidence based sent was also obtained at the start of the interview. Another benefit of the intervention expressed by the Participants were also told that they could discon- informants was that research had been conducted tinue their participation at any time. and published in a highly regarded scientific journal, showing positive results. The fact that research had been conducted gave the respondents a sense of trust in the method regarding its potential to have a Results positive impact on the target group. The opportunity The analysis resulted in three main categories and 10 to use and adopt a developed and assessed interven- sub-categories (Table I). Verbatim quotations from the tion gave a sense of quality and safety in the planning interview persons (IPs) are used to illustrate the find- and implementation of the dance classes. ings and show a link to the original data, and are It is something that has been researched, there are numbered at random. good results, it is a target group that we are to prioritize. [. . .] I think that it has massive importance that it has been researched. (IP11) Table I. Overview of the results presented as categories and sub-categories. Endorsement of own beliefs Main category Sub-category For some of the informants, the positive research Perceived appeal and Pent-up demand trustworthiness results strengthened their own perception of dance Perceived as an evidence-based as a positive influence on health. It was also some- method Endorsement of own beliefs thing that they expressed as a strong argument with Convenient information Information channels colleagues and political leaders. Transferable concept Contextual factors Organizational position Ah, personally I am really passionate about this and I Collaborative strategies Personal competence and qualities have always believed in it, so it was fantastic that Time constraints there is now scientific proof that dance is a good Reach of the intervention thing. (IP6) 4 N. CARLSSON ET AL. Convenient information position in the field of public health. They had the mandate, knowledge and/or the assignment to The informants picked up information about the inno- implement the intervention, and a few informants vation through several channels, through the Internet, could take the decision to implement the project from colleagues or through informal channels. How the themselves. For informants not in a decision-making innovation was presented played a vital role, because it position, it was sometimes hard to convince leaders was easy to repeat the message and pass it on to others. about the importance of the intervention, and sev- eral attempts had to be made to persuade manage- Information channels ment to implement the intervention. The media seems to have played a vital role in the Yes, it has gone well, it has, it takes a lot of work to diffusion of the intervention. Apart from the articles keep relationships going. [. . .] [We] found people who published in a scientific journal and presentations were interested in this who were managers or super- given at scientific meetings, the intervention has visors or who had authority from them so it could be been positively depicted in local newspapers as well carried it out in a good way. (IP8) as on news reports on television, radio and Internet (YouTube). The informants described that their initial Collaborative strategies contact with the dance intervention was primarily Most of the informants expressed that establishing through networks connected to their profession, the idea within the organizations as well as at the newsletters and e-mail lists. It may also have been a political level played a vital role in the outcome of the direct call from a manager or political leader to assess implementation of the dance intervention. To achieve the information about the dance intervention and durability in the project, financial resources and give an opinion on whether it could be useful in devoted staff were described as key components. their organization. . . . it is so important that you build up a foundation Transferable concept like we have done. Do the prep work, and then make A facilitating circumstance for the diffusion of the sure that each stage is anchored in it. (IP8) intervention was that the information about the The informants described different collaborative dance intervention was perceived as appealing to arrangements between and within municipalities the informants. The short film clip explaining the and county councils as necessary for the implementa- intervention made the information accessible and tion of the dance intervention. For example, coordi- easy to pass on via e-mail or to show in a meeting. nating groups were specially set up for the The day before there had been a report on it on implementation process. Collaboration arose exclu- Aktuellt [the current affairs TV programme]. Because sively where the dance project was adopted and the research had been published and was interna- appeared in diverse ways depending on the resources tionally recognized, the link was active for a long within the organization. The informants expressed a time. So we could send it to other people to help wish to collaborate across organizational boundaries describe what it was. (IP11) but described the structure for collaboration between the organizations as vague. Some of the respondents Contextual factors claimed that none of the organizations wanted to take on the main responsibility or be in charge of Decision-making powers in implementing the dance the financial resources. They also experienced diverse project varied among the informants but they all opinions regarding the responsibility for the interven- faced the need to firmly establish the idea inside tion and/or target group. their organization as well as externally in collabora- tion with others. The main factors hindering the initia- No, then I said that I thought it sounded interesting tion process were limited time within the office and/ but that there needed to be a few others from the county council involved; it can’t just be put on the or difficulties finding staff with the required compe- municipality I thought. (IP3) tence and qualities. Finding the right means to finance the intervention was sometimes difficult, A key element in the original dance intervention is often because of joint financial responsibilities that it was free of charge for the participating girls, between municipalities and county councils. including transportation to the dance classes. Because of the societal structure in Sweden, in most scenarios Organizational position described by the informants, the dance intervention The informants’ position in their organization dif- thus required shared financial responsibility between fered, which was reflected in their approach and county councils and municipalities. The joint financial advocacy opportunities when initiating the dance responsibility was described as a predicament by intervention. Half of the respondents had a strategic some informants. INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 5 problems, i.e., stress and psychosomatic symptoms. Personal competence and qualities The informants mentioned several factors that may The informants described the recruitment of a dance have had an impact on the diffusion of the dance instructor with special professional and personal qua- intervention. There was a demand for some kind of lities as a key factor in the outcome of the dance intervention aimed at adolescent girls; the dance intervention. Social skills and the ability to create a intervention was perceived as evidence based and sense of undemanding kinship with the girls seemed compatible with the informants’ beliefs and values. critical. Skills such as empathy and motivation were Further, information regarding the intervention was also key features. For some of the informants, the packaged in an appealing format and was easy to recruitment of a suitable dance instructor proved to pass on. The initiation was hindered and/or facilitated be a challenge. by local conditions concerning, for instance, organiza- . . . I am completely convinced that even if you recruit tional factors, recruitment of dance instructors and a really competent dance teacher who doesn’t have participants, and time constraints. these qualities or social skills, or even some of them, you are not going to get the same results. (IP1) Perceived appeal and trustworthiness Time constraints Some of the results in our study can be understood Some informants described that the time required to with reference to Rogers’ diffusion of innovations the- recruit a person with the right qualities to start the ory (Rogers, 2003) and subsequent implementation dance course for instructors was limited. Others frameworks such as the ecological framework con- described that they had to act within a limited time- structed by Durlak and DuPre (2008) and the frame to get the intervention started. The time limits Consolidated Framework for Advancing were described by the informants as negative for the Implementation Research (CFIR) developed by results of the implementation. Damschroder et al. (2009). The perceived relative I had about two weeks to try to recruit teachers for advantage, i.e., the degree to which an innovation is the course so we were really, really short of time. [. . .] perceived as better than what it supersedes, is one of then we found out, probably through rumours, that it the key elements in Rogers’ theory. In the extensive was the last time the course would be held. (IP4) framework and review conducted by Durlak and DuPre (2008), the perceived need for an innovation Reach of the intervention as well as perceived benefits of the innovation desired Informants expressed difficulties regarding recruit- at the local level were found to be consistently related ment of girls who were eligible to take part in the to positive implementation results. Further, the infor- dance groups. The target group was small and sensi- mants expressed that the expected benefits of the tive to dropout. To recruit participants to the dance innovation came at a relatively low cost, with the groups, exceptions from the original intervention perceived promise of rapid results for the target were made and, for example, girls without internaliz- group (Philipsson et al., 2013). This perception ing problems were included. Other informants explains the interest in the innovation. Providers described that they were eager to make sure that who see a specific need for an intervention, believe the intervention was followed as intended. Further, that the intervention can produce benefits, and have some informants struggled with equality issues and the skills and confidence to do what is expected from felt they had to offer the intervention to boys as well. them have been found to be more likely to imple- . . . we could relax the rules a little too; then we could ment intervention programmes with a high level of say that all the girls who wanted to could join in. fidelity (Durlak & DuPre, 2008). (IP10) In this study, the respondents expressed that they Another concern described by some informants was were particularly susceptible to the innovation at that if the dance intervention included only a small hand because it filled a gap between pressing group of girls, the intended public health effect would demands from the political leadership calling for not be reached. Projects aimed at a larger group of action for adolescent girls with psychological health young people seemed preferable in order to decrease problems and available public health innovations tar- the prevalence of psychological health problems geting this group. This fits well with what is labelled among adolescents. tension for change in the CFIR. Tension for change is part of the implementation climate; if the current situation is perceived as intolerable by stakeholders Discussion and there is a need for change, this contributes to a The aim of this study was to explore experiences of positive implementation climate (Damschroder et al., the diffusion and initiation of a public health inter- 2009). Further, the results in the present study show vention targeting adolescent girls with internalizing that the scope of the intervention was in concordance 6 N. CARLSSON ET AL. with individual and personal beliefs. This reflects com- informants with a mandate to make decisions regard- patibility, a sub-construct of implementation climate ing the implementation obviously had an advantage (Damschroder et al., 2009), which is also an important in organizing dance groups. For others, issues with factor for diffusion (Rogers, 2003). Similar results have finding suitable co-workers and partners between been reported regarding the implementation of community and municipality, as well as finding solu- another dance intervention where the stakeholders’ tions regarding funding and solving practical pro- personal beliefs regarding the effects of the interven- blems, were time consuming. Lack of support from tion were important for convincing the organization the organization has been reported as a key barrier to to implement and support the dance intervention implementation (Demers & McKinley, 2015). Some (Demers, Thomas, Wittich, & McKinley, 2015). informants reported that collaborative strategies The dance intervention was perceived as compre- were useful to carry through the dance intervention, hensible and relevant by the informants. Further, it which can be understood with reference to several was perceived as a realistic and practically possible implementation frameworks highlighting cooperation intervention to implement. This reflects that the inter- and collaboration among local agencies (Durlak & vention was feasible, i.e., that it can be used within DuPre, 2008). the given context (Proctor, Silmere, Raghavan, Aarons, Fidelity to the original intervention varied; some & Griffey, 2011). In the taxonomy by Proctor and informants described high ambitions to follow the colleagues, feasibility is distinguished from appropri- original intervention, whereas others made modifica- ateness (or compatibility), as appropriateness is the tions to solve different contextual problems. A few perceived fit of an innovation while feasibility is the informants mentioned changing the inclusion criteria actual fit in terms of, for example, resources or other to gain a broader recruitment base. However, in a requirements (Proctor et al., 2011). qualitative study evaluating the intervention, it was found that the girls participating in the dance inter- vention experienced stress relief during the dance Convenient information class because it was a place where they did not feel critically evaluated, as they did in their daily life. The rate of adoption was infused by the way in which Further, it was found that connecting with other information could be passed on to others. The argu- girls with the same kind of problems as themselves ment that the intervention was based on research contributed towards feeling comfortable in the dance gave confidence to the advocates for the innovation group (Duberg et al., 2016). Changing the target and was used to convince peers and co-workers to group to include boys or girls without internalizing adopt the innovation. However, the research results, problems in order to recruit more adolescents to the or the fact that there was only one available effect groups may decrease the effectiveness of the inter- study, were not questioned or critically addressed by vention for the girls who need it most. The impor- any of the respondents, possibly indicating a high tance of a shared habitus and experiences in public trust in scientifically demonstrated results. The study health interventions has been emphasized in other results were available as popular science, and the intervention groups (Bunn, Wyke, Gray, Maclean, & intervention itself as well as the results were pre- Hunt, 2016; Coalter, 2013) and may be equally impor- sented in a straightforward manner. According to tant for adolescent girls with internalizing behaviour. Damschroder et al. (2009), ease of access to digestible However, more research is needed to find out information regarding an intervention and how to use whether mixed groups can be as effective. it practically in organizations increases the readiness for implementation. The information and knowledge can come from experts, staff, documents and compu- Methodological considerations terized systems. Regarding the dance intervention, information from experts was in the form of both This study has a number of shortcomings that must research literature and a film clip. The importance of be addressed. The voluntary nature of participation design and packaging is a construct from CFIR that in the study means that the stakeholders who chose seems to be less well addressed than other constructs to participate may differ from those who declined in implementation studies (Ilott, Gerrish, Booth, & participation. Reasons for declining participation Field, 2013). However, in the present study, this included changed work situation, perceived recall seemed to be of particular importance in the rapid bias or a non-response to the invitation. Possibly, diffusion of the intervention. the individuals who accepted participation were more interested in the intervention or represented organizations where the implementation had been Contextual factors more successful, and they therefore had the inter- The informants mentioned several difficulties that vention more at the forefront of their mind. The arose during the implementation process. Overall, participants represented various organizations, INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 7 positions, levels of work experience, genders and Acknowledgements ages, which contributed to a large variation in the The authors would like to thank the informants for their sample. This heterogeneity increases the possibility participation in the study. of viewing the implementation of the dance inter- vention from different angles, which can be consid- ered as a strength of the study. Transparency was Disclosure statement sought by describing the sampling procedure and No potential conflict of interest was reported by the data analyses in detail. authors. Telephone interviews were used for the data col- lection. A disadvantage associated with this method is the limited interaction, e.g., changes in body language Funding and facial expressions are lost (Musselwhite, Cuff, This work was supported by the Medical Research Council McGregor, & King, 2007). However, the perceived of Southeast Sweden (Forskningsrådet i Sydöstra Sverige). anonymity associated with telephone interviews may reduce response bias due to social desirability because the participants are less affected by the pre- References sence of an interviewer (Musselwhite et al., 2007). 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Office for Europe; 2016 (Health Policy for Children and doi:10.1186/s13012-015-0242–0 Adolescents, No. 7). http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal of Qualitative Studies on Health and Well-being Taylor & Francis

Exploring experiences among adopters during the diffusion of a novel dance intervention in Sweden

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INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 2018, VOL. 13, 1438697 https://doi.org/10.1080/17482631.2018.1438697 Exploring experiences among adopters during the diffusion of a novel dance intervention in Sweden a b a a c Noomi Carlsson , Agneta Kullberg , Ida-Klara Johansson , Paula Bergman , Janna Skagerström and Agneta Andersson a b Public Health & Healthcare, Regional Executive Office, Jönköping, Sweden; Division of Community Medicine, Social Medicine and Public Health Science, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden; Research & Development Unit in Local Health Care, and Department of Medicine and Health Sciences, Linköping University, Linköping, Sweden ABSTRACT ARTICLE HISTORY Accepted 5 February 2018 There is a demand for interventions aimed at adolescent girls with psychosomatic problems. In 2013, positive results were reported from a dance intervention programme addressing girls KEYWORDS with internalizing problems. The research team behind the intervention immediately received Implementation; requests from municipalities and county councils interested in using the intervention. From psychosomatic; diffusion; an implementation point of view it is unclear what made the intervention spread without an innovation; dance active plan. The aim of this study was to explore adopters’ experiences about the diffusion intervention and initiation of a public health intervention targeting adolescent girls with internalizing problems. Interviews were conducted with 12 people who were engaged in initiating the intervention in different settings. Data were analysed using conventional content analysis, yielding three categories: perceived appeal and trustworthiness, convenient information, and contextual factors. The results reflected that the participants found that there was a need for an intervention and found the dance intervention to be evidence based and not too complex to perform. Further, there was available information on the project which could easily be distributed to decision makers and others. When initiating the intervention, factors related to economy, possibility for collaboration and recruitment were of importance. rated health at 12 and 20 month follow-up (mean Introduction difference 0.62 and 0.40) and was a positive experi- Psychosomatic symptoms and mental health pro- ence (Duberg et al., 2013). In a qualitative study, girls blems among adolescents have increased rapidly who had participated in the dance intervention worldwide in recent years (Bor, Dean, Najman, & expressed that the intervention had given them a Hayatbakhsh, 2014). According to the World Health feeling of being free, and increased self-trust and Organization (2012, 2016), Sweden has seen a parti- confidence (Duberg, Möller, & Sunvisson, 2016). The cularly large increase in mental health problems. The dance intervention, organized as a complement to the prevalence of self-rated psychosomatic problems school health services, was demonstrated to be cost- among Swedish adolescents has increased in the effective compared with usual school health services past few decades, as has the number of contacts alone (Philipsson, Duberg, Möller, & Hagberg, 2013). with inpatient, outpatient and primary care due to Despite the relatively limited scientific evidence at psychosomatic illness (Folkhälsomyndigheten, 2016). the time, the intervention received widespread media All health care in Sweden is publicly funded by taxes coverage and the research team immediately received and mainly organized by two authorities: county requests to educate dance instructors and instruct councils and local municipalities. Throughout them how to set up the intervention in other loca- Sweden, these authorities are trying to tackle this tions across Sweden. In conjunction with the research complex public health issue and the political pressure process, the research team at Örebro University on decision makers is considerable. offered courses for dance instructors according to A dance intervention programme for adolescent the dance intervention programme. Although the girls with internalizing problems, i.e., with stress and intervention has spread to several municipalities, it is psychosomatic symptoms, was developed and a ran- still unclear what characteristics of the intervention domized controlled trial was performed by a Swedish made it spread without an active dissemination plan. research team and published in JAMA Pediatrics in The gap between research and practice has been 2013 (Duberg, Hagberg, Sunvisson, & Möller, 2013). widely reported and discussed. Traditionally, the pub- Evaluations show that the intervention improved self- lic health impact of intervention studies has not been CONTACT Noomi Carlsson [email protected] Folkhälsa och sjukvård, Region Jönköpings län, Box 1024, Jönköping 551 11, Sweden © 2018 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 2 N. CARLSSON ET AL. the concern of health researchers (Bauer, The dance instructors were asked to provide contact Damschroder, Hagedorn, Smith, & Kilbourne, 2015). information for their stakeholders in decision making However, interest in implementation science has and/or collaboration partners in the dance interven- grown in the past few decades to study what influ- tion. Among 27 potential informants provided by the ences the implementation of new practices (including dance instructors, 18 were strategically selected and interventions, programmes and services) and what asked to participate in the study. Most of the selected strategies might be effective to support implementa- informants had a directorship. The nine potential tion. Numerous so-called determinant frameworks informants who were not asked to participate were have been developed to describe barriers and facil- on sick leave, had a new job or had a peripheral itators that influence the implementation and use of position in relation to the dance project. To generate new practices (Nilsen, 2015). Most of these frame- a variety of experiences of the intervention process, works describe three types of determinants that influ- selection was based on the organizational role of the ence implementation: perceived attributes of the respondents. Further, heterogeneity regarding the practice (e.g., complexity and relative advantage in municipality or counties where the respondents relation to the current practice); individual character- worked was sought to capture the diffusion of the istics of the users of the new practice (e.g., attitudes, intervention in different settings. The potential infor- beliefs and motivation concerning the new practice); mants were informed about the study design and and contextual factors (e.g., organizational support purpose via e-mail in November 2014 and a reminder and support from colleagues and time constraints) was sent in December 2014. (Cochrane, Olson, Murray, Dupuis, Tooman, Hayes., Twelve of the 18 potential informants agreed to be 2007; Damschroder et al., 2009; Grol, Wensing, & interviewed and were contacted by telephone to Eccles, 2005; Rycroft-Malone & Bucknall., 2010). The schedule a semi-structured telephone interview. The frameworks also address various strategies that sup- informants represented four different regions in port implementation, ideally accounting for as many southern Sweden and were all employed in munici- determinants as possible to achieve successful imple- palities or county councils. Most were employed mentation of a new practice (Bauer et al., 2015). either in public health departments or in children Despite the fact that implementation science has and education or culture departments. The infor- identified many implementation barriers, new prac- mants’ professions included public health planner, tices sometimes spread by themselves, without the physiotherapist, and manager or coordinator in school use of any conscious strategies. Rogers’ diffusion of health, public health or health care. Eleven of the 12 innovations theory (Rogers, 2003) deals with the respondents were women. Most of the informants spontaneous spread of new practices, i.e., innovations. were community officials, decision makers and/or pro- The theory posits that diffusion of new practices in a moters of the dance project. Three of them had also social context, e.g., health care, is influenced by a participated in the course to become a dance instruc- number of factors, including the setting, the users, tor. Five people did not answer our e-mail or declined the perceived need for the intervention and external to participate. influences. Several implementation frameworks are influenced by the work of Rogers and have identified Procedure similar factors as being important (Damschroder et al., 2009; Greenhalgh, Robert, Bate, Macfarlane, & The interview guide was based on Rogers’ attributes Kyriakidou, 2005; Gurses et al., 2010). However, more of innovations, relative advantage, compatibility, com- research is needed to understand how public health plexity, trialability and observability (Rogers, 2003). interventions are perceived and spread within politi- For example, the question “How do you view the cally controlled organizations outside the health-care dance intervention in relation to how you have sector. worked before?” was intended to capture relative The aim of the present study was to explore adop- advantage, “Did introduction of the dance interven- ters’ experiences of the diffusion and initiation of a tion meet your expectations to intervene with the public health intervention targeting adolescent girls target group?” to capture compatibility and with internalizing problems, i.e., stress and psychoso- “Describe your experiences of initializing the dance matic symptoms. intervention” to capture complexity. The guide contained questions on initial contact with the dance intervention, reasons for considering Methods the intervention, response to the intervention, initia- tion process and goals of the intervention. Twelve Recruitment and informants telephone interviews were conducted by N.C. and A. Individuals who participated in the courses to become K., six by each author. The interviews were recorded a dance instructor during 2013–2014 were contacted. and lasted on average 27 minutes (range 19– INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 3 43 minutes). All interviews were performed in Swedish Perceived appeal and trustworthiness and transcribed by a professional transcriptionist, and The dance intervention filled a clear and pent-up selected quotations were then translated into English demand for a solution to a public health problem. In by a professional translator. addition, the intervention was perceived as trust- worthy by the fact that positive results were pub- lished in a scientific journal, and it also endorsed the Analysis informants’ own beliefs and expectations. The data were analysed using conventional content Pent-up demand analysis according to Hsieh and Shannon (2005). The Enhanced pressure from the political leadership about interviews were transcribed verbatim and read by all handling the increasing prevalence of psychological authors several times to obtain a sense of the whole. health problems among adolescents was described by Initially, the transcribed text was coded by N.C. and A. the participants. This was seen as a challenge within their K. separately. The data material was structured into professional assignment as they perceived a paucity of meaning-bearing units and then condensed, and sub- options. The informants expressed that, at the time when categories and main categories were constructed. they first heard about the dance intervention, they had Throughout the analysis process, all the main cate- limited or no interventions to offer the target group. gories and codes were discussed among all the authors until consensus was reached. Verbatim quota- Yes, well the issue was actually raised in political forums because mental ill health is a major problem with us, so it tions are provided to illustrate each subcategory. has actually been a prioritized area for a number of Selected citations were translated by a professional years. (IP1) translator. The respondents recognized the dance project as an intervention that, from several aspects, was realistic to achieve and thus offered a possible solution to face the Ethics challenge described above. Described advantages of the The study was approved by the Regional Ethical Board dance intervention were the focus on a distinct health- in Uppsala, Sweden (Dnr 2014/090). The participants promoting activity and the possibilities to perform the were informed that the material from the interviews intervention within a reasonable budget and training would be presented in a way that guaranteed con- initiative. fidentiality. Informed consent was obtained by the participants’ positive replies to the e-mail. Verbal con- Perceived as evidence based sent was also obtained at the start of the interview. Another benefit of the intervention expressed by the Participants were also told that they could discon- informants was that research had been conducted tinue their participation at any time. and published in a highly regarded scientific journal, showing positive results. The fact that research had been conducted gave the respondents a sense of trust in the method regarding its potential to have a Results positive impact on the target group. The opportunity The analysis resulted in three main categories and 10 to use and adopt a developed and assessed interven- sub-categories (Table I). Verbatim quotations from the tion gave a sense of quality and safety in the planning interview persons (IPs) are used to illustrate the find- and implementation of the dance classes. ings and show a link to the original data, and are It is something that has been researched, there are numbered at random. good results, it is a target group that we are to prioritize. [. . .] I think that it has massive importance that it has been researched. (IP11) Table I. Overview of the results presented as categories and sub-categories. Endorsement of own beliefs Main category Sub-category For some of the informants, the positive research Perceived appeal and Pent-up demand trustworthiness results strengthened their own perception of dance Perceived as an evidence-based as a positive influence on health. It was also some- method Endorsement of own beliefs thing that they expressed as a strong argument with Convenient information Information channels colleagues and political leaders. Transferable concept Contextual factors Organizational position Ah, personally I am really passionate about this and I Collaborative strategies Personal competence and qualities have always believed in it, so it was fantastic that Time constraints there is now scientific proof that dance is a good Reach of the intervention thing. (IP6) 4 N. CARLSSON ET AL. Convenient information position in the field of public health. They had the mandate, knowledge and/or the assignment to The informants picked up information about the inno- implement the intervention, and a few informants vation through several channels, through the Internet, could take the decision to implement the project from colleagues or through informal channels. How the themselves. For informants not in a decision-making innovation was presented played a vital role, because it position, it was sometimes hard to convince leaders was easy to repeat the message and pass it on to others. about the importance of the intervention, and sev- eral attempts had to be made to persuade manage- Information channels ment to implement the intervention. The media seems to have played a vital role in the Yes, it has gone well, it has, it takes a lot of work to diffusion of the intervention. Apart from the articles keep relationships going. [. . .] [We] found people who published in a scientific journal and presentations were interested in this who were managers or super- given at scientific meetings, the intervention has visors or who had authority from them so it could be been positively depicted in local newspapers as well carried it out in a good way. (IP8) as on news reports on television, radio and Internet (YouTube). The informants described that their initial Collaborative strategies contact with the dance intervention was primarily Most of the informants expressed that establishing through networks connected to their profession, the idea within the organizations as well as at the newsletters and e-mail lists. It may also have been a political level played a vital role in the outcome of the direct call from a manager or political leader to assess implementation of the dance intervention. To achieve the information about the dance intervention and durability in the project, financial resources and give an opinion on whether it could be useful in devoted staff were described as key components. their organization. . . . it is so important that you build up a foundation Transferable concept like we have done. Do the prep work, and then make A facilitating circumstance for the diffusion of the sure that each stage is anchored in it. (IP8) intervention was that the information about the The informants described different collaborative dance intervention was perceived as appealing to arrangements between and within municipalities the informants. The short film clip explaining the and county councils as necessary for the implementa- intervention made the information accessible and tion of the dance intervention. For example, coordi- easy to pass on via e-mail or to show in a meeting. nating groups were specially set up for the The day before there had been a report on it on implementation process. Collaboration arose exclu- Aktuellt [the current affairs TV programme]. Because sively where the dance project was adopted and the research had been published and was interna- appeared in diverse ways depending on the resources tionally recognized, the link was active for a long within the organization. The informants expressed a time. So we could send it to other people to help wish to collaborate across organizational boundaries describe what it was. (IP11) but described the structure for collaboration between the organizations as vague. Some of the respondents Contextual factors claimed that none of the organizations wanted to take on the main responsibility or be in charge of Decision-making powers in implementing the dance the financial resources. They also experienced diverse project varied among the informants but they all opinions regarding the responsibility for the interven- faced the need to firmly establish the idea inside tion and/or target group. their organization as well as externally in collabora- tion with others. The main factors hindering the initia- No, then I said that I thought it sounded interesting tion process were limited time within the office and/ but that there needed to be a few others from the county council involved; it can’t just be put on the or difficulties finding staff with the required compe- municipality I thought. (IP3) tence and qualities. Finding the right means to finance the intervention was sometimes difficult, A key element in the original dance intervention is often because of joint financial responsibilities that it was free of charge for the participating girls, between municipalities and county councils. including transportation to the dance classes. Because of the societal structure in Sweden, in most scenarios Organizational position described by the informants, the dance intervention The informants’ position in their organization dif- thus required shared financial responsibility between fered, which was reflected in their approach and county councils and municipalities. The joint financial advocacy opportunities when initiating the dance responsibility was described as a predicament by intervention. Half of the respondents had a strategic some informants. INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 5 problems, i.e., stress and psychosomatic symptoms. Personal competence and qualities The informants mentioned several factors that may The informants described the recruitment of a dance have had an impact on the diffusion of the dance instructor with special professional and personal qua- intervention. There was a demand for some kind of lities as a key factor in the outcome of the dance intervention aimed at adolescent girls; the dance intervention. Social skills and the ability to create a intervention was perceived as evidence based and sense of undemanding kinship with the girls seemed compatible with the informants’ beliefs and values. critical. Skills such as empathy and motivation were Further, information regarding the intervention was also key features. For some of the informants, the packaged in an appealing format and was easy to recruitment of a suitable dance instructor proved to pass on. The initiation was hindered and/or facilitated be a challenge. by local conditions concerning, for instance, organiza- . . . I am completely convinced that even if you recruit tional factors, recruitment of dance instructors and a really competent dance teacher who doesn’t have participants, and time constraints. these qualities or social skills, or even some of them, you are not going to get the same results. (IP1) Perceived appeal and trustworthiness Time constraints Some of the results in our study can be understood Some informants described that the time required to with reference to Rogers’ diffusion of innovations the- recruit a person with the right qualities to start the ory (Rogers, 2003) and subsequent implementation dance course for instructors was limited. Others frameworks such as the ecological framework con- described that they had to act within a limited time- structed by Durlak and DuPre (2008) and the frame to get the intervention started. The time limits Consolidated Framework for Advancing were described by the informants as negative for the Implementation Research (CFIR) developed by results of the implementation. Damschroder et al. (2009). The perceived relative I had about two weeks to try to recruit teachers for advantage, i.e., the degree to which an innovation is the course so we were really, really short of time. [. . .] perceived as better than what it supersedes, is one of then we found out, probably through rumours, that it the key elements in Rogers’ theory. In the extensive was the last time the course would be held. (IP4) framework and review conducted by Durlak and DuPre (2008), the perceived need for an innovation Reach of the intervention as well as perceived benefits of the innovation desired Informants expressed difficulties regarding recruit- at the local level were found to be consistently related ment of girls who were eligible to take part in the to positive implementation results. Further, the infor- dance groups. The target group was small and sensi- mants expressed that the expected benefits of the tive to dropout. To recruit participants to the dance innovation came at a relatively low cost, with the groups, exceptions from the original intervention perceived promise of rapid results for the target were made and, for example, girls without internaliz- group (Philipsson et al., 2013). This perception ing problems were included. Other informants explains the interest in the innovation. Providers described that they were eager to make sure that who see a specific need for an intervention, believe the intervention was followed as intended. Further, that the intervention can produce benefits, and have some informants struggled with equality issues and the skills and confidence to do what is expected from felt they had to offer the intervention to boys as well. them have been found to be more likely to imple- . . . we could relax the rules a little too; then we could ment intervention programmes with a high level of say that all the girls who wanted to could join in. fidelity (Durlak & DuPre, 2008). (IP10) In this study, the respondents expressed that they Another concern described by some informants was were particularly susceptible to the innovation at that if the dance intervention included only a small hand because it filled a gap between pressing group of girls, the intended public health effect would demands from the political leadership calling for not be reached. Projects aimed at a larger group of action for adolescent girls with psychological health young people seemed preferable in order to decrease problems and available public health innovations tar- the prevalence of psychological health problems geting this group. This fits well with what is labelled among adolescents. tension for change in the CFIR. Tension for change is part of the implementation climate; if the current situation is perceived as intolerable by stakeholders Discussion and there is a need for change, this contributes to a The aim of this study was to explore experiences of positive implementation climate (Damschroder et al., the diffusion and initiation of a public health inter- 2009). Further, the results in the present study show vention targeting adolescent girls with internalizing that the scope of the intervention was in concordance 6 N. CARLSSON ET AL. with individual and personal beliefs. This reflects com- informants with a mandate to make decisions regard- patibility, a sub-construct of implementation climate ing the implementation obviously had an advantage (Damschroder et al., 2009), which is also an important in organizing dance groups. For others, issues with factor for diffusion (Rogers, 2003). Similar results have finding suitable co-workers and partners between been reported regarding the implementation of community and municipality, as well as finding solu- another dance intervention where the stakeholders’ tions regarding funding and solving practical pro- personal beliefs regarding the effects of the interven- blems, were time consuming. Lack of support from tion were important for convincing the organization the organization has been reported as a key barrier to to implement and support the dance intervention implementation (Demers & McKinley, 2015). Some (Demers, Thomas, Wittich, & McKinley, 2015). informants reported that collaborative strategies The dance intervention was perceived as compre- were useful to carry through the dance intervention, hensible and relevant by the informants. Further, it which can be understood with reference to several was perceived as a realistic and practically possible implementation frameworks highlighting cooperation intervention to implement. This reflects that the inter- and collaboration among local agencies (Durlak & vention was feasible, i.e., that it can be used within DuPre, 2008). the given context (Proctor, Silmere, Raghavan, Aarons, Fidelity to the original intervention varied; some & Griffey, 2011). In the taxonomy by Proctor and informants described high ambitions to follow the colleagues, feasibility is distinguished from appropri- original intervention, whereas others made modifica- ateness (or compatibility), as appropriateness is the tions to solve different contextual problems. A few perceived fit of an innovation while feasibility is the informants mentioned changing the inclusion criteria actual fit in terms of, for example, resources or other to gain a broader recruitment base. However, in a requirements (Proctor et al., 2011). qualitative study evaluating the intervention, it was found that the girls participating in the dance inter- vention experienced stress relief during the dance Convenient information class because it was a place where they did not feel critically evaluated, as they did in their daily life. The rate of adoption was infused by the way in which Further, it was found that connecting with other information could be passed on to others. The argu- girls with the same kind of problems as themselves ment that the intervention was based on research contributed towards feeling comfortable in the dance gave confidence to the advocates for the innovation group (Duberg et al., 2016). Changing the target and was used to convince peers and co-workers to group to include boys or girls without internalizing adopt the innovation. However, the research results, problems in order to recruit more adolescents to the or the fact that there was only one available effect groups may decrease the effectiveness of the inter- study, were not questioned or critically addressed by vention for the girls who need it most. The impor- any of the respondents, possibly indicating a high tance of a shared habitus and experiences in public trust in scientifically demonstrated results. The study health interventions has been emphasized in other results were available as popular science, and the intervention groups (Bunn, Wyke, Gray, Maclean, & intervention itself as well as the results were pre- Hunt, 2016; Coalter, 2013) and may be equally impor- sented in a straightforward manner. According to tant for adolescent girls with internalizing behaviour. Damschroder et al. (2009), ease of access to digestible However, more research is needed to find out information regarding an intervention and how to use whether mixed groups can be as effective. it practically in organizations increases the readiness for implementation. The information and knowledge can come from experts, staff, documents and compu- Methodological considerations terized systems. Regarding the dance intervention, information from experts was in the form of both This study has a number of shortcomings that must research literature and a film clip. The importance of be addressed. The voluntary nature of participation design and packaging is a construct from CFIR that in the study means that the stakeholders who chose seems to be less well addressed than other constructs to participate may differ from those who declined in implementation studies (Ilott, Gerrish, Booth, & participation. Reasons for declining participation Field, 2013). However, in the present study, this included changed work situation, perceived recall seemed to be of particular importance in the rapid bias or a non-response to the invitation. Possibly, diffusion of the intervention. the individuals who accepted participation were more interested in the intervention or represented organizations where the implementation had been Contextual factors more successful, and they therefore had the inter- The informants mentioned several difficulties that vention more at the forefront of their mind. The arose during the implementation process. Overall, participants represented various organizations, INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 7 positions, levels of work experience, genders and Acknowledgements ages, which contributed to a large variation in the The authors would like to thank the informants for their sample. This heterogeneity increases the possibility participation in the study. of viewing the implementation of the dance inter- vention from different angles, which can be consid- ered as a strength of the study. Transparency was Disclosure statement sought by describing the sampling procedure and No potential conflict of interest was reported by the data analyses in detail. authors. Telephone interviews were used for the data col- lection. A disadvantage associated with this method is the limited interaction, e.g., changes in body language Funding and facial expressions are lost (Musselwhite, Cuff, This work was supported by the Medical Research Council McGregor, & King, 2007). However, the perceived of Southeast Sweden (Forskningsrådet i Sydöstra Sverige). anonymity associated with telephone interviews may reduce response bias due to social desirability because the participants are less affected by the pre- References sence of an interviewer (Musselwhite et al., 2007). 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Journal

International Journal of Qualitative Studies on Health and Well-being – Taylor & Francis

Published: Jan 1, 2018

Keywords: Implementation; psychosomatic; diffusion; innovation; dance intervention

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