Henna Hasson

Research problem and specific questions: This program sheds light on the implementation challenges involved in changing health determinants to achieve improvements in public health. The aim of the program is to explore implementation challenges related to decision-making and practical implementation of structural interventions as well as preventive programs and their implication for health equity. The program combines expertise in public health and implementation science with the goal of identifying ways to close the gaps in health among societal groups. Data and method: The program builds on complexity theory to reflect that implementation of public health initiative involves multiple, often interdependent, stakeholders, decisions and activities. The program has three phases. The first is an exploratory qualitative phase including interviews with local politicians and administrators (in municipalities and regions) to understand how they make decisions about public health, including how the needs of different societal groups and conflicting societal goals are prioritized. The second phase involves several naturalistic experiments of local implementation and de-implementation cases investigating barriers and facilitators to these processes, strategies to overcome barriers, management of fidelity and adaptations and implementation outcomes. This entails a participatory approach in which the local actors implement initiatives and participate in collecting data. Analysis includes qualitative and quantitative cross-case comparisons. In the third phase, implementation capacity-building interventions aimed at decision-makers and implementers of public health initiatives are designed and evaluated. Relevance and utilisation: Although Sweden has one of the most developed welfare systems and ambitious public health policy goals, health inequalities are growing and systematic inequalities in health remain in almost all health outcomes and determinants. Implementation of structural interventions and preventive programs are needed, yet implementation research shows that these too often fail to reach, retain and deliver value to those most in need. If implementation between groups diverge, implementation of public health initiatives may increase rather than decrease health inequalities. This program addresses this contradiction by developing new knowledge on how public health initiatives can be implemented for disadvantaged populations. Plan for program realisation: This multidisciplinary program takes a participatory approach involving three research environments at two universities. A total of 63% of the costs cover salaries for the 12 participating junior and senior researchers. Operating costs (15%) include reference group reimbursement, communication activities and data collection.

Mental health problems in children and adolescents are a major public health concern. Anxiety is the most common problem, but only a minority of those affected receive adequate care. Access to early interventions within primary care has the potential to combat a detrimental trajectory for children and adolescents, but more research is needed. Today, there is a lack of studies exploring early interventions for anxiety adequate to implement within primary care.In response to the increasing mental health problems in children and adolescents in Sweden, a first line mental health (FLMH) has been developed. A challenge for the FLMH has been to identify evidence-based interventions fitting the needs of their patients and organization, as interventions almost exclusively have been developed and evaluated within a psychiatric context. Adaptations of evidence-based interventions are made regularly in everyday practice, but research shows that such adaptations typically are conducted reactively rather than proactively. Adaptations are made in response to practical restraints rather than to provide a better fit for the target group and commonly without considerations of how core components will be affected.The overall aim of this project is to increase access to evidence based interventions for children suffering from mild to moderate anxiety. Using a scientific method, we will develop an intervention targeting childhood anxiety adapted to fit within primary care. We will explore the process of adapting evidence-based interventions within the FLMH and evaluate the effect of the intervention in a randomized controlled trial conducted at FLMH-units. The project provides guidelines on how evidence-based interventions can be adapted in the FLMH. If proven effective, the intervention could be beneficial for a large part of the population and contribute to better public health. After development and evaluation in everyday clinical practice, implementation will be straight-forward.

To ensure the provision of health and welfare services of high quality, safety and cost-effectiveness, managers and professionals are required to implement changes such as new methods and guidelines. Despite this, managers and staff have little training and support in implementation. Lack of implementation capacity is particularly problematic since the new national knowledge-based management structure has the utmost goal that all professionals should use the best knowledge within every encounter with clients and patients. The management structure will provide knowledge-based methods but lacks a plan for how the health and welfare workforces should implement these in practice.The proposed project aims to investigate how implementation capacity can be built within health and welfare organisations by evaluating team training in evidence-based implementation.The Building Implementation Capacity (BIC) intervention builds on the Behaviour Change Wheel and considers implementation as a matter of behaviour change. The intervention will be provided to a total of 90 teams of both managers and staff working in health and welfare organisations. The intervention provides the participating teams with knowledge and skills in applying a systematic implementation model. A longitudinal mixed-methods evaluation will be applied to investigate the extent to which the intervention results in success in practical implementation and the extent to which it develops implementation capacity in the teams and the wider organisation.The uniqueness of this project is that it focuses not only on the implementation of a particular method or guideline, but also evaluates the development and sustainability of implementation capacity in participating organisations. As such, this project aims to contribute to understanding how work teams can build sustainable implementation capacity, and in doing so, contributing to fulfilling the goal of the new national knowledge-based management structure.

A large number of interventions used in health care lack evidence of effectiveness and may be unnecessary or even cause harm and should therefore be de-implemented. Lists of these types of ineffective (i.e., low-value) practices have become common, but these lists have little chance of leading to improvements without sufficient knowledge regarding how de-implementation can be carried out. Professionals’ decisions regarding de-implementing these practices are not only a matter of scientific evidence

the puzzle is far more complex with relational, economic and personal interests playing a role.This project aims to investigate how health care professionals navigate the landscape of their individual preferences, conviction of scientific evidence, patient requests and health care system goals to make decisions regarding de-implementation of low-value care.This multidisciplinary project is carried out in four steps, starting with an explorative design to study tensions health care professionals encounter when dealing with low-value practices. Thereafter, a factorial survey experiment will be applied to empirically test how professionals carry out decision-making while considering the tensions. A framework for professionals’ decision-making concerning de-implementation and intervention suggestions will be developed to guide de-implementation of low-value care in health care practice. The project contributes by providing new knowledge on how and why professionals make decisions related to low-value practices. It offers a wider contribution to the research on implementation in terms of closing the gap between research and practice. This project’s novel contribution lies in approaching this gap from the perspective of the care practices used in health care that lack evidence of effectiveness rather than studying how new evidence can be implemented.

As the prevalence of chronic illness increases, the demands on healthcare services change. The few hours per year that persons with chronic conditions see healthcare professionals represent a mere fraction of their 24/7 lived experience of coping with their condition. Without patient participation no treatment can be carried out

thus healthcare services are co-produced. This reality requires a shift from professional-oriented care toward patient-oriented supported self-care. Co-care refers to the decisions and activities shared by patients, their informal caregivers, and professionals, aimed at achieving goals valued by the patient. Consequently, in contrast to involve patients in healthcare, healthcare needs to get involved in people’s self-care, to the extent that the patient needs and desires. Making this shift, however, has been challenging for health care practice.Given this implementation gap, the current program is based on five patient-driven co-care innovations and aims to study how new models of self-care and co-care are best implemented in everyday health care practice and patients’ lives, supported by eHealth. This program is collaboration with patients, their informal caregivers and healthcare providers, to ensure that the research meets patients’ needs. The program is conducted in two phases studying: 1) the implementation of the five patient-driven co-care innovations and the development of patient-valued outcome measures and 2) the impact of the co-care innovations on clinical practice, care organization and patient-valued outcomes, the spread and scaling up of the innovations and production of best practice guidelines. Multiple research designs (e.g. comparative case studies, participatory workshops, adaptive intervention design) will be used. The program generates knowledge that enables people with chronic conditions, their informal caregivers and formal healthcare providers to effectively engage in co-care.