Getting Dressed for Success : Implementing Health-Promoting mHealth in Swedish Child and School Healthcare Services

Background: Implementing new interventions or new ways of working in welfare organizations is often challenging, even when their effectiveness is well established. This also applies to digital interventions, including mobile health (mHealth), which can support children’s and adolescents’ mental health and healthy lifestyle behaviors, but that have not yet become an established part of routine practice in child and school healthcare services in Sweden. Aim: To generate knowledge about the implementation of mHealth interventions that support health promotion practices during routine health visits in Swedish child and school healthcare. Studies: The thesis comprised four sub-studies, examining implementation during the preparation phase (Studies I and II) and the active implementation phase (Studies III and IV). Study I used a qualitative design to explore organizational readiness for mHealth implementation in child and school healthcare. Interviews were conducted with nurses, managers, and policymakers, and analyzed using inductive content analysis. Readiness was perceived as having trusting conditions for implementation. The capability to manage the health-related data generated by mHealth, together with governance at national, regional, and local levels, emerged as dealbreakers for readiness. Alignment between mHealth and current ways of working, along with camaraderie within teams, were also identified as important aspects of readiness. Study II employed a quantitative prospective observational design to assess six dimensions of organizational readiness, reflecting different aspects of preparedness and conditions for implementing mHealth among child healthcare nurses prior to implementation, and to examine their association with nurses’ subsequent mHealth adoption. Data on the six readiness dimensions were collected through questionnaires, and adoption data were retrieved from the mHealth child healthcare interface. Analyses included Rasch analyses, descriptive statistics, and regression-based methods. Nurses reported varying degrees of readiness across dimensions, however, none were significantly associated with adoption. Higher degrees of collegial readiness showed indications of potential relevance for adoption. Study III used a qualitative design to explore high school students’ perceptions of determinants influencing their adoption of a recommended mHealth tool during health visits. Data were collected through interviews and analyzed using inductive content analysis. The decision to adopt mHealth was shaped by students’ developmental stage and involved balancing personal beliefs with influences from peers and adults. Students emphasized the importance of alignment between the mHealth tool and their individual beliefs and experiences. Determinants also extended beyond the individual and the technology itself, underscoring the importance of raising awareness outside the health visit, as well as the presence of responsive and supportive adults within the school environment. Study IV employed a qualitative design with cross-case comparisons to investigate similarities and differences in implementation determinants across five schools with varying mHealth adoption levels. Determinants were explored through interviews with nurses and principals, and adoption was assessed through students’ charts. Most determinants were similarly manifested across schools. However, schools with higher adoption levels were characterized by stronger principal engagement, closer alignment between the mHealth intervention and student population needs, and clearer perceived regional guidance. While the implementation process was generally student-centered, the highest adopting-school also conducted systematic cross-professional implementation activities and exhibited an organizational culture aligned with the intervention. Conclusions: mHealth implementation is influenced by multilevel contextual factors across both inner and outer contexts. Some factors influence the entire process, while others are particularly decisive during the preparation phase. In this phase, organizational readiness is perceived as the presence of trusting conditions, where the ability to manage health-related data and clear governance structures act as dealbreakers for achieving readiness. Although the findings do not provide evidence of an association between organizational readiness and implementation outcomes, they indicate a trend suggesting that collegial readiness may relate to higher levels of implementation outcomes. Governance needs remain central throughout the implementation process and are strongly affected by the structural complexity of child and school healthcare services. Implementing mHealth within health visits alters routines beyond individual nurses and requires collective efforts both among nurses and across professional groups. The implementation involves a complex structural and social alignment between the intervention and the organizations, professionals, and end-users. Finally, end-users are central agents in implementation, shaping both the implementation process and its outcomes and their adoption of mHealth requires multifaceted, life-stage-tailored strategies that extend beyond individual health visits. Overall, mHealth implementation can be understood as a co-implementation process between end-users and professionals.