Exploring expectations and readiness for healthy lifestyle promotion in Swedish primary health care: a qualitative analysis of managers, facilitators, and professionals

Figures & data

Table 1. Description of participant characteristics.

Participants	Age, mean (min–max) years	Sex, Men/Women	Profession	Working years within primary care, mean (min–max) years
Individual interviews
Managers (n = 6)	47.8 (40–55)	1/5	1 Care administrator, 2 district nurses, 1 Midwife, 2 Physiotherapists,	15.7 (5–28)
Appointed internal facilitators (n = 10)	43.9 (31–58)	0/10	3 District nurses, 1 Midwife, 2 Nurses, 1 Occupational therapist, 3 Physiotherapists	9.35 (1.5–33)
Focus groups
A (n = 7)	48.4 (30–59)	2/5	1 Counsellor, 2 District nurses, 1 Midwife, 2 General practitioners, 1 Physiotherapist	10.4 (6 months −27)
B (n = 4)	41.5 (34–50)	0/4	1 Assistant nurse, 1 Counsellor, 1 Midwife, 1 Physiotherapist,	5.3 (4–7)
C (n = 4)	58.2 (49–63)	0/4	1 Counsellor, 2 District nurses, 1 Paediatric nurse,	12.8 (2–22)
D (n = 6)	50.3 (25–65)	1/5	1 Assistant nurse, 1 Care Administrator, 1 Counsellor, 1 District nurse, 1 General practitioner, 1 Physiotherapist	13.7 (3–36)
E (n = 5)	42.2 (26–49)	2/3	1 Counsellor, 1 District nurse, 2 General practitioners, 1 Physiotherapist	5.2 (3–9)

Table 2. Example of the data analysis process.

Quote	Category	CFIR sub-construct	CFIR construct	CFIR domain
We may have to schedule in another way, so they feel that they have the time and possibility to discuss this [lifestyle habits]	Allowing flexible working schedules to overcome time barriers	Available resources	Readiness for implementation	Inner setting
We need to improve our competence within this field. I realised (…) that there were quite many clichés that I thought were true. And yeah, I don’t think I’m the only one with little knowledge; instead, we all need more knowledge to dare have these conversations	Clarify why the change is needed and let us improve our competence	Access to information and knowledge

Table 3. Readiness for implementation – the perspectives of PHC managers, appointed internal facilitators and health care professionals.

PHC managers	Internal facilitators	Health care professionals
Leadership engagement supporting the implementation of health promotion
Top management should provide PHC managers support and communicate health promotion as a PHC commission.	All management levels should show that health promotion is important and part of routine practice.	Managers must show that health promotion practice is important and prioritised.
Show support by communicating the vision: health promotion needs to be carried out.	Managers should expect health promotion from us HCPs.	Managers must clarify this is what we do and what they expect from us.
Health-promoting practice requires participation from all HCPs and is therefore mandatory.	Managers should emphasise that health-promoting practice is mandatory.	Managers should clarify individual responsibility to participate in the health-promoting practice. The practice should be mandatory.
Provide time to plan and prepare.	Need time to plan and prepare.	Need time to plan and prepare.
Provide education, tools, and follow-up goals.	Expect to work as a team with managers to push, remind, follow up, provide feedback, and acknowledge HCPs’ efforts and ideas.	Warrant opportunities to learn more for professional development and improved competence.
Available resources – resources supporting the change into a health promotion practice
Considering minor changes in working schedules to support and solve tight working schedules and lack of personnel.	Need to feel free to change work schedules to have time to discuss lifestyle behaviour change with patients.	Staff shortage and high workload require more flexible working schedules and more time to discuss lifestyle with patients.
Access to information and knowledge supporting the change into a health promotion practice
All HCPs need to understand the intentions of the health-promoting practice.	All HCPs need to know why they engage in a health-promoting practice.	HCPs need to understand and relate to why they engage in a health-promoting practice.
All HCPs need rapid and updated knowledge of lifestyle habits and motivational interviewing.	HCPs’ competence varies and increased knowledge of lifestyle habits and skills in motivational interviewing is warranted.	Uncertain to raise questions on lifestyle habits because of insufficient knowledge. Managers should offer education for all HCPs at different levels.
All HCPs need to know how to refer patients to HCPs with higher competence.	Building inter-professional teams with HCPs having expertise would increase the quality of lifestyle interventions.	Building inter-professional teams with HCPs having expertise would improve the quality of lifestyle interventions.
Routines, checklists, manuals, and training would support the HCPs.	Routines, flowcharts, and checklists would support HCPs.	Routines, flowcharts, and checklists for reminders and help to provide equal care.

PHC: primary health care. HCP: health care professionals.

Table 4. Implementation climate and engaging for the health-promoting practice – the perspectives of PHC managers, appointed IFs and health care professionals.

PHC managers	Internal facilitators	Health care professionals
Relative priority of the health-promoting practice
Need for clarified goals regarding the PHC commission on health promotion.	Managers should communicate that health promotion is a highly prioritised commission and a work task for all HCPs.	Need to clarify goals on prevention and health promotion with other goals, such as accessibility to PHC.
Need for top management support in prioritising health promotion and integration into ordinary routines.	Health promotion needs a higher priority. If understaffed, health promotion most easy to omit.	Need support to prioritise health promotion among patients and work tasks.
Organisational incentives and rewards supporting the change into a health-promoting practice
Economic incentives can enable initial prioritisation, but not in the long run.	Economic incentives may enable prioritisation.	Economic incentives can have negative consequences, such as opportunism.
Health promotion should have high priority in regulatory documents, including goals, follow-ups, and rewards.	Follow-ups and rewards are required to improve health promotion practice.	Follow-ups and rewards are needed to improve health promotion practice.
Engaging: support internal facilitators (IFs) and primary health care (PHC) managers to implement a health-promoting practice
PHC managers		Internal facilitators
The IFs should become experts in health promotion and champions for the practice of health promotion.		Need for increased knowledge on lifestyle habits and motivational interviewing, and how to encourage and support co-workers.
Expect support from external facilitators and share ideas and experiences with other managers.		Working in pairs, support from the manager and external facilitators, and the time set for the assignment would facilitate the work of IFs.

PHC: primary health care; IF: internal facilitator; HCP: health care professional.

Table A1. Interview guide for interviews with managers.

Interview question	CFIR domain, construct and sub-construct
How would you describe the engagement of higher manager levels?	Inner setting – Readiness for Implementation Leadership Engagement
What driving forces would motivate you to lead this work and be a part its success?	Inner setting – Implementation Climate Organizational Incentives and Rewards
How will the health-promotion practice be handled among other, competing, missions and tasks?	Inner setting – Implementation Climate Relative Priority
What changes are needed to implement the practice at the PHC centre?	Inner Setting – Structural Characteristics or Available resources
Do you have a plan for the implementation at your PHC centre?	Implementation Process – Planning, Engaging
What do you expect your employees to do?	Inner setting – Readiness for Implementation Leadership Engagement
What do you think your employees may need to start working according to the health-promotion practice?	Inner setting – Readiness for Implementation Leadership Engagement
How will you engage your employees?	Inner setting – Readiness for Implementation Leadership Engagement
What kind of support may you need?	Inner setting – Readiness for Implementation Leadership Engagement

Table A2. Interview guide for interviews with internal facilitators.

Interview question	CFIR domain, construct and sub-construct
Your mission as an internal facilitator is to support your colleagues at the PHC centre, how confident do you feel?	Implementation Process – Formally Appointed Internal Implementation Leaders
How will you start?	Implementation Process – Formally Appointed Internal Implementation Leaders
What kind of support do you think you will have to provide to your colleagues?	Implementation Process – Formally Appointed Internal Implementation Leaders
How do you think your manager will value your efforts as internal facilitator?	Inner setting – Implementation Climate Organizational Incentives and Rewards
What kind of support do you think you will need to accomplish your mission as an internal facilitator?	Implementation Process – Formally Appointed Internal Implementation Leaders
What may trigger your colleagues to work more health-promoting?	Implementation Process – Engaging
What changes might be needed so that you and your colleagues can work according to this health-promoting practice?	Inner Setting – Structural Characteristics or Available resources
How will this health-promoting practice be prioritised among other, competitive, work tasks?	Inner setting – Implementation Climate Relative Priority

Table A3. Interview guide for focus group discussions with health care professionals.

Interview question	CFIR domain, construct and sub-construct
What would motivate you to work more health promoting according to this practice?	Characteristics of individuals – Knowledge and Beliefs about the Intervention
How confident do you feel in your ability to implement this practice?	Characteristics of individuals – Self-efficacy
What would trigger you to ask your patients about their lifestyle habits and health?	Implementation Process – Engaging
How will this health-promoting practice be prioritised among other, competitive, work tasks?	Inner setting – Implementation Climate Relative Priority
What would facilitate for you to work according to this health-promoting practice?	Implementation Process – Engaging
What changes might be needed so that you and your colleagues can work according to this health-promoting practice?	Inner Setting – Structural Characteristics or Available resources
What kind of support to do expect from your manager or others to succeed with this?	Inner setting – Readiness for Implementation Leadership Engagement

Table

CFIR domain and construct	CFIR general definition construct	CFIR sub-construct	CFIR general definition sub-construct	Adapted definition	Category^a
Inner Setting
Readiness for Implementation	Tangible and immediate indicators of an organizational commitment to its decision to implement an innovation.	Leadership Engagement	Commitment, involvement, and accountability of leaders and managers with the implementation of the innovation.	Commitment, involvement, and accountability of PHC middle and top managers with the implementation of the health promoting practice.	Show manager support and clear communication Engage by communicating vision and goals State mandatory to participate
		Available Resources	The level of resources organizational dedicated for implementation and on-going operations including physical space and time	The level and type of present or absent resources in PHC for implementation of the health promoting practice, including staffing and time and how to overcome these barriers.	To have flexible working schedules would overcome time barriers
		Access to Knowledge and Information	Ease of access to digestible information and knowledge about the innovation and how to incorporate it into work tasks.	Ease of access to digestible information and knowledge about health promotion needed to develop and integrate it into work tasks.	Clarify why the change is needed and let us improve our competence Practical support
Implementation Climate	The absorptive capacity for change, shared receptivity of involved individuals to an innovation, and the extent to which use of the innovation will be rewarded, supported, and expected within their organization.	Relative Priority	Individuals’ shared perception of the importance of the implementation within the organization.	PHC managers and HCPs’ perceptions of the importance of the implementation of a health promoting practice within PHC .	Clarify goals and commissions on health promotion Top management supporting high priority of health promotion
		Organizational Incentives and Rewards	Extrinsic incentives such as goal-sharing, awards, performance reviews, promotions, and raises in salary, and less tangible incentives such as increased stature or respect	Extrinsic incentives such as goal sharing, awards, rewards, financial incentives, and less tangible incentives.	Pros and cons of economic incentives Need for follow-ups and rewards
Process
Engaging	Attracting and involving appropriate individuals in the implementation and use of the innovation through a combined strategy of social marketing, education, role modelling, training, and similar activities.	Formally Appointed Internal Implementation Leaders	Individuals from within the organization who have been formally appointed with responsibility for implementing an innovation as coordinator, project manager, team leader, or other similar role.	Individuals from within the PHC centres who have been formally appointed with responsibility for implementing the health promoting practice at their PHC centre as an internal facilitator.	Appointment of internal facilitators and their role
		External Change Agents	Individuals who are affiliated with an outside entity who formally influence or facilitate innovation decisions in a desirable direction.	Individuals who are affiliated with an outside entity who formally support the PHC centres and facilitate the implementation of the health promoting practice in a desirable direction.	Support to engage co-workers at the PHC centres

PHC: Primary health care.

^a Categories were created within the CFIR constructs following the principles of deductive content analysis [36].

Elo S, Kyngäs H. The qualitative content analysis ­process. J Adv Nurs. 2008;62(1):107–115. doi: 10.1111/j.1365-2648.2007.04569.x.

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Data availability statement

The datasets generated and analysed during the current study are not publicly available because they contain information that could compromise the integrity of the participants but are available from the corresponding author at reasonable request.