Implementation Research on the Effects and Results of a National Health Promotion Project


The purpose of this study was to describe the implementation of the Finnish government’s 2017-2018 key project titled “Effective lifestyle counselling for social and health care cross-functionally” (VESOTE) in primary health care organizations in Southwest Finland. The study also aimed to illustrate the project’s impacts on nursing practices in primary health care organizations in terms of lifestyle counselling. Data were collected from all of the primary health care organizations in Southwest Finland by using a questionnaire. The data were analyzed qualitatively and by using descriptive statistics. The participants considered the VESOTE project important in terms of its contents. However, only individual measures of the project were adopted into practice. Organizations require tools to monitor the implementation of a new operating model. This should be taken into account when launching national projects.

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Dalbom, L. , Tuominen, M. , Löyttyniemi, E. and Rautava, P. (2023) Implementation Research on the Effects and Results of a National Health Promotion Project. Health, 15, 695-709. doi: 10.4236/health.2023.156044.

1. Introduction

Finland is currently undergoing a significant restructuring of its health and social services. The aim of the reform is to reduce health and welfare inequalities and ensure equal and high-quality health and social services.

New working methods are slow to take root in practice in social welfare and health care. Research methods concerning the diffusion of proven practices, implementation of research evidence and assessment of impacts are needed [1] .

This study examines a key project on the promotion of national health with regard to the success of the project’s regional implementation and execution. The project was carried out during Prime Minister Sipilä’s government term in 2015-2019. All in all, the key project received funding of EUR 2.7 million, and 11 areas of the hospital district participated in the project. The allocated funding for the district examined in this study was EUR 232,800.

The purpose of health policy is to influence public health. An important instrument in fulfilling health policy goals is the promotion of health and welfare at individual, community and population levels [2] [3] . When it comes to promoting health and welfare at the population level, the broad objectives of the government, cross-functional policy programmes and the role of non-governmental actors are of major importance [4] [5] . Implementation is often carried out through national development projects, where the financing for implementation is tied to the funding given by the state to municipalities [6] .

In the 21st century, many different projects to promote national welfare and health have been executed in Finland as tools of strategic guidance. The National Development Programme for Social Welfare and Health Care (KASTE) was carried out in 2008-2011. It served as a tool of strategic guidance for the reform and management of social and health policy [7] . The KASTE II programme was carried out from 2012-2015. The aim of the programme was to narrow the gaps in social welfare and health care as well as to develop the structures and services of social welfare and health care towards a customer-focused direction [8] . During Prime Minister Sipilä’s government term in 2015-2019, the government programme initiated five key projects concerning welfare and health [9] . The VESOTE (Effective lifestyle counselling for social and health care cross-functionally) project was one of the key projects of Sipilä’s government, and it was funded by the Ministry of Social Affairs and Health (STM). The objectives set for the VESOTE project were the implementation or reinforcement of effective and high-quality lifestyle counselling operating models, development of lifestyle counselling expertise, utilisation and spreading of best practices, reinforcement of the multi-functionality and multi-professionality of lifestyle counselling as well as the utilisation of the expertise and experience of the third sector in lifestyle counselling [10] .

The challenge with project-based development is that the work is often limited by the project’s timeframe, and the project’s outputs cannot be implemented in a way that would result in permanent changes in the service system [6] [11] . Achieving a change in operations requires, for example, combining the measurement of health benefits with explanatory studies on the conditions and barriers to the change. This would enable the evaluation of the implementation and its conditions [12] .

1.1. Implementation as an Activity and a Research Subject

Implementation refers to the process of turning evidence-based practices into practice using methods tailored to the operational environment. In implementation, it is important to consider and identify any obstacles and provide assistance in overcoming them [12] [13] . Implementation is described as a process that includes at least the following stages: 1) exploration, 2) preparation, 3) implementation, and 4) sustainment [14] .

Implementation research is used to promote and examine the implementation of research evidence into practice in different operational environments [15] [16] . Implementation research includes several types of research and all of the approaches that can be used to scientifically examine and promote the implementation of research evidence into practice [16] [17] . The theoretical framework has been formed as a result of the combined research efforts of different disciplines, including the theories of psychology and sociology as well as organisational theories. These theories have made it possible to explain the reasons for how and why the implementation of effective practices or new information succeeds or fails [13] . Implementation research can also include overlapping theoretical perspectives. Process theories describe the process of turning research evidence into practice. Theories of change explain which factors have an impact on the results of implementation. Evaluation theories instruct on how to assess the success of implementation [13] [17] [18] .

1.2. The Facilitators of Implementation

In particular, the following factors that predicate the success of implementation can be identified based on background literature:

The commitment of all of the parties: This includes building trust and properly defining and clarifying concepts and criteria [19] [20] .

A shared vision, in other words, a recognised common need for change that will be addressed, and the inclusion of all of the people in the organisation and their participation in decision-making [21] [22] [23] .

Communication and information flow must be open, continuous, consistent and regular. Information should be easily available and communication methods should reach all of the stakeholders with ease [24] [25] [26] .

Readiness for change includes employee awareness of the purpose of the change, and the implemented change should meet the needs of the organisation and customers as well as support the work and values of the employees [22] [23] .

Recruitment has an impact on the success of implementation. For instance, a manager selecting people employed in customer work for training courses should survey the employees’ readiness and motivation to develop their work towards an evidence-based direction. It has been found that an employee’s prior work experience and theoretical orientation play a role in this [20] .

1.3. The Importance of Understanding the Implementation Process in Leadership

Leadership plays an important role in the implementation process [27] . Without strong and supportive leadership, new operating models will fail to turn into systematic operations in practice [28] [29] [30] . In health care, leadership plays quite a significant role in implementing and establishing new methods. As such, clinical leadership is very complex, and leaders face changing and increasing requirements to ensure cost-effective and high-quality treatment [31] [32] .

Employees play a key role when it comes to changing operations but change cannot be achieved without the management’s support. The most significant professional group for the success of the implementation process is the middle managers [33] . Previous studies have shown that the attitudes, priorities and behaviour of managers have an impact on the results of implementation [27] [31] . Managers need to understand the entire process of implementation, and they should be able to identify the facilitators of implementation as well as the factors that hinder it and address those obstacles [28] [29] [34] . More information is needed on how leadership can change processes for individuals’ work, groups and organisations [35] [36] . Nevertheless, it has been found that inspiring leadership that leads by example promotes the implementation of new methods [37] [38] . The implementation also benefits from a manager’s focus on active co-operation with other actors [39] .

For the success of implementation, it is important that the middle management receives support from the senior management. The senior management should communicate to the middle management that the implementation process is at the top of the organisation’s list of priorities, and they should guarantee adequate staff and training resources [33] . In turn, the role of the decision-makers, officials and senior management is significant in ensuring that the decisions necessary for the changes are made, and that the changes on a national level correspond with those of the implementing party in the organisation’s strategy [20] . The domain of implementation research has highlighted the need to invest in leadership training and expertise in change management [27] [40] [41] .

2. The Purpose and Aim of the Study and Research Questions

The purpose of this study is to investigate how the practices developed in the region-wide health promotion programme were implemented in social welfare and health care. The aim of the study is to identify the factors that contributed to the successful implementation of the results of the projects both from the point of view of the management and those employed in customer work and thus promote successful implementation.

The Research Question Is

How were the measures and outputs of the project put into practice in primary health care organizations according to the managers and professionals in nursing?

3. Materials and Methods

3.1. Target Group and Data Collection

The study focused on organizations that organise primary health care services that participated in the regional project. The target organizations covered the entire region of Southwest Finland. Further training courses on lifestyle counselling were arranged as part of the project, and nursing professionals employed in customer work from all of the organizations participated in the courses. The survey was targeted at 58 managers and 93 people who participated in a further training course.

The survey was conducted using the REDCap (Research Electronic Data Capture) tool and delivered to the target group via e-mail. Contact information was collected during the regional project. Research permits were granted by all of the 15 organizations that organise primary health care services. These permits were signed by either the municipality’s/joint municipal board’s director of medical services or welfare and health director between November 2020 and August 2021.

Data was collected during the autumn of 2021 and reminder messages were sent eight times.

The questionnaire was drafted based on the factors that had been identified in the background literature as conducive to implementation. The questions concerned commitment, shared vision, communication and information flow, readiness for change and recruitment as well as the implementation of the project’s outputs.

Three managers and three nursing professionals pretested the questionnaires. At the start of the questionnaire, the respondents were asked to fill out the following background information: age, occupation, duty (at work) and how many years they had worked in nursing or in a managerial position. The purpose of the background questions was to illustrate the target group’s work experience. A cover letter and privacy statement were included at the start of the questionnaire.

This article reports the findings for the questions that best correspond with the research question. Structured, semi-structured and open-ended questions were used in the questionnaire as well as Likert scale statements. The open-ended sections of the semi-structured questions and open-ended questions were used to gain deeper insight into the questions.

3.2. Data Processing and Analysis

The number of categorical variables and percentages for the two different groups (managers and employees) were given in frequency tables. The responses for the Likert scale statements were analysed using the Cochran-Armitage trend test to determine the level of difference between the two employee groups. The association between the other categorical variables was determined using Fisher’s exact test. Statistical significance was established in the tests with a two-tailed p-value if the p-value was less than 0.05. These analyses were conducted using the SAS 9.4 software.

The responses to the open-ended sections of the semi-structured questions and open-ended questions are presented in this article to help explain the phenomenon.

3.3. The Background Information of the Respondents

A total of 73 people responded to the survey (a response rate of 48%). Out of all of the respondents, 29% were in a managerial position (21 chief nursing officers/directors of nursing/middle managers) and 71% (52) were nursing professionals employed in customer work who participated in the project’s further training course for lifestyle counselling. Public health nurses made up 42% (n = 22) of the respondents who participated in the training course, 35% (n = 18) were registered nurses, 15% (n = 8) were physical therapists and 8% (n = 4) of the respondents listed a different educational background.

The age distribution for 10% of the managers that responded to the survey was 21 to 40 years, 85% (17/20) of the managers were 41 to 60 years and 5% were 61 years or older. The median for working years in a managerial position was 10 years, with quartiles Q1 = 7 and Q3 = 13.75.

According to the responses, seven managers had taken up their current position after the project, and five of these managers responded that they were aware of the project.

The age distribution for 21% of the nursing professionals that responded to the survey was 21 to 40 years, 69% (36/52) of the nursing professionals were 41 to 60 years and 10% were 61 years or older. The median for working years in nursing was 21 years, with quartiles Q1 = 15 and Q3 = 32.5.

4. Results

There was a statistically significant difference between the experiences of managers and nursing professionals when it came to the necessity of the VESOTE project funded by the Ministry of Social Affairs and Health: the managers felt that the project was more necessary than the nursing professionals did (p = 0.0006).

In terms of how well the regional project’s contents corresponded with the needs of their organization, the managers reported better correspondence than the nursing professionals (p = 0.014).

Moreover, the managers perceived their control over the contents of the regional project as being better than did the nursing professionals (p = 0.013).

The following observations could also be made based on the data, although there were no statistically significant differences between the groups: more than half of the participants responded that they had driven the change in lifestyle counselling practices within their organization. The majority of the managers and nursing professionals felt that they had received sufficient information on the regional project and its goals. They also thought that communication had been regular. The respondents felt that the outputs of the regional project partially corresponded with the needs of their organization. However, the outputs were implemented only on an individual basis.

Out of all the nursing professionals, 78% (38/49) had asked to participate in the training that was organised during the project. A total of 96% (50/52) of the nursing professionals felt that they could utilise what they had learned during the training in customer work. The nursing professionals who had sought to communicate on the knowledge they had acquired through the training amounted to 75% (38/51).

According to the managers, the employees were selected for the training courses based on the employee’s motivation 83% (15/18), readiness to utilise the knowledge acquired through the training in customer work 72% (13/18), suitability to develop lifestyle counselling within the organization 50% (9/18), ability to communicate on the knowledge acquired through the training to others within the organization 33% (6/18) and prior work experience 22% (4/18). A total of 17% (3/18) of the managers responded that all of the interested individuals were able to participate in the training.

In terms of the outputs of the regional project, the respondents felt that the service offering for lifestyle counselling met the needs of their organization the best. Out of the managers, 83% responded that the offering corresponded with the needs of their organization well, whereas the number for the nursing professionals was 52.9%. This was a statistically significant difference (p = 0.045). A total of 75% of the managers responded that the service offering was put to use, whereas only 11% of the nursing professionals said that the service offering had been adopted into practice.

Implementing a New Operating Model

The responses to the open questions are presented in this article to illustrate the quantitative analysis: the managers and nursing professionals listed meetings as a means of monitoring the implementation of the operating models produced in the project. They also brought up the lack of systems/tools for systematic monitoring. “There are no means to do this, the only thing you can do is ask individual nurses.” (Manager 17)

In the open questions, the respondents listed increasing expertise, engaging the management, need for support, accessibility, comprehensiveness, continuity and values as facilitators of implementation.

The managers pointed out training courses for the entire work community as a promoting factor for the implementation of the project’s outputs. The respondents also listed committing the management to the practices and having middle managers monitor the realisation of agreed goals and train others in how to adopt the new procedures as contributing factors to implementation.

“We could support the implementation of outputs better by providing training for the entire work community.” (Manager 19)

The nursing professionals expressed that they need support from the managers for their own work and that managers also need support to ensure that implementation occurs and new practices take root.

“More guidance for the managers.” (Nursing Professional 4)

The managers also felt that it was necessary to receive support from the organization’s management and for the organization’s management to be committed. “Support from the manager (which has been very thin due to the increased workload, especially during the COVID-19 pandemic).” (Manager 7)

The outputs that will be implemented should be easily available. Implementation could be facilitated by arranging joint training courses within the organization as well as integrated region-wide training courses that take different actors and occupational groups into account. In this way, co-operation could be supported both cross-functionally and across municipal borders.

“More people would have participated in the training, and there would have been co-operation with the neighbouring municipalities.” (Nursing Professional 15)

The respondents also called for repetition. “Repetition, training like this should be organised approximately once every 3 years.” (Nursing Professional 52)

Implementation was also seen as a value judgement.

“By instilling it properly into practice and valuing it in everyday work the way it should be.” (Nursing Professional 18)

5. Reflection

This study found that the majority of the nursing professionals felt that they could not influence the contents of the regional project. Thus, it can be concluded that a shared vision was not achieved on every organisational level during the project. Shared vision refers to the understanding on every level of the organisation that a method corresponds with a common identified need. It is important that everyone in the organisation is involved and participates in the decision-making at every stage of the implementation process [1] [17] [21] [22] [23] .

An important facilitator of implementation is the active and committed participation of stakeholders throughout the whole process of implementation within the organisations where operations are being changed. The stakeholders should also have the power to drive the operational change in their respective organisations [23] [42] . For example, [43] found in their study that the successful implementation of a new practice requires staff participation at every stage of the implementation process. In this study, only half of the managers and nursing professionals felt that they had advanced the change in lifestyle counselling within their organisation.

Both the managers and nursing professionals expressed a need for means to monitor the implementation of the new operating model. Clinical leadership is subject to demands to guarantee cost-effective and high-quality treatment [31] [32] . Yet, in order to respond to such demands it is necessary to have frameworks in place to effectively utilise information from different levels [44] . Furthermore, the respondents emphasised the necessity of support from the middle and senior management. In fact, many studies have shown that this is an important factor for the success of implementation [20] [28] [29] [30] [33] .

While the recruitment of employees plays an important role at every stage of the implementation process, it is crucial for success during the sustainment stage of the new methods [22] . When recruiting professionals and selecting employees in customer work for training courses, it is important to identify the individuals’ capabilities and motivation to develop their work towards an evidence-based direction [13] [20] . The majority of the nursing professionals had asked to participate in the training. Almost all of the respondents felt that they could utilise the knowledge acquired through the training course in customer work. Most of the respondents had sought to communicate on the information they had acquired during the training within their organisation. According to the managers, the most important factor in selecting employees for the training was the employee’s motivation, while the second most important factor was their readiness to utilise the knowledge they had gained from the training in customer work. The third most important aspect was the employee’s suitability for developing lifestyle counselling within the organisation, followed by their ability to communicate on the information they obtained during the training to others within the organisation. The least important factor was the employee’s prior work experience. According to the results, the employees that were selected for the training were nursing professionals who were motivated to develop lifestyle counselling and implement operating models. Most of these employees felt that they could utilise, at least on an individual level, what they had learned during the training.

This study examined the success of the regional project’s implementation in primary health care organisations. The managers felt that they were able to influence the contents of the regional project better than the nursing professionals did. A total of 54% of the managers thought that they had agency over the contents. Only 12% of the nursing professionals felt that they could at least somewhat influence the contents. Thus, it can be concluded that the participation of the nursing professionals remained low, and that the managers experienced greater control over the contents than the nursing professionals did. This is likely one of the factors that explain why activities developed during a project fail to be implemented into practice, as employees feel detached from them. Similar results have been found in several studies on implementation [45] [46] [47] . Approximately half of the managers felt that the outputs were put into practice. Yet, almost all of the nursing professionals responded that this was not the case. Thus, the outputs of the regional project were implemented on an individual basis within the organisations, and implementation was not carried out systematically at a regional level. With regard to the outputs of the regional project, the respondents felt that service offering for lifestyle counselling met the needs of their organisation the best. The majority of the managers felt that it had been implemented into practice. However, most of the nursing professionals responded that this had not happened. This is an important observation, as being able to describe the lifestyle counselling services offered by municipalities, organisations or well-being services counties improves their availability and accessibility since it facilitates directing customers to those services. This objective is also included in the Sustainable Growth Programme for Finland, which is funded by the EU’s temporary recovery instrument (Next Generation EU). As of writing this paper, it is being implemented as part of a programme concerning the multisectoral service concept to promote health and well-being that is co-ordinated by the Finnish institute for health and welfare (THL).

The Reliability of the Results and Ethics

The recipients were informed that responding to the survey is completely voluntary, and that they could end the survey at any point prior to sending their responses. The survey was conducted anonymously. No names regarding the organisations or any other direct identifiers that could be used to directly identify individual respondents were collected during the survey [48] . All of the collected data was treated as confidential in accordance with the legal requirements and good research practice. Neither individual respondents nor organisations can be identified based on the reporting of the study’s findings.

Reminder messages were sent a total of eight times, which is more than usual. This was done to ensure that the recipients had adequate opportunities to respond to the survey considering the challenging circumstances in the region caused by the COVID-19 pandemic. The response rate was lower than expected, causing a risk of selection bias. Therefore, the results can only be considered indicative and no generalisations can be inferred based on them [49] . Furthermore, the study focused only on one of the 11 regions in the VESOTE project. Therefore, the applicability of the results to other similar cases may be undermined due to the results being based on data from just one region [50] . The reliability of the study suffers due to its small data set, which further asserts the fact that the results may only be treated as indicative. However, the data covers all of the primary health care organisations included in the future well-being services county.

The results of this study are in line with the findings of previous studies that concluded that outputs will not be implemented into practice without systematic measures and the active participation of actors from the outset. Therefore, the results of this study can be considered transferable when it comes to promoting successful implementation despite the limited data set. On the other hand, the small data set produced statistically significant results.

The credibility of a study can be strengthened by having the researcher spend sufficient time engaging with the research phenomenon [51] . The first author of this paper has participated in the co-ordination of the regional project.

6. Conclusions

According to the results of this study, the nursing professionals felt that they had no agency over the contents of the development work. No systematic changes to the lifestyle counselling practices in nursing work were made as a result of the project. Instead, changes were made only on an individual basis, and they were dependent on the actions of the manager and/or individual employees. The development of lifestyle counselling practices should not be reliant on a development project. Rather, the development work should be conducted on a long-term basis, and professionals should be involved in the work from the beginning.

The results of the study corroborate the previous findings in that focusing on the results achieved during a project is not enough for a permanent change to take root in the service system. As this study has also shown, efforts must be made to systematically implement evidence-based activities into practice and make them a part of everyday work. Customers cannot be guaranteed equal access to effective care unless knowledge about effectiveness is translated into everyday actions [12] . When it comes to implementing changes in health care, support systems and leadership programmes are required for the planning of implementation, development of evaluation and organisation [52] .

The results of this study offer needed information on working life practices that should be utilised to increase effectiveness.

The VESOTE project funded by the Finnish Ministry of Social Affairs and Health covered over 4 million residents, whereas the population for the project area used in this study was 500,000. The purpose of the project was to improve lifestyle counselling services. The challenges of the project were its sizable objectives in relation to its allocated resources as well as the project’s broad target area. The commitment of actors is crucial for the success of a project. Otherwise, producing permanent changes for a service system can be challenging. Local actors from the organisations that are changing their operations should be involved right from the start of the implementation process. Consistent means to measure the effectiveness of projects need to be developed.

Finland is currently going through a significant transformation regarding its service system in social and health care and the developing well-being services counties. Improving the quality and consistency of services is key objectives for the well-being services counties. Based on this study, it can be concluded that the lack of consistent investment in the implementation process and monitoring the success of implementation may spell failure or lengthy delays for project-based development work. To ensure that health policy goals are met, more attention needs to be paid to supporting implementation at a regional level. Furthermore, implementation should not be dependent on individual projects if the goal is to produce permanent changes.

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.


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