The Swedish National Board of Health and Welfare (SNBHW) decided in November 2011 on the national guidelines for methods to prevent disease. These guidelines focus on four areas: tobacco use, hazardous alcohol use, insufficient physical activity and unhealthy eating habits. Since the introduction of the guidelines, healthcare systems in Sweden, i.e. regions, have established efforts for the implementation of these guidelines.
The results of the four case studies is illustrated in Fig. 2 showing an overview of the various links in the process of translation and captures and summarises the complex organisation. The different relationships and connections between levels, logics, actors, initiatives and activities in the figure illustrate connections in a way that clarifies the chain’s strong and weak links. The figure should be read as activities from the initiative taken at the national level (macro), where policy guidelines are developed in the administrative logic – by the Swedish National Board of Health and Welfare – and then via managing health promotion activities at the regional level (meso), to the realisation in clinical practice at the local clinical level (micro).
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Participation in guideline development: path dependency
Generally, the empirical analysis shows that multiple logics are combined when guideline development begins. At the national (macro) level, the policy is initiated through regulatory initiatives and the provision of resources. Actors from both the administrative and professional logics collaborate in order to develop the guidelines. Several of these actors, working with guideline development nationally, came from the regions where they also had worked with disease prevention policies. There was a clear link –path dependence – between the different settings, in that previous work created opportunities for starting the work in the regions.
It was obvious that active actors in all parts of the healthcare system took on a role in the translation and were not randomly chosen to carry out the work. Instead, there was a clear path dependence in terms of who was given the assignment and where the translation was initiated and became an integrated part.
The earlier work has clear consequences for the design of the regional guideline work, as one senior member of the administrative management team in the South Border Region said:
“[We have]… worked on and worked with networks and development issues and so on – overall. So that is my role, and it still remains. And then when the guidelines came, it was the strategist [for health promotion] – my predecessor – who took the ball and ran with it.”
In the East Sweden Region, the tobacco cessation work, an essential part of the guidelines, is mentioned as having been particularly successful and something that they have been able to build on. Their translation strategy in relation to the guidelines was based on “… having carried out long and solid tobacco work in the East Sweden Region”, as one of the respondents explained. The strategy is perceived as a well-structured approach that has supported them in continuing with disease prevention efforts, thereby enhancing the translation. Since the new guidelines included tobacco use, they could here be incorporated into an existing governance model and the translation went smoothly, with a good outcome. The general guidelines followed the path that had been developed through the tobacco cessation work.
This shows that the key actors in the regions had a strategy of being active early in the process and preparing the regional organisation for a smooth introduction of the guidelines. They influenced the design of the guidelines in line with the organisational structure and culture. By following the path of earlier implementation processes they prepared the region to enhance the implementation by forming networks where the nationally formed guidelines where translated into the regional setting. Since the key translators were based in the same administrative logic, the Swedish National Board of Health and Welfare at the national level and regional administrations, the translation only crossed one border in the multilevel-multilogic model – from the national to regional level, but still within the same logic. The path dependence enforced the translation here and made the guidelines an administrative and policy concern. The clinical professionals were excluded at that time. This absence was later used as a justification for medical doctors’ non-participation.
What was translated? The interpretative viability of disease prevention – an opportunity for the broader scope of health promotion?
Most commonly, the implementation of the guidelines was translated to fit into the regions’ public health work. The starting point for this work was a concept developed by the public health centre. A policy administrator from the Polar Region said: “… we lean completely towards what they have been working with” for this implementation.
This approach – health promotion rather than disease prevention – was also embedded at the political level. A member of the regional council in the Polar Region explained that the guidelines raised the issues surrounding public health, linking to the work that had previously been initiated:
“… I think that when the guidelines came, we got support in our work and support with public health work. Therefore, this is what we should do, this is prevention, it is not treatment. And then, how do we work with prevention in a comprehensive way?”
The regional policymakers perceived that they had discretion in making decision on how to proceed with the initiative. One central aspect was the perceived flexibility  of the guideline that they used to frame the implementation into structures and meanings that were already in use – public health or general health promotion work. In a similar way, a previously initiated programme on health guidance for the population in the East Sweden Region was integrated into the implementation of the guidelines. There, the public health centre was active in developing health promotion, i.e. screening for the healthy population. As in several other regions, health calls were offered to all 30-, 40-, 50- and 60-year-olds. In the early stages of the guideline work, key actors in public health worked to explain the importance of engaging with the issues and broadening the scope of the guidelines. The original intention behind the focus of disease prevention was to engage individual patients whenever they entered the healthcare system for a specific health problem, not population-based health promotion. However, this distinction was not clear for the actors at the regional level.
An analysis manager said that there was a lot of resistance from the medical profession and that those who ran the questions had to defend the work, and pointed out that they encountered resistance within the organisation:
“… Maybe it was mostly from the medical profession, who actually felt that they should do this too? On top of everything else, we will have that in 15 minutes with the patient… The health director had to go out and argue for the case, and our public health manager was out talking too.”
The translation had to be enforced by several key actors from the regional administration promoting the guidelines into the local-professional practice. Although the intention of the guidelines for disease prevention was to identify and support individual patient health issues during their episode of care, the actors at the regional level viewed it as a public health policy. Consequently, the policy changed in practice from disease prevention at individual level to health promotion at public level. The implementation of the guidelines showed a flexibility to adapt within the multilevel-multilogic structure through translation to fit several different policy agendas and practices.
Designing activities at the regional level
When managing disease prevention at the regional level, administrators started several different activities. It was, however, difficult to get everyone on board. The translation into the professional logic proved to be trickier in all regions. The main impression was that when the translation of the disease prevention guidelines gives certain groups stronger positions, it also automatically leads to other professionals playing a minor role.
In this case, we identified mandatory participation in specific activities as a starting point. The South Border Region, for example, demanded that those who worked with disease prevention should have training in professional counselling for tobacco cessation. This training gave participants the skills and recognition to contribute to the implementation and continued translation of the disease prevention methods. Problems then arose when healthcare personnel without the specific training were assigned these counselling activities. One of our interviewees, a head of health strategy in the South Border Region, pointed this out and said:
“We saw that there were many doctors who were qualified to provide counselling in connection with tobacco… However, we have clearly stated in our care programme that it is tobacco cessation, and then you should be trained. And we have not trained any physicians in tobacco cessation, virtually none.”
The interviewees highlight this as something that may be summarised as passive resistance among physicians that we could see in most regions. By not engaging in training and activities linked to the disease prevention methods, they were disqualified by the system. Despite not actively terminating the practical use of the guidelines, they passively allowed them to “die”. This was a common counter strategy among physicians resisting the implementation by translating the guidelines structure into their professional clinical practice. One of the interviewees in another region argued that there was a major problem with the medical profession not stepping in and participating actively in the guideline work:
“Healthcare is still very hierarchical and thus getting doctors who advocate preventive work or life-long work. [are]– zero.”
This points to a more general problem regarding which groups are included in the work on an issue. When actors in the administrative logic design mandatory activities, that are supposed to support the translation, these activities actually may create resistance to the process of translation.
Although we noted some resistance among professionals – albeit passive – there was generally strong support for disease prevention as an idea. An elected member of the regional council in the Capital Region stated that:
“We may have slightly different perceptions of what is the highest priority, but it is obvious that health promotion measures have strong support.”
The policymakers provide legitimacy for the work throughout the healthcare system by symbolically signalling importance and providing the necessary resources to do the work. The East Sweden and Polar regions both prioritised disease prevention and had relatively stable political leadership at the time of our study. By contrast, there was more turbulence in the South Border and Capital regions. Uncertainty about financial prioritisations in the South Border Region had interrupted the introduction of the disease prevention methods. A medical adviser in the South Border Region gave voice for how the administrative management perceived that the work had changed since the last election:
“After the last majority shift in the council, a lot of politicians changed… so there are a lot of new people and they have other priorities… Now the focus is on accessibility and care locations and overcrowded emergency rooms…”
The reprioritisation in the South Border Region also led to considerable financial resources being deducted from disease prevention, which in turn undermined the translation of the guidelines. Even if guidelines for disease prevention originate in a policy initiative, they are also founded in evidence-based research in the medical professional logic, which in turn must encourage the policy logic to prioritise the issue to support the implementation.
In the South Border Region, when financial support for disease prevention dissolved, resources became embedded in the ordinary budgets – mainly within their already strained financial situation. The argument was that primary care was assigned more and more tasks while the total allocation of resources remained unchanged. The disease prevention activities became secondary. Despite the ambition of supporting the translation of guidelines from the policy logic perspective, policy officials at the regional level failed to bridge the administrative logic to translate the guidelines into functional practice in the local profession level logic. A manager from the Capital Region pointed out this barrier to translation into primary care practice by reflecting:
“No, but clearly this is so, there are too many studies showing that primary care’s share of the cake has remained largely unchanged and… and it is quite clear that… primary care must take more and more follow-ups, checks, of chronic illnesses and so on, and then you do not get more resources but are assigned bigger tasks without it being possible to change or with the same way of working, then it is clear that this part can be ironed out.”
Similarly, a general practitioner in the Capital Region reflects on the problems of how to organise the work in primary care:
“Are we the ones who have the resources for this… do we get… the… financial resources needed to be able to carry out this assignment in a good way… Because there are many actors who can really do with the primary preventative work and I do not see it as obvious that the health centres and primary care should take this into consideration.”
In this case, the policy reprioritisations had to be supported by the medical professionals with evidence proving the importance of the guidelines and structures for funding and organisation formed by the administrative logic. This indicates that despite the high policy priority of the issue, there is a need for re-assembly in all logics at regional and local levels to translate national policy into local practice.
Using guidelines in practical clinical work: The specifics of the patient meeting
The outcome of the translation process is the changes in clinical practice that help patients to live healthier lives in order to prevent disease. The impact is entirely dependent on it being realised in clinical practice. Here, the guidelines need to be translated into everyday work. The translation was hampered by uncertainties about how to use the guidelines in practice. All regions had professional healthcare strategists based in the administrative logic coordinating the implementation of the guidelines in clinical settings. One healthcare strategist in the South Border Region reflected on the usefulness of the standards in the meeting with the patient:
“… I was pretty critical of the National Board of Health’s indicators that we may not need to measure exactly how many standard glasses a person drinks to carry out an intervention… Of course, you can discuss anyway, and the patient may open up a little bit and say ‘I might drink a little too much’.”
The healthcare professions are used to making nuanced and individual-centred assessments, and these competencies are not considered in the design of the guidelines, which constrains the translation process. Things cannot only be just black or white, as one specialist physician in general medicine in the Capitol Region said:
“… I really have no problem with the legitimacy of these questions, nor do I think that many other people have, either. What was being questioned and discussed was our duty, so to speak, to address these issues in all contacts with patients, because it became a bit black or white. It was a [professional] group that was pushing this hard, and they were very specific that we should always use our precious time with patients to ask questions about living habits.”
There are several policies that must be implemented in practical daily clinical work, and the medical professions indicates a resistance towards their capacity to translate everything into their short meetings with patients. They have a different logic of priorities that hampers this translation, even if they agree with the evidence-based core values of guidelines.
To continue the translation of the guidelines, the problems and challenges faced by the organisation need to be embedded in clinical management. Leading actors at the primary care units such as managers and dedicated employees must enforce the translation by being ambassadors for the guidelines in practice. One way to continue the realisation and thereby the translation of the guidelines into clinical work was to embed them in the ordinary organisational structures. A healthcare strategist pointed to the need to continue this work:
“… It should ideally be anchored in existing processes. And that is happening – there is a lot of process work everywhere.”
The local leadership, i.e. the care unit management’s responsibility and engagement, was crucial for keeping up translation in the implementation. A critical aspect was to clarify how the guidelines relate to other issues that simultaneously compete for attention to be translated, within the limited scope for change that exists in an organisation. When running multiple processes, or translations, it was especially important that management helps all employees to understand whether – and if so, how – different initiatives can or even should be linked together. There are different technologies that management can use to support the translation process.
Technical support for disease prevention methods
Technology played an important role in the translation process. Adapting and creating new technical solutions to support clinical practitioners in their everyday work is part of the translation process. These development efforts mostly took place at the regional level. By technology, we mean structured coding and reporting systems, web-based support systems or descriptions of work processes.
Early in the development of the guidelines, codes for disease prevention activities was developed. By measuring activities through these codes, the aim was to support task evaluation, budgeting and knowledge management. However, the codes led to uncertainty, as if professionals were uncertain which language is spoken in the organisation. An expression of this is the central activity of coding, as described by a manager at a primary care unit in the South Border Region:
“We have to work with countless codes, action codes in the journal… Physical activity consists of four different codes, simple advice, as well as more developed advice and specialist advice and… yes. And then the prescription of physical activity. You have to know which of them to click, have I done the simple tips or some more? You do not really know and so you skip the registration.”
The technology of coding was taken one step further in the East Sweden Region through a locally developed method called the Health Chart. This is a specific, integrated part of the digital patient record system. The region had invested in extensive technology development to obtain an integrated solution that could be used continuously to document living habits, by using the codes in the guidelines. An analysis manager in the region pointed out the value of this development:
“Before, you documented… yes, a little wherever you wanted, there were questions about tobacco in many of the hundreds of templates that are in the journal system and it was not so easy to find statistics on it. Then we created a uniform template, based on the guidelines, they follow the same flow, the same questions, so that you can compare nationally and make the work visible.”
Here the technology becomes a carrier of the disease prevention methods, and in this way contributes to strengthening the translation by transferring the meanings of the guidelines into a useful tool for the medical professionals.
In addition to the technology that deals with registering the disease prevention methods, the possibilities for data analysis were also highlighted and seen as a justification for the coding. Several of the interviewees argued that there are significant difficulties in obtaining good data analyses of the disease prevention work. A medical advisor in the South Border Region said:
“… it is very difficult, almost impossible, to pick data at the aggregate level. Unfortunately, they have not delivered the output data tools we have requested. We are trying to find out how to do it and create it ourselves here centrally. We have even been given some government funding to create a system for generating quality indicators at the primary care level.”
Technologies can translate meanings across the different levels and logics. The design of such technology is critical, since it must fit into both the logic and the ambitions of the sending and receiving contexts to help actors to associate their practice with the core meaning and values of the implementation programme. The selected disease prevention technologies vary among the regions, and due to the self-governance of the regions there were no national guidelines on the technologies for translations.