Putting families and local professionals at the heart of implementation research: A qualitative implementation study on Greenland’s universal parenting programme MANU 0-1 Year

Research output: ThesisPh.D. thesis

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Abstract

Introduction and background: Context matters. The influence of context in implementation has received increasing attention in implementation research. This includes a discussion of the right fidelity-adaptation balance when interventions are tobe implemented in a new context, a relevant discussion when looking at nationalpublic health interventions. In Greenland, public health interventions are typicallyadopted evidence-based programmes or developed based on general understandings of the country’s context. They rarely build on local resources and strengths ofthe different towns and villages. Evaluations of interventions show how interventionsare not sustained after initiation, they are not adaptable to local context and intervention recipients’ needs are barely explored prior to the development of interventions.

The Greenlandic parenting programme MANU 0-1 Year, which stands for MeeraqAngajoqqaat Nuannaarneq meaning ‘child’s and parent’s happiness’, henceforthMANU, was developed to provide expectant and new parents with information andreflections on parenthood through pedagogical exercises. MANU is a universal programme that intends to be accessible to all expectant and new parents. Ultimately,MANU is expected to secure a healthy foundation for children’s development and tocontribute to the prevention of adverse childhood experiences. The programme isbased on developmental theories, international evidence on the First ThousandDays and the intent to reduce the high prevalence of vulnerable families in Greenland. Parents’ perspectives were only explored to a limited extent during the development process of MANU. Furthermore, from the outset of MANU’s implementationa tension existed between the MANU team’s ambition for implementation fidelity andthe local professionals’ need to adapt the programme to fit their local context.

Arctic and Greenlandic public health scholars are increasingly drawing attention tothe importance of integrating or building on cultural belief and relevance, values andlocal practices when developing and implementing interventions.

Objective: The aim of this PhD project was to study the local implementation of theparenting programme MANU 0-1 Year and parents’ experiences with the programmein regard to expectations, needs, culture and values.

Conceptual framework: The Consolidated Framework for Implementation Research (CFIR) by Damschroder et al. (2009) was applied due to its breadth of in cluded aspects that influence implementation. It provides an overarching systematicclassification of implementation determinants in different contexts. Furthermore, thePhD project applied a community-based participatory research (CBPR) approachfollowing the five stages introduced by Reimer and Rink (2020) and based on thekey principles by Wallerstein et al. (2018). CBPR focuses on creating partnershipsand building trust between the researchers and the community people, who ultimately are meant to gain from the research. Finally, the framework outlining the potentialadverse effects of public health interventions by Lorenc and Oliver (2014) provided aretrospective perspective on MANU’s unintended effects.

Study design and methods: The PhD project has been performed in accordancewith the Declaration of Helsinki, and the Greenlandic Science Ethics Committee(Danish: Videnskabsetisk Udvalg) granted ethical approval of the project. As a keyCBPR element a reference group consisting of nine different stakeholders was established and was involved throughout the PhD project. Different qualitative methodswere applied, including open-ended and semi-structured interviews, observations,document analysis and a sharing circle. Data were collected in three of Greenland’sfive health regions.

Results: The results are presented in three sections in this PhD dissertation. First,parents’ perspectives on parenthood and child-rearing are described. Parents described the live changing experience it was to become a parent, and they point outtoqqissisimaneq (English: security and care) and ataatsimoorneq (English: community or feeling of togetherness) to be important aspects in child-rearing. Secondly, bothparents’ and professionals’ experiences with MANU are presented. Both strengthsand challenges with MANU’s format, content and accessibility were identified. Forexample, MANU group sessions have the potential to create a space for parents toreflect, however, group sessions are not necessarily accessible to everyone. Finally,professionals’ perspectives on local implementation include aspects related to: theorganisational structure and context they are working in; the circumstance of havingto prioritise limited resources which leads to MANU not being a priority; the professionals need for support and skills to maintain motivation for implementation andsustainment of the programme.

Discussion: The PhD dissertation discusses how national programmes like MANUoften are disconnected from local contexts, since they are based on the assumptionthat dissemination of materials and sending professionals to trainings will enablesustainable implementation of new interventions. Then the applicability of implementation frameworks, specifically the CFIR and the updates to the CFIR framework, arediscussed in relation to the Arctic context, interventions recipients’ perspectives on implementation outcomes and sustaining interventions in a context with persistenthigh turnover. This then leads to introducing CBPR as an integral part of implementation research in order to meet equity in implementation. Intervention studies conducted in the Arctic describe how CBPR contributes to a culturally sensitivity intervention and to the community taking ownership of the intervention. Finally, methodological and ethical considerations are presented.

Conclusion: It is concluded that by putting families and local professionals at theheart of implementation research, interventions will more likely be culturally sensitiveand increasingly relevant to local contexts. Furthermore, potential barriers in implementation and adverse effects of an intervention could be addressed early on andlikely prevented.

Implications: The dissertation includes suggestions for future research and recommendations for public health practice. The latter includes input form the referencegroup, who shared their thoughts on how they would like to adjust MANU and otherhealth promotional interventions based on this project’s results.
Original languageEnglish
Awarding Institution
  • University of Southern Denmark
Supervisors/Advisors
  • Larsen, Christina Viskum, Supervisor
  • Kvernmo, Siv, Supervisor, External person
  • Tjørnhøj-Thomsen, Tine, Supervisor
Date of defence16. Jun 2023
Publisher
DOIs
Publication statusPublished - 7. Jun 2023

Keywords

  • CBPR
  • Qualitative Research
  • Implementation
  • Parenting Program
  • Health Promotion
  • Health Prevention
  • Arctic
  • Circumpolar
  • Participatory
  • Parenthood
  • Consolidated Framework for Implementation Research
  • Evaluation
  • Kinship
  • Indigenous
  • Greenland

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