The Ecology of Sustainable Implementation: Reflection on a 10-Year Case History Illustration

The primary aim of this paper is to illustrate the strategic and ecological nature of implementation. The ultimate aim of implementation is not dissemination but sustainability beyond the implementation effort. A case study is utilized to illustrate these broad and long-term perspectives of sustainable implementation based on qualitative analyses of a 10-year implementation effort. The purveyors aimed to develop selective community prevention services for children in families burdened by parental psychiatric or addictive problems. Services were gradually disseminated to 23 sites serving 40 municipalities by 2013. Up to 2013, only one site terminated services after initial implementation. Although many sites suspended services for shorter periods, services are still offered at 22 sites. This case analysis is based on project reports, user evaluations, practitioner interviews, and service statistics. The paper focuses on the analyses and strategies utilized to cope with quality decay and setbacks as well as progress and success in disseminating and sustaining the services and their quality. Low-cost multilevel strategies to implement services at the community level were organized by a prevention unit in child psychiatry, supervised by a university department (purveyors). The purveyors were also involved in national and international collaboration and development. Multilevel strategies included manualized intervention, in-practice training methods, organizational responsibility, media strategies, service evaluation, staff motivation maintenance, quality assurance, and proposals for new law regulations. These case history aspects will be discussed in relation to the implementation literature, focusing on possible applicability across settings.