Sustaining an intervention for physical health promotion in community mental health services: A multisite case study.

There is a growing body of literature on sustainability, but its definition and the factors that affect it are not well understood. This paper focuses on the sustainment of health promotion interventions in community mental health organisations, where the institutional context has been found to play an important role. Normalisation Process Theory (NPT) was used to characterise the extent of sustainment of health promotion interventions and to identify important factors that influence it. The study builds on a previously reported qualitative multiple case design focusing on four Danish community mental health organisations. We aimed to include cases (provider organisations) with varied political-administrative contexts that were expected to impact sustainment. Data included 27 semistructured interviews with managers and frontline staff. The analysis adopted a thematic approach combining within-case and cross-case analysis. One important factor contributing to sustainment was the high degree of coherence generated during and after implementation. Perceptions of meaningfulness and formal tools for external accountability such as municipal activity plans also stimulated the cognitive participation of management and staff in sustaining the intervention. On the practical level of collective action, working with health promotion in a continuous way was particularly supported by two formal tools: internal health policies and municipal activity plans. Sustainment was further aided by reflexive monitoring based on ongoing informal assessments, supplemented by information required for status reports to the municipality on individual users and information from the annual individual user health checks. Future studies should adapt NPT to a broader range of cases to assess more thoroughly its contribution to the literature on sustainment. Future interventions need to pay closer attention to securing continuous and active local management support as well as to political-administrative contexts as potential external drivers of sustainment.