Nr: XXX/Spring 2017 Master thesis, 15 credits
Master’s programme in Public Health, 120 credits
Feeling as a part of the greater whole
A Grounded Theory-study of the process of working in an innovative public health initiative in northern Sweden
Cecilia Wagenius
Supervisors: Anna-Britt Coe
Linda Sundberg
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Acknowledgements
To all of you involved in the SAM-project within Norrbotten county council, who invited me in to the world of SAM, and your thoughts about it, with such enthusiasm…
To all of my informants, who invited me in to your reality and offered me your perspectives and opinions; and opened up so easily and freely so that the interviews felt more like conversations with a friend…
To my supervisors, who supported me through headache and steered me right when I was lost; who always had an open door and gave me energy and joy in the working process…
To my friend, who helped me through computer mayhem and loss for words…
To my parents, who taught me the fine arts of fika, being silent and breathing…
To myself, for my curiosity and persistence…
To Joel, who encouraged, cooked, listened and brewed coffee during the whole process…
To all of you that have been, and are, and will be, involved in the work of making the society a better place for the youth…
…this thesis is dedicated to you all.
The whole is greater than the sum of its parts.
- iii - Preface
During the year that I worked with the thesis several alarming incidents occurred that had large impact on either local level in my home region, on a national level, or on a global level. Hatred, accidents, war, terror and feelings of despair have filled my reality in the past year. It reminds me of how inequalities and lack of understanding one another can lead to hatred and unnecessary suffering.
It also reminds me of how devastatingly easy it can be to forget suffering when we are not constantly reminded of it, and ironically enough it is as easy to be blind to the suffering we see every day.
However, it also reminds me of how fragile life is, and how strong and helpful people can be when disaster strikes – empathy, openness and selfishness are core values that goes without saying.
All that has happened makes me think of the importance of standing together, working together, and wanting to understand each other. Although, standing together can feel like a naïve and romantic view of the world, it is not all pleasant and smooth. Just think of a vacation with your family and relatives – people that you supposedly know and understand, then what about standing together and
collaborating with people that you do not know, nor understand, and that might have another
background and perspectives than you. How can we even think that it would be possible? With risk of being cliché I immediately start to think of Lennon‟s last line in the song Imagine: “And the world will live as one”. During this year I could not imagine this, especially when living in a highly individualistic society where everyone seems to only look after themselves; and it is almost as we “need” accidents and terror to wake up and see the value of others. A strong individual is still weak without the support of others. It is as if it is only when the “societal disease” has been revealed (through its horrible
symptoms of e.g. increased mental ill-health, increased incidence of suicide, decreased social trust and increased hatred and terror) that we are forced to take action. But what about before that, is there nothing that could be done to prevent the disease? How come we rather cure it than prevent it?
One of my informants said: “we need to be allowed to fail. And if we fail doing this then at least it was for a good cause and it didn‟t do anything worse.” Perhaps this is what frightens us to try: that it might get worse? Often when working with prevention it can be difficult to know if it got better or worse, or didn‟t matter. Sophisticated measurements and evaluations are needed to know if the innovation was effective and efficient. But what I‟ve learned from this year when listening to people talking about these catastrophes, and in my time with the thesis, is that people with different background, views and priorities can and want to stand together to prevent diseases (metaphorical ones as well as real ones).
And when listening to these people it is far more easy for me now to imagine a world that lives as one.
To end with a last quote from one of my informants who, with a little frustration, captured this with the sentence that: “You don‟t become a hero because you successfully avoid a catastrophe – you become a hero when you successfully rescue others from one.” I believe that it is exactly this that we need to see and change. We do not only need to collaborate together and understand all the different perspectives. Imaginably we also need to treat each other as heroes, and see ourselves as heroes, when we are active parts of avoiding a catastrophe. Even though we will never know of it; by being a stand up person, that stands up for others and together with others – we will prevent a catastrophe and someone will not need rescue. Imagine, we could be heroes…
Cecilia
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Abstract
Introduction: One of the main public health issues in Sweden today is to support the psychosocial health of the youth. To meet this need the social determinants of health should be addressed, which involves working broadly, preferably over organizational boundaries.
Furthermore, public health work such as this is often performed through projects, one example being the pilot project SAM in the county council of Norrbotten. One of the crucial aspects determining projects‟ success is the process of adapting to a project for the participants. Aims: The aim of the present study is to analyse how professionals experience working in a new public health project that is designed as collaboration across sectorial borders with the focus on prevention. With the specific aims of the study being to i) investigate how participants create engagement and stay engaged in a new public health project, and ii) to investigate how participants tackle doubts and uncertainties when working in a new public health project. Methods: The study is conducted by using grounded theory method with a constructivist approach. Data collection was performed through interviews with eight informants involved in the SAM-project. Results: The study suggests that it is necessary for the participants to feel as a part of the greater whole to be involved in, and continue working with the project; i.e. that they see that they are part of a collective effort that is larger than themselves and their immediate reality.
The greater whole is composed by i) seeing the need of it, ii) finding it meaningful to be part of it, and iii) feeling a belonging to it; furthermore the participants use a set of strategies to (re)create these three aspects.
Conclusion: The study presents encouraging results of the process of adapting in public health projects for its participants. It is possible to collaborate over organizational boundaries and the collaboration in itself strengthens both the willingness and ability to work with public health matters together with others. By gaining a richer understanding of how professionals create motivation to collaborate, how they handle their doubts, together with knowledge of the strategies that are being used to (re)create the engagement; we can increase the possibilities of
implementing innovative public health projects.
Key words: grounded theory, implementation research, mental health, multi-sectorial collaboration, preventive interventions, youth
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Contents
Acknowledgements ... ii
Preface ... iii
Abstract ... iv
Introduction ...1
Aims... 2
Methods ... 3
Description of study area and the pilot project SAM ... 3
Study design ... 3
The researcher – a piece of the research ... 4
Selection of informants ... 5
Data collection ... 5
Analysis ... 6
Ethical considerations... 7
Results ... 8
Feeling as a part of the greater whole makes us want to travel together ... 8
The four stages of the process ... 10
Traveling together is needed – it takes a village to raise a child ... 10
Traveling together on this path gives meaning ... 13
Traveling together can be bumpy – the need of belonging ... 16
Striving to (re)create a notion of a greater whole during the journey ... 18
The model “The oval wheel of the greater whole” ... 21
Discussion ... 23
Strengths and limitations of the study ... 27
Trustworthiness ... 27
Reflexivity ... 28
Further limitations ... 29
Conclusions ... 30
References ... 31
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Introduction
One of the main public health issues, in the north of Sweden as well as in Sweden in general, is the trend of mental ill-health among the younger population. Health issues such as
depression and anxiety are the identified key challenges to tackle regarding the younger population in Sweden, together with the increasing trend of addiction among youth [1, 2].
The causes for these trends are still unclear. However, there are reasons to believe that it is related to overall societal changes or changes in the social context of children and youth, since this trend is visible among all societal groups [2]. Also, we know that children and youth are very much affected by their social context, which is mainly school, family and friends (i.e. some of the main social determinants of health) [3].
Enhancing mental wellbeing among young people is not only important from a societal aspect (by enabling a stronger and more consistent workforce in the future, lesser pressure on the health care sector now and in the future etc.) but mainly from an altruistic aspect of reducing suffering among children and adolescents, both now and later in their lives. Sweden is also part of the United Nations children's convention (although not legislated), meaning that the society has an obligation towards the health and wellbeing among the young [4].
By taking action in the social aspects of children and youth, and their context, public health professionals can make the changes that might be needed to steer away from these negative trends mentioned above. Instead of focusing too much and too often on the care aspects (of diagnosing and treatment) it is perhaps time to take a stronger stance in the social
determinants of health (SDH) for the youth; to facilitate the prevention of ill mental health and promoting wellbeing among this population.
One example of an innovation to tackle the SDH among the young can be found in the county of Norrbotten. The county council of Norrbotten have stated that actions are needed to change the trend of increased mental ill-health and suicides among adolescents [5]. To tackle this issue a pilot project, SAM (In Swedish Samverka – Agera – Motivera, translates to:
Cooperate – Act – Motivate), was launched in August 2014 in two municipalities within the county council of Norrbotten, and will end in July 2017. This pilot project is a test of a new way if working (cooperating and collaborating over organizational borders in matters regarding prevention and promotion) with issues of preventing ill-health and promoting health, and a new way of thinking about this issue (to think broadly, on a societal level, on how all organizations can affect the issue, and building the work on a value base). It had the long-term plan of eventually being implemented in all municipalities within the county.
The aspects of a new way of working and thinking seemed very interesting and spurred initial questions when I was first presented to the pilot project – how is it for participants to work in these kinds of projects? Do they find it frustrating or thrilling, or both? Another aspect that arose during the time I listened and learned more about the process of the pilot was the doubts and uncertainties that were expressed by participants. Hence, questions arose from my interest of where the negative aspects originated from and how they are handled in the course of the project. These experiences initiated the later process of forming the aims of the present study (further described below).
When striving to facilitate for increased wellbeing among the young (an endeavour this study is part of) - why study how participants work, as a group, within a project instead of putting
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the effort in studying what interventions they should implement? The answer might be superfluous but the question is still important to address. As Svedberg discusses, in modern organizations professionals often work in groups, such as project groups, and it is a difficult task “to translate (others‟) ideas and visions into actions and launch them in a complex reality” [6]. Svedberg continues to describe how, because of all the difficulties and
complexities, the group is “a fragile and at the same time crucial link in the chain between idea and execution. If the group does not work this chain will break.” [6]. Therefore,
questions such as e.g. how project-groups should be constructed, how the participants keep their motivation and engagement in the progress of the project, and what obstacles the participants might meet and how they handle them; are important to address in this strive.
If the Swedish society wants to make long lasting changes regarding public health issues, such as the mental wellbeing of the young, professionals will need to work in a consistent manner over the boundaries of societal/public sectors and the organizations within them.
And do this over time. Otherwise they will probably not reach all relevant SDH. When working with public health issues neither the problem, nor the solution, can be connected to one single organization or authority. Due to indications, mentioned above, of that it is society at large through the young‟s social context that affects the mental health and wellbeing among children and adolescents; it is relevant to see all sectors that have any connection to the young as part of the solution.
Thanks to increased knowledge about social determinants of health (such as how education, environment, family etc. affect children and youth) [3]; we now know that we need to
collaborate and cooperate between different organizations, actors and authorities to succeed in having effect on the issue of mental health and wellbeing among the youth. The question remains however of how this multi-sectorial collaboration should be carried out to facilitate the struggle of solving a complex problem in a complex reality. This thesis will hopefully help constructing one piece to this puzzle.
Aims
The aim of this study is to analyse how professionals experience working in a new public health project that is designed as collaboration across sectorial borders with the focus on prevention. With the specific aims of the study being to i) investigate how participants create engagement and stay engaged in a new public health project, and ii) to investigate how participants tackle doubts and uncertainties when working in a new public health project.
The present study contributes to the field of implementation research by studying why project participants are motivated and likewise unmotivated to start working and continue working with the project. This could help understanding how the implementation process of public health projects, which aims to prevent ill-health and promote health, could be
constructed to facilitate their success. Furthermore, the present study takes place in a unique setting and investigates a unique pilot project during the end of its pilot-period and in the planning phase of being scaled-up and implemented as part of the ordinary work.
The remainder of the thesis is organized as follows: firstly, there will be a description of the study‟s context and method for data collection and analysis. Following this, the results will be presented together with the interpretation of the findings. Next, the findings will be
discussed in relation to previous research and suggestions will be given for future research.
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Finally a description of the strengths and weaknesses of the study will be given mainly through a discussion of the trustworthiness.
Methods
Description of study area and the pilot project SAM
The present study was conducted in the county council of Norrbotten, which is the most northern county in Sweden. With its‟ 98 911 km2 of land it is Sweden‟s largest county and constitute about a quarter of the whole area of Sweden. There are 14 municipalities in the county and a total population of 250 570 inhabitants, and thereby it is the 7th lowest populated county of the 21 counties in Sweden. The region consists mostly of forest and mountains but has also several large rivers and a coastline.
As mentioned previously, SAM was introduced as a pilot project to tackle the increased occurrence of mental health problems among children and youth in the county council of Norrbotten. Several municipalities were interested to be part of the pilot and two of these were selected. The aim of the project was to: ”prevent mental ill-health among children and youth in Norrbotten.” The project is further described as follow: “We work for increased awareness, competence and Cooperation and to Motivate more to raise the questions of mental health. We Act for the rights, of all people in Norrbotten, to have a good life and so that each young person, regardless of background, shall be viewed as significant.” [5]. The project rests on a value base consisting of six values: Ethical considerations, Evidence based, Norm-critique, Equity, Equality, Team spirit. The intention was that these values needed to be considered in both the process of SAM as well as in all the interventions within the pilot project.
SAM was described as a flexible pilot project, it started with the intention to test the grounds so to speak, but it had several fixed goals as well: i) “to describe, enable, develop, test,
evaluate and communicate methods and ways of collaboration that creates valid conditions for a foundation of good mental health for all, ii) to perform the project in the two chosen municipalities during three years, iii) to support on-going projects that work with promoting health among children and youth, and iv) that after these three years a well-functioning battery of interventions that can be used as a work-model in other municipalities within the county.” [5]. The pilot-project‟s target group was professionals that meet and work with children, adolescents and parents; and that, together with youths, work together to raise innovative ideas and create good conditions for participation of the youth [5].
Study design
Due to that the aim of the present study is to analyse how professionals adapt to the work of the project grounded theory was used as the design to collect and analyse data. Grounded theory allows the researcher to approach data collection and analysis in an open manner without specifying too closely beforehand what is thought to be the important factors [7; 8].
More explicitly, a constructivist approach was taken in the present study. This was because it fits with the aims due to that a constructivist approach acknowledges that people construct their realities and that multiple realities can exist within the same phenomenon (in this case a project) because several people are involved. Furthermore, the research performed with this approach is very much focused on questions of “how – and sometimes why –
participants construct meanings and actions in specific situations” [9]. In this case how
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participants construct motivation to work in the project and how they perceive and tackle the doubts that emerges in it, with the specific situation of working in a new pilot-project, with a new approach, in the context of Norrbotten. Grounded theory is a systematic method to collect and analyse qualitative data; however, it also offers flexibility by providing guidelines rather than a set of rigid rules to follow. The aim of using this method is to formulate a final theory, which is grounded in the data [7; 8]. In summary, this method was chosen because it can work as a tool, a shovel, to dig up answers of how individuals adapt to the work in
projects such as SAM. In line with the aim of the study this is done through a search for how the participants perceive the work, and collaboration, in the project and what possible motivators and doubts they might have.
Grounded theory consists of several strategies: coding, memo-writing and collecting theories [7]. It is through these strategies that the study‟s final theory, or model, will be formed. To ensure that the theory is well rooted in the data and thereby in the reality of the informants, an approach of constant comparison between data, codes, categories and theory is used [7].
The strategies mentioned can be used in diverse ways, in other words: grounded theory can be used by researchers with different epistemological views [9]. As mentioned above, the present study was conducted following the constructivist approach presented by Charmaz [7]. This approach is based on previous grounded theory styles, developed by Glaser and Strauss. As described above, this approach was chosen partly because of the fit with the aims of the present study, and partly because it alters from the earlier approaches by taking a relativistic stance and acknowledging the existence of several realities. Furthermore, this strategy is relevant for this study because it allows reflexivity of the researcher‟s part of the research process, and it recognises that the research is in turn part of a social context in a reality constructed by the participants in the study (including the researcher) [7]. This approach is therefore fruitful when a study, like the present one, is in search of how and why processes, and actors‟ experiences and perceptions, are constructed the way they are. It acknowledges that individuals have several standpoints, roles and realities – in other words this approach embraces the complexity of reality [10].
The researcher – a piece of the research
This study is very much a product of the context within it is constructed; therefore it is
necessary to address the context, namely the researcher and her world. The researcher makes conscious decisions but also instinctive ones; with her pre-understandings, interest and knowledge the researcher should be seen as a part of the research [10]. In other words, the researcher is subjective in her reflections, even if the collected data would be “objective” – which is not the case in this study due to that the researcher has integrated with participants and has influenced them during data collection by interviewing them. And thus I see the researcher as a tool in all research and that it is therefore important to highlight who she is.
Perhaps it is most important in qualitative studies and in grounded theory in particular, because the researcher is in a way leading the data to the final analytical framework. Much of the quality of the data collected in qualitative research depends on the researcher‟s previous experience and knowledge of both the topic and the method; but also, her curiosity, ability to be open, to understand the implicit meanings, and finally to make people comfortable to talk freely about their experiences and thoughts [9; 12]. I have a background in sociology, my major was social psychology. Much of my previous theoretical experiences, as well as personal interest, have been connected to organizations and the processes within them (cultures, norms, group-processes, factors affecting health etc.).
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Moreover, as mentioned above, one important aspect of using the constructivist grounded theory method is the reflexivity of the researcher‟s part of the study. Meaning that the researcher need to be aware that her previous understandings will probably affect what she sees in the data and how she understands what she sees. Charmaz [7] states that “rather than seeing your perspectives as truth, try to see them as representing one view among many.” The researcher needs to put herself in the informants‟ shoes and try to see the world through their eyes. This is a challenging task but important so that the researcher does not impose any concepts or meanings to the analysis that does not fit the data [7]. One way of being able to do this is by knowing more about the setting, the context and the participants in the study.
Dahlgren et al [12] states how important it is for the researcher to have knowledge about the field where the study will take place. This is mainly relevant for observational studies;
however, I believe that this aspect is important for all studies where the social context and other processes might affect the participants. The authors mean that gaining this knowledge is important because the qualitative studies are based on a holistic worldview, that it is the social context and processes within it that affects the individuals and therefore one need to understand the world of the informants, from their viewpoint, to understand them and their actions [12]. During the time of this study there were several chances for collecting relevant knowledge; during the end of summer last year, I had a short internship of two weeks at Folkhälsocentrum: a department within the county council of Norrbotten. It was then I was introduced to the SAM-project and got the possibility to learn more about it. I also got the chance to participate in project-meetings and take an active part in the practical work of SAM. Moreover, the staffs at Folkhälsocentrum were generous with providing me with information (both in written and oral form). This, together with the observations during the conference in December 2016 (further explained below), gave me deeper understanding of the context, norm systems and social structures connected to the project. In April 2017, I also got the chance to participate in a project-meeting in a new municipality where SAM is
starting. No additional data was collected at this point but it gave me as a researcher a richer understanding of the process of SAM, now in its initial phase.
Selection of informants
The informants were purposively selected with the inclusion criteria that they should have been involved in anyone of the groups that had existed throughout the project, one in each municipality, or from the overall project-group on a regional-level. Or that they were
identified as a key figure in another way, thought to have rich information about the process of the project. No selection was done on the criteria of whether the informants had been involved since the beginning or not, nor what their role in the project-group and their profession was. Eighteen possible informants were found and invited to participate in the study, eight of these accepted to take part in the study.
Data collection
Consistent with the emergent design the study started with an open mind and the aims of the study were formed during initial observations at a conference (which had the purpose to present the work performed during the pilot) and with two intensive interviews. Both the observations during the conference and the two initial interviews helped gather a rich pre- understanding of the pilot project and who had been involved and how. Thereafter, further six intensive interviews were conducted, with a clearer focus based on the now developed
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research questions. The data from the two earlier interviews could also be used later, together with the data from the other six interviews, to form the final analysis.
All interviews had open ended semi-structured questions, with the intention to cover the study-questions. All interviews were conducted in the mother tongue of both the informants and the researcher. One informant was interviewed at two separate occasions, something that Dahlgren et al [12] suggest increases trust between informant and interviewer. Three of the interviews were performed in person and due to practical reasons the other five were done over the phone.
Analysis
Grounded theory methods have an emergent character; they are both inductive and iterative.
The researcher starts with an open mind and inductive data to continue in a comparative process where the analysis evolves throughout the collection and interpretation of data.
Therefore, the researcher‟s work pendulates between conjectures and data to eventually end in a theory that is rooted in the data and thus in the informants‟ own perceptions and realities [10].
The analysis of the study has been performed in several steps presented below and in Figure 1. The analysis has developed through a constant comparison between data and emerging categories as well as between interviews (meaning that when a theme, or important codes are emerging in one interview the same theme or codes has been searched for in previous
interviews) [7]. Due to using constant comparison the analytical steps are not as clear cut as in many other designs, because it is performed parallel with the continuous data collection and the researcher goes back and forth between the steps of coding, categorising and memo- writing.
The analytic process consisted of following steps: Firstly, memos were made throughout the entire process. Secondly, the data (from both the first and second set of interviews) were first taken through the process of initial coding. This was done in a line-by-line method, a strategy that is helpful e.g. to unearth “implicit concerns as well as explicit statements” [7]. The next step was to perform focused coding. This was done together with sorting and grouping the initial codes. In short, focused coding helps to reveal what story the initial codes are telling. It is now the analytical level is sharpened in the study [7]. The focused codes suggested several categorises that seemed to be important for the study, these categories were then shaped and altered continuously through the process of constant comparison until the final product was decided on, which will be described below.
Some of the emerging themes from the first four informants were discussed in the fifth interview to verify that my analysis was grounded in the perspectives of the informants. The interview-guide for the latter three interviews was renewed to focus more on the emerging themes, but kept the open-ended format. Next, all memos that had been produced were revisited to search for previous preliminary categories, or other thoughts. Then, the categories were analysed again, some alternations were done by constant comparison between data, codes and memos. Also, the categories, what they tell us, and how they are connected to each other, were discussed with colleges to test their workability. The analysis of the categories then continued, now by further help from theoretical coding families. Now to try to reconstruct the actions and processes that these categories consists of and to
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understand how they are related to each other [13; 7]. Finally, four categories were formed and framed. Along with the process of further untangling what is happening in these categories, a process of constant comparison between data and the categories with their subcategories went on simultaneously as expansions of knowledge from previous studies were made. Next, theoretical coding was conducted; this was done by sorting memos and working with lifting the analysis to a theoretical level [7]; which resulted in the final model of the process of adapting to a collaborative and broad project (Figure 2). Open Code 4.0 was used for initial coding of data.
Ethical considerations
All informants received a written informed consent when asked to take part of the study, together with a description of the study and its‟ general aim. The informed consent was also discussed briefly before the start of each interview to make sure that everything felt
comfortable for the informant and that no misunderstandings were at place.
Research problem and opening research questions Sensitizing concepts and
general disciplinary perspectives
Data collection Initial coding Data collection Focused coding
Initial memos raising codes to tentative categories Advanced memos refining
conceptual categories Using theoretical
coding families
Theoretical coding Theoretical memo-
writing and further refining of concepts
Adopting certain categories as theoretical concepts
Sorting memos Integrating memos and
further refining categories Writing the first draft
Search for previous research
Memo-writing
Reexamination of data
Figure 1: Chart over the research process of the present study, based on the figure presented by Charmaz [2006:11].
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Results
Below the results are presented starting with a description of the core category and the four stages that constitutes the core category, followed by an example of initial codes. Thereafter the four stages of the process are described more in detail. The results-section will end with a presentation of the final model: The oval wheel of the greater whole, which brings the results together and shows how it all is connected.
Feeling as a part of the greater whole makes us want to travel together The analysis resulted in a core category Feeling as a part of the greater whole makes us want to travel together, which tells the story of motivators and uncertainties that arises among participants when working together and adapting to a new project with a broad approach. The core category reflects a process (Figure 2) constituted by four stages that are neither sequential nor static; they are at work throughout an on-going process and can be reshaped through the journey. Moreover, they are interlinked and dependent on each other.
The four stages are: i) Traveling together is needed – it takes a village to raise a child; ii) Traveling together on this path gives meaning; iii) Traveling together can be bumpy – all need to feel belonging; and iv) Striving to (re)create a notion of a greater whole during the journey (Table 1). Together the stages create the core category “the greater whole”, which is consisted of all these parts combined. It is more than merely one or two of these aspects, it is all four and together they comprise more than their separate parts combined. The greater whole is about seeing a need of a collective effort, to find it meaningful to be part of it and to feel a sense of belonging to this greater whole. Furthermore, to make this possible; a set of strategies are being used to (re)create the understanding of the need, the meaningfulness and the sense of belonging.
Additionally, the four stages are not completely separated from each other but have connections and links between them. Firstly, seeing the need of tackling the issue at hand from a societal perspective, aiming at the social determinants of health, the participants in the project also forms a sense of meaning and belonging by placing oneself in this bigger picture as a piece of the puzzle. This cannot be done without the strategies in stage four that (re)creates, among other things, knowledge of the puzzle. Secondly, some participants may already see the bigger picture, finding it meaningful, and feel that they belong in this work;
while others join the project without being in any of these stages. Through the collaboration they may develop a view of the need of a broader take on the issue, a meaning to be part of it, and a sense of belonging to the project. To do this together with others is the key feature here.
If others are part of the greater whole, together with oneself, it will make the participant more motivated to continue being part of the project. However, if any of these three first stages (needing, meaning, and belonging) are lacking the participants might leave the collaboration. This is so because if a person sees the whole picture and truly want to engage in it, and sees how she fits into it, or identifies herself with it – she will be motivated to take on the journey – together with others. And if not all three stages are present, doubts and worries might occur that will decrease the motivation and engagement. When this happens, stage four will help create the stage(s) that is lacking; if stage four is present and working.
It is worth emphasising how stage one and three are clearly linked to one another. The first stage tells the story of seeing the whole picture and how all pieces of the puzzle fit together,
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while the third stage tells the story of how the participants handle the issue that occur when not all the pieces of the puzzle are there. Feeling as a part of it all is partly about seeing the need of the greater whole. And seeing the need of the greater whole and one‟s own part in it is partly about feeling that one belongs to it.
Building bridges between organizations has shown to not only help create unison but also to help the participants to see, and understand, how they all fit together in this greater whole. It is a pilot project and with this follows, as perhaps predicted, questions and uncertainties.
This can be difficult when we want to know what that is expected of us, and what that should be done etc. If the organizations, together, solve these questions and form a collective
understanding of where they are going and how they are to get there they have the chance of creating a greater whole. And through a continuous collaboration the greater whole will be recreated, and perhaps changed. For example, in ten years‟ time, if they are still collaborating in this issue they probably still might feel as a part of the greater whole but aspects of it has changed, such as other social determinants of health are seen as more important and thereby others are part of the greater whole.
The four stages were constructed by grouping initial codes and analysing their meanings. To help the reader to gather a better understanding of what lays behind these stages the thesis presents a set of examples of these initial codes (Table 1). A greater in-depth understanding of the stages and the overall process will be further described below.
Table 1: Examples of initial codes that created the four categories
Traveling together is needed
Traveling together on this path gives meaning
Traveling together can be bumpy
Striving to (re)create a notion of a greater whole during the journey
Examples of initial codes:
Examples of initial codes:
Examples of initial codes:
Examples of initial codes:
Needing collaboration and cooperation
Needing to work with the big picture
It takes a village to raise a child
Seeing the whole picture
Wanting others’
knowledge and perspectives
Seeing collective rewards
Collaborating for the youth
The sum of all parts is greater than…
Being part of the whole strengthens my work
Passengers are missing
Difficult to see the whole picture Not feeling included
Wanting others to be part of the journey
Not joining in, just sitting in the car
It becomes clearer with time
Building bridges
Forming collective views
Forming collective knowledge Wanting clarity
‘We need to continue discussing’
Viewing conversations as creating unity
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Traveling together is needed – it takes a village to raise a child
This stage is about how the participants see the issue in a bigger picture and realises that they need each other. They see that they cannot do this journey by themselves. More than doing this together as merely a want, this study suggests that the participant sees it as a need.
Two ways of seeing the need of the bigger picture emerged in this study. Firstly, how the mental health and wellbeing of the youth is affected by the society at large; i.e. the
participants view the SDH as important aspects and have a will of working comprehensively with the wellbeing of the youth. Secondly, that all sectors are needed in the work of
promoting health and wellbeing and preventing ill-health, that “it takes a village to raise a child”. These two ways of perceiving a need of the bigger picture are described further below.
The first aspect of how the bigger picture is needed is that of how society affects the children and adolescents. In turn, three parts of this is detected in the interviews: i) several factors that affect mental health and wellbeing is needed to focus on (i.e. SDH); ii) there should exist individual support parallel with a lessened focus on individual behaviour; and iii) there is an unhealthy view of mental health and wellbeing in itself, that affect the youth‟s perceptions on health.
One first example of how the participants see the bigger picture is when Informant 8 describes a new intervention they are implementing in their organization and ends with saying that: “However, later we realised that this is not doing the whole job – we need other things as well”. Also, the informants discussed how different aspects in society affect the mental health and wellbeing of the youth and how it can have large implications now as well as in the future; for the individual as well as for society. For example, Informant 6 says:
“it [the work in the SAM-project] has also been about language, e.g. if one cannot understand the language then one cannot make use of one‟s education…and then one cannot take part in society, and it will have overall effects [on the individual‟s life in the future]. Thereby language is one dimension of providing good opportunities for young people to succeed and manage. And if one do not succeed nor manage then that will also show itself in their health.”
Additionally, Informant 2 talks of the importance of working with the SDH and how a broad view is needed to do this. The informant also problematizes the possibilities of doing this but that it can be managed if everyone takes part in the work, which is related to the second aspect of this stage (that all sectors are needed in the work):
“[My aim] it is about this of thinking in a more broad perspective on…euhm…on health really. To include a perspective of promoting health, to include participation in society…well the whole spectrum of the social determinants of health really, I guess that is what I want to include in this. And perhaps someone has it [the responsibility of issuing the work of promoting health and prevent ill-health from a societal perspective] as 20% of their ordinary work description and then you don‟t have the time to gather necessary information about this and being able to work with it in that manner, this structural perspective. […] But we can all support each other. […] I mean to start thinking in this manner that all the work within the whole municipality matters.”
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Furthermore, the findings show an opinion of a need, or will, to change the focus from the individual to the social and societal factors that affect individual, i.e. SDH. For example, changing from emphasis on behavioural change of the individual to focusing on a more secure physical and psychosocial environment. Informant 2 phrases it as:
”we will not solve the structural problems on an individual level. This with increased mental ill-health is about a societal development. Sure, we can support individuals but…you know what I mean? […] However, an intervention for supporting parents is something else than a method for behavioural change. […] It becomes…you put it [the responsibility] on the young when you implement a CBT [cognitive behavioural therapy]
in schools.”
However some of the participants also mention how there is a need for the interventions to offer support on a more individual basis, for each individual‟s specific need, for example Informant 8 who states that when they adjusted the physical education in a school in the municipality they wanted to implement a focus on the individual:
“and then we really pushed for the health-aspect. And the teachers, they started to really think a lot about this, it wasn‟t only that they got more time in class [to do what they already did], but rather that they started to think very very much on an individual level, for the pupils‟ best.”
Furthermore, more than merely seeing that different specific factors affect the youth the participants also talk of how we, and especially the youth, are affected by the societal view and norms of psychosocial health and wellbeing in itself. For example, Informant 5 talks of this and says:
“And I think that this is visible when one works with them [meaning pupils] that there is like an expectation of…well like „life is fun all the time‟. And they are fed with this…and even more than adults I think, this about that you should be successful and happy and bla bla bla all is well and fun...and there should be a beautiful surface and all that. But life is bloody gloomy! […] I think that everyone knows someone that is not feeling good […] and that should not be seen as something strange. And they should know that one can get help if one wants to.”
The second part of seeing the need of the bigger picture is that all sectors are needed in the work of promoting health and wellbeing and preventing ill-health. Meaning that the participants see a need of the various perspectives, information and knowledge that all separate sectors can offer. By seeing the larger picture of how youth‟s mental health and wellbeing is affected by various aspects in society; and not simply a matter of individual factors or one part of their social reality, such as school or family; the participants perceives that all sectors are part of the puzzle. And therefore that the work that the project entails is not possible for only one organization or authority to perform by themselves, they are all simply parts of the puzzle, and thus the solution. Moreover, the participants see the work with mental health and wellbeing of the young as something that coincides with other aims and/or work, within their own organizations as well as others.
What emerged in the interviews was also how the participants see this problem that needs to be solved and either they already have an understanding of how this can be done (and then the solution is seen partly in other sectors) or they do not have a concluded thought of how to
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meet this need – and then they reach out to others to receive help.Meaning, the participants see a need of, and value, the knowledge from others, others point of view and their
commitment. They see that it is the society at large that affects children and adolescents and that therefore several organizations, authorities etc. can be, and should be, part of the solution. Informant 1 talks of this and says “it is good that there are people working with these aspects [that they in that specific organization know little about]. That is assuring. We need their support in knowledge.” Or as Informant 3 expresses it:
“we would need support, to form a multi-sectorial collaboration, so that we all can see how we should collaborate for… well really so that the whole society would get more knowledge about the issue […] all organizations need to be part of the work”.
Furthermore, the participants mean that several actors are needed to form an understanding of the whole, with everyone‟s specific perspectives and knowledge. Informant 4 states that this is partly what the collaboration in the project has resulted in:
”Well, here I think that SAM has made a difference. That we together have created a broader understanding of what that affects the mental health of the youth. […] and that we need each other to form an understanding of what that exists […] who does what where and when and so on.”
As mentioned above, the participants sees that because they are all parts of the puzzle they can together “fill the gaps” and make sure that all children and adolescents have gotten the chance of a healthy and fulfilling life, and that no one is left behind when in need. The important aspect here is that all parts of the puzzle are needed to lay the puzzle; if a piece is missing there will be a gap and the picture will not be complete (which will later be seen in the third stage). Informant 3 offers an example of how the participants worked over
organizational boundaries to fill the gaps, so to speak, and how they need each other to work for the best for the youth:
“We looked e.g. on what main issue is it we can see from the children‟s clinic and the prenatal clinic-point of view? Well, it is that they never get to see some of the children, when the families don‟t show up with the kids on these visits. They are in preschool but the children‟s clinic and the prenatal clinic never reaches them. And then we could immediately see that here we must cooperate, we need a group that work comprehensive […] and that one has overseen all these parts of what that can be the causes of why we have not reached our aims [of, among other things, increased mental health of the youth]”.
Finally, as a part of seeing the bigger picture is how the participants talk of how they can see how the work of SAM goes hand in hand with other things they are striving for (such as that all pupils should pass their classes), showing how they see various parts of the big picture and how they fit together. Moreover, the participants discuss how they can link these different things together in an overall effort to help the young. Informant 1 gives an example of this view, as well as concluding many of the other aspects already mentioned above:
“and then to make sure that all teachers know about it [the plan of future work with SAM]
[…] and it will coincide with our other goal – so that it will not be something separate, but we intertwine this with health, wellbeing. We have already started activating […] the teachers in physical education to work with this about physical education and health. And
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then […] the teachers might still argue that „we do not have enough floor ball sticks – but it is not about that, it is more about the content and the view of the subject and in the meeting with the pupils. And how can we promote…so that everyone feels that it is joyful to exercise and take care of oneself and one‟s life now and in the future? Then it is also about drug-preventive interventions, and it is about sex education, and these aspects of equity and equality and all these parts. Career guidance is also raised [as an issue in this work] now – how are we working with that? Already with the pupils in first grade…so that they will get positive views of the future so that they may reach their life-goals. They might live in…under conditions so to speak, where they have experienced unemployment through several generations. Then it is very important that we start working with this with
„what can you be? What do you want to be? You have possibilities…‟ I mean to show [them] possibilities. You can see how I will interconnect everything! *chuckles*”
Traveling together on this path gives meaning
This stage is about how the participants find the work in the project meaningful, both in relation to their values and to their work. Mainly two aspects emerged from the interviews:
Firstly, the participants find it meaningful to be part of a project which has the purpose to help improving the mental health and wellbeing for children and adolescents. When asked what obstacles that can be seen to get the work-model of SAM implemented in the
municipality, Informant 8 answers:
“Well, finances are an aspect of it. But then again, finances don‟t matter when you get kids and young to feel good. And if we look further in the future…we get the [financial]
rewards then, plus we “win” more kids that are feeling well. Do you understand what I mean? That by seeing it in a societal perspective…what we invest here - in giving pupils the best conditions, we will get back in the future, by having more pupils that are not in need of societal support in the future...that will end school with their diplomas, that will get a job, that will have good self-esteem, confidence. So that they will be able to handle the life after school.”
Additionally, there is a view of helping the young is also meaningful to society at large (but in the end it is still seen as most important to help supporting young individuals to succeed in life and prevent ill-health among this population-group). And to be able to execute the meaningful job all organizations need to be involved. When asked if the informant believes that other organizations also see it in a societal perspective, Informant 8 continues:
“Yes. At least I hope so. I mean, if we would see it in the same way, everyone, then we would see the rewards of […] the earlier we will have the interventions… [meaning parental guidance when the child is really young and in preschool] the less a child, a young person, will cost the society and for all organizations. But most of all, less human suffering! That is my full conviction, all pupils want to succeed. […] and in all of this it is the pupil that matters, it is for them, after all, that we exist – both school, social services and county council.”
More than seeing that doing this together is needed (as seen in stage 1); the informants talked of the importance of also the children and youth of being prepared for society in a more mental and emotional way. Meaning that they see the need of raising children and youth that can handle life, more specifically life in the Swedish society and they want to do this by offering them broader “life-knowledge”. For example, when the general and broad perspective of a method was questioned by the researcher in some of the interviews the informants most often answered that it has to be broad. And that also those that, at this
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moment, are not in need of support should get the knowledge because they will most probably need it in the future. Thereby, by working in this broad way the project offers a sense of meaningfulness for the participants as well as for the youth. For example, Informant 5 expresses it as following:
“No I like that it is on a general level, I think it is good…I think it is damn good! It is in a way a positive compulsion [meaning that it is good that participation in the intervention is mandatory in school]. The way I think is that everyone feels bad at some point in life.
[…] And a positive effect as I understood it, and something that was shown in the evaluations, was this with “we got to know each other” – it was easier to get to know each other and create a better community spirit in the class. […] These are soft values right here. They are substantial…or of great value. And then one can only hope that they will continue to use these tools, or methods, later in their everyday lives. It is after all foremost that that one would want, or do want – that everyone can take with them some sort of thought about how they should think or act when they feel in a certain way. Or to prevent from feeling in a certain way. […] This work feels meaningful! It is towards adolescents, it goes hand in hand with my own values, my job, my opinions and how I think. […] As long as I understand the purpose and all that. ”
Helping the young is much more than merely here and now, it is part of the future and the greater whole. These children and adolescents will have a better future, they will be equipped for life that is and that will come. The SAM-project is useful for those that are having
problems or are feeling unwell at the moment as well as for those that are happy at the moment. Everyone needs to feel better about themselves, even adults, and we all need these
“tools” that the interventions in the project will give the young to be able to handle negativity that comes with life. The participants sees it as helping children and adolescents‟ mental health now, will do them good in the present and in the future, in various aspects such as facilitating to get in to the labour market and living a fulfilling and happy life. The
participants want to build a greater whole, a society with healthy children, adolescents and adults that all can be part of society. Working with the issue of mental health of the youth within the greater whole offers meaningfulness in a larger way – as seen in stage 1 the participants see the need of working with this issue because it strengthens democracy,
further, as seen in the examples above, it helps the youth to believe in themselves and to fulfil their dreams or making it possible for them to actually have dreams.
Secondly, the participants in the project can find a greater meaning with their own work when it is part of the greater whole. The informants discussed and exemplified how their own work was strengthen by collaborating with others in this issue, as well as how the
collaboration creates something that is larger than only the sum of all its parts. For example, Informant 6 describes the benefits of the project by stating that:
“Partly it [the SAM-project] is about lifting the knowledge in a larger context, and to get advice and support from other actors, I have collaborated a lot with others […] it lifts my opportunities to work with adolescents‟ participation and raise their voices locally.”
Moreover, Informant 1 talks of the importance of collaborating over organizational
boundaries and clearly showing everyone how their work is connected to each other and to the issue. And that it is then that they will truly accomplish a change because they are stronger in unison than what each one can do separately:
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“we have been working with…linking it [the different organizations‟ work in the issue of the mental health among young people] to the bigger picture, and that is not easy […] but as I see it, if we manage to show the links then we have reached a long way, because then it will give a much larger effect.”
The participants also find the knowledge, support and perspective of others to be valuable resources. By involving everyone that can help in the project the participants creates a strong unison that can fill the gaps (to draw back to the first stage). And with the collective
knowledge and perspectives the participants in the project can see, and feel, how they can make a larger impact. It can also be that by standing united the participants find it easier to argue for the importance of working with the issue they find meaningful and vital – the health and wellbeing of young people. This is noticeable when Informant 3 says:
“We have now found a good model of how to work that is functional and that we believe is a good way of conducting this work – that we together create a base knowledge, that we together discuss the pros and cons., that we together discuss the mental health and wellbeing. Because it is after all…we see it from different angles […] and then I believe that it is important to become united, to strengthen the cooperation and what it is that we shall locally, and regionally, work with. […] And we have reached out to the whole society with information about this issue; we would not have been able to do that by ourselves.
[…] It increases the significance of the issue when one has all the sectors behind it – because it shows that we work together in a substantial work, which promotes wellbeing.”
Additionally, beside societal rewards the participants see that the rewards for the involved sectors specifically. For example, by helping children to build a stable mental base and feel good about themselves in preschool, the participants view it as something positive that this might reduce the workload for those in social services in the future, even though they are part of other sectors. Therefore, being part of something larger gives meaning and one can
appreciate rewards that are seen in other sectors as a reward to oneself, or vice versa: to appreciate that others are given resources to perform a work that later will reward one‟s own sector. For example, Informant 7 says:
“We have a well-established collaboration between the social service and education. So it has probably been more and more about that one sees that what is good for the school also benefits social services etc. They receive fewer cases if we succeed with the children.
If they are well and pass school then it will be less likely that they might end up at social services. Then one might have had a greater acceptance that we are implementing most interventions in schools [instead of increasing the resources for social service].”
The results suggests that the participants find it meaningful to have a positive purpose to help others and to be part of something larger than themselves, their work and their organization; and therefore they are motivated to work in a project that is connected to the greater whole. Meaning that the work that they (already) do becomes more meaningful by being part of this project; more specifically: by collaborating with others towards a joint goal, or vision, the participants find a higher meaning with their work. Perhaps more importantly, as mentioned, the general aim of strengthening children and youth and bettering their mental health is a meaningful journey that motivates the participants.
However, to find this meaningful entail that the participants also can see the need of the greater whole and one‟s own part in it (stage 1), as well as feeling that one belongs to it (stage
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3). There are also strategies (stage 4) for (re)creating the meaningfulness of this work, such as collaborating and discussing over organizational boundaries will lead to an increased understanding of the greater whole and one‟s part in it and then also to see the
meaningfulness of the collaborating and joint rewards.
Traveling together can be bumpy – the need of belonging
The third stage shows the difficulties of traveling together in a project such as SAM. It tells the story of complexities of being engaged in this work through the question of belonging to the project and/or the issue, and how the participants handle this. If there is no feeling of belonging it might affect the participation in the project negatively – both for those that lack it and for the others (who wants that everyone has a sense of belonging to the whole picture).
One aspect of this is the uncertainties of how roles and organizations fit into it all. It will be difficult to understand the greater whole and feel that one belongs to it – together with others; if one cannot see the other sectors‟ and organizations‟ pieces to the puzzle. The uncertainty of how sectors belong in the project was mostly discussed regarding involvement from “directly” affected organizations (such as schools) and “indirectly” affected
organizations (such as e.g. culture-departments within the municipality). Meaning that it might be easier to see the connection for those who were directly affected by the project. One of these aspects was the relation to how organizations within the health sector are connected to organizations in other sectors, through this project. There was a view of that the health sector focuses mainly on curative care, which is not the project‟s main purpose, and therefore there might be a gap between the project and this sector. Still, this is a sector that the
participants believe to be highly important as a part of the project because it is related to the health of young people. For example, Informant 4 states:
“However, then there are others that…for example those that work with individual curative care and that do not work with preventive actions […] they are not directly affected by SAM, because they work with the youth when they already are unwell. But at the same time they are part of the project groups and there we have had difficulties in how to build the bridges between the preventive and the curative…and we have still not figured that out.”
All informants discussed the issue of how some key actors, organizations and/or a whole sector were missing, and how this was a loss. As seen in stage 1 the participants that engage in this work see the need of others and therefore it creates worries when this need is not met.
Informant 8 talks of how organizations are missing and show a feeling of loss due to this:
“There has been difficulties involving these organizations that handle many of the young persons that are unwell […] but they have probably not felt really part of…because from the start we had some of these organizations with us [in the project]…but I think they didn‟t see their part in it really.”
The informant continues then with describing how these organizations could and should fit in SAM, together with other organizations. And how they “would be natural ingredients for the project and thereby the best for the young.”
To feel as a part of the whole is perhaps not only dependent on the individual or organization itself but also dependent on the others – whether they can see how this fits into the whole,
