160 CHAPTER 6 The narrative, widely spread, was turned into action through the efforts of dedicated champions at different levels. At the local level, proactive coordinators or facilitators acted as driving forces for coalitions’ progress. At regional and national level, these individuals were described as ambassadors, advocates or visionary leaders who consistently keep Solid Start on the policy agenda, and who inspire others. In the adoption of innovations or transformations, such strong and committed ‘champions’ or ‘change agents’ are frequently described as key factors to initiate, promote and sustain a certain movement or collaborative initiative (19, 20, 25, 27-30). In addition to designated champions, it is essential that informal champions emerge from intrinsically motivated frontline professionals in order to stimulate the engagement of peers (29). Moreover, collaboration among multiple champions, especially those in different positions (e.g. care provider and project coordinator), is described as beneficial (27). This may contribute to boundary-spanning across levels and services, and possibly help to address the gaps that currently arise when a champion leaves. Continuously emphasizing the narrative and providing support to champions across all levels may contribute to the long-term integration of the action program Solid Start into everyday practice of all professionals. 2. National governmental stewardship with strong local focus is a promising combination The combination of stable national governmental stewardship with a strong local focus increased the action program’s adoption, as it provided a clear direction and support while it simultaneously ensured alignment with local contexts, practices and networks. Previous evidence also indicates that implementing and sustaining integrated care involves balancing two approaches: a top-down and bottom-up approach (7, 31-33). Currently, literature describes missed opportunities due to an over-reliance on top-down approaches in integrated care (7). A more traditional top-down approach can create favourable conditions (regulations, finances, governance) and external motivation for change (7, 31). In our study, a consistent ‘push’ and structured program with supportive mechanisms from the national government (referred to as national governmental stewardship) prompted a sense of urgency, guided local policy agendas and steered local action. These supportive mechanisms extended beyond mere financial support, including practical support in setting up a coalition Solid Start and implementing interventions. Simultaneously, our study also identified various barriers to integration at systemic level (e.g. limited resources, collaboration-inhibiting laws and regulations), and highlighted the need for more responsiveness to local stakeholders’ needs, meaning there is still potential for improvement. Next, a bottom-up approach fosters engagement and support from professionals who are directly involved in changes, allowing for future-proof innovations that align with local needs (31). In this thesis, encouraging and facilitating municipalities to create their own approach increased flexibility to respond to unique local situations and developments. The synthesis of Wodchis and colleagues (33) on integrated elderly care explains how bottom-up initiatives require top-down support to sustain and spread, and Behrendt and Ramanuj (32) convey that learning processes are part of the synergistic interaction
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