3.1. Implementation/Adoption
RECRUITMENT
The program implementation commenced in February 2018 and took two years, as it was impacted by the complexities of navigating the hospital systems and by the COVID-19 pandemic. The adaption and adoption process required many iterations of recruitment processes and program delivery due to extensive consultation and navigation of interdependent, but unaligned, hospital systems. This included an extensive ‘review and approval’ process. This involved the expected reviews by Ethics and Governance committees, as well as information and communications technology governance (for agreement regarding website hosting, text message delivery and recruitment), management and clinicians of obstetrics, midwifery, dietetics, physiotherapy, and pregnant women (regarding content approval and updates required and program delivery), mater education (for program content), hospital marketing (for brand alignment, production of locally branded content, promotion of the research, and the txt4two program, recruitment), and research marketing (for brand alignment, branded content, promotion of the research and the txt4two program, recruitment), legal services (due to the research collaboration between interstate collaborators), and administration service (for booking and for recruitment processes). Often, negotiations with one department resulted in additional approval from other departments (management, marketing), with multiple ethics amendments required.The project team identified enablers for the program adoption. The health service (management, clinicians, and women) embraced digital disruption, and this was viewed as an enabler because digital education resources for women and families had already been developed. The project being led by an embedded research dietitian, who worked across the clinical domain, was seen to facilitate the evidence-based adoption and allow for early, wide (and persistent) stakeholder engagement with an understanding of hospital systems. The robust implementation and co-creation plan provided a road map for implementation that was seen as a facilitator, along with the decision to be flexible and pragmatic, allowing for adaptability, when required, to fit with stakeholders and infrastructure. Barriers to adoption were also identified. Significant negotiations that elongated timeframes included legal agreements and intellectual property ownership and transaction across institutions and between individuals. Tailoring the content for the requirements of individual health professionals and marketing and ethics required more negotiation than expected. Navigating technology infrastructure was more complicated than anticipated. For example, gaining approval to use the system to go live took nine months, due to information technology delays and the integration being deemed a low priority. Through discussions, it was initially believed that this online process aligned with the hospital’s online intake form; however, this was later identified as being a separate process, unable to incorporate study registration, due to its own implementation trial. 