Context

In Norway, there are 357 municipalities. Each municipality is responsible for health-promoting and preventive services in the antenatal period and for children and their families [18]. Together with general practitioners (GPs), PHNs and midwives are responsible for providing primary care during the perinatal period. All pregnant women are entitled to free follow-up consultations with their midwife and/or GP. During pregnancy, women are offered nine consultations, including foetal diagnostics and ultrasounds, with additional needs-based follow-up and a home visit in the early postpartum period [19]. After birth, women and children are provided the Infant healthcare program, a standardized program consisting of 14 individual and group consultations, including a home visit, delivered mainly by PHNs [20].

Aim

The study aimed to explore midwives’ and public health nurses’ experiences of the intervention and the early implementation process, three months post-training in a guided digital intervention.

The guided intervention

Mamma Mia was developed as a fully automated digital intervention designed to prevent perinatal depression and enhance subjective well-being among perinatal women. It consists of 44 structured sessions delivered over approximately 11 ½ months, starting in the second trimester and continuing until the baby is six months old. The program targets risk and protective factors, including attachment, couple satisfaction, social support, and subjective well-being, utilizing psychoeducation, mindfulness, and meta-cognitive strategies. Mamma Mia is free of charge, providing a scalable and accessible tool for universal prevention of perinatal depression [21].

The goal of providing Mamma Mia with guidance from midwives and PHNs at MCHCs is twofold: 1) support the use of the intervention and 2) facilitate and promote perinatal mental health and subjective well-being by providing person-centred and tailored care based on the individual woman’s needs. The exploration and support use the Efficiency Model of Support (EMS model), which aims to enhance digital intervention use and clinical efficacy by addressing five key failure points: usability, engagement, fit, knowledge, and implementation [22]. The blended version aims to identify and address these failure points stepwise, ensuring users benefit fully from the intervention and explore additional needs. Midwives and PHNs received training in this approach during the two-day training as described in the training manual [23,24].

Training and supervision

To facilitate the implementation of the guided version of Mamma Mia, a comprehensive plan and a detailed guide for recruitment and the guided intervention were developed to support the study and its implementation [24]. Training and supervision were delivered by three trainers through a two-day digital training program (Table 1), followed by monthly 1-hour digital supervision, to ensure adherence to the intervention protocol and provide ongoing support for healthcare professionals during implementation. The three trainers who delivered the training sessions and supervision were selected based on their professional background as midwives and PHNs and their experience with quality improvement in MCHCs. Manuals for training and supervision were developed to support trainers.

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Table 1. The structure of the two-day training sessions.

https://doi.org/10.1371/journal.pdig.0001348.t001

Study design

This study employed a qualitative descriptive design to explore midwives’ and PHNs’ experiences of implementing a blended digital intervention, Mamma Mia, into routine maternity and child health. A qualitative, reflexive thematic analysis approach was chosen to capture participants’ own accounts of meaning, uncertainty, and adaptation during early implementation, rather than to test predefined hypotheses.

Data were analyzed using reflexive thematic analysis (RTA), as described by Braun and Clarke [25], which was selected for its flexibility and suitability for examining how professionals make sense of complex, context-dependent change. RTA enabled an inductive, interpretive engagement with the data, allowing patterns of meaning to be developed through iterative reflection rather than through quantification or saturation-based logic [26, 25].

The study adhered to the COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist for transparency and rigor (Tong, Sainsbury et al., 2007), followed the principles of the Declaration of Helsinki [27], and received ethical approval from the Regional Ethical Committee (ref. no. 112830). The study forms part of a larger multisite randomized controlled trial (MaMi Trial II, ISRCTN ref: 29971). All participants provided written informed consent at baseline and orally consented before the FGs.

Participants and recruitment

This study included 32 healthcare professionals from eight municipalities spread across 15 MCHCs in Norway. Midwives and PHNs were purposively selected to ensure maximum variation based on geographical location (urban vs. rural), clinic size, and training group affiliation. This sampling strategy aimed to capture a broad range of perspectives across different implementation contexts. In clinics with fewer than 14 employees, all eligible staff were invited to participate; in larger clinics, a subset was selected to ensure feasibility while maintaining diversity. To support open dialogue and interaction, focus groups were kept deliberately small, promoting equal opportunity for all to contribute. Invitations were distributed via Microsoft Teams, followed by SMS reminders sent 48 hours prior to the scheduled session.

Data collection

Demographic data were collected via an electronic questionnaire. Qualitative data were collected between May 2022 and October 2023 through six focus groups (n = 4–8) lasting from 1 hour and 11 minutes to 1 hour and 33 minutes. Focus groups were chosen to explore how professionals jointly negotiated understandings of the intervention, implementation challenges, and their professional role in guided digital care. Group interaction enabled participants to build on one another’s accounts, challenge assumptions, and reflect on shared organizational practices, thereby enriching the analytical material.

Interview procedure and Use of the CFIR

The focus groups followed a semi-structured interview guide informed by selected constructs from the Consolidated Framework for Implementation Research (CFIR), particularly those related to individual competence, training, organizational fit and support, and early implementation experience (https://cfirguide.org/tools/tools-and-templates/; Table 2) [11]. CFIR was used as a sensitizing framework to ensure that interviews addressed known implementation domains, while still allowing participants to raise issues they perceived as most salient. Importantly, CFIR did not function as an analytic coding framework. Instead, it guided the focus group discussions and supported comprehensive data generation without constraining the inductive analytic process. This approach allowed themes to be developed reflexively from participants’ accounts, while remaining attentive to implementation-relevant dimensions such as readiness, support, and contextual fit. Follow-up questions were used flexibly to encourage elaboration and clarify meanings. Information about the research aim, background, and research interest of the moderators was provided before each interview.

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Table 2. Main interview questions based on CFIR.

https://doi.org/10.1371/journal.pdig.0001348.t002

All interviews were conducted in Norwegian. Prior to the interviews, the FG moderators had digitally met with participants on two occasions, one meeting which was an invitation to participate in the study, and an information meeting after being randomised to provide the guided version of Mamma Mia. The first author (ESO) facilitated all focus groups, supported by a second moderator (TS). After each session, the second moderator summarized key points raised and asked participants to confirm, nuance, or expand on these interpretations. These processes supported immediate reflexive engagement with the data rather than formal member checking. Discussions were video- and audio-recorded and transcribed verbatim. Field notes and transcripts were reviewed iteratively to support familiarization and reflexive awareness of emerging interpretations. Reflexivity was treated as an ongoing analytic practice, shaping how patterns were identified, questioned, and refined across the analytic process, rather than as a discrete procedural step. All data were securely stored in accordance with ethical guidelines.

Data analysis

The demographic variables (age, gender, years of professional experience, and professional role) were analyzed using SPSS, Version 27.0 [28], and are presented as descriptive statistics (frequencies, percentages, range, and means).

Qualitative data were analysed using reflexive thematic analysis, following Braun and Clarke’s six-phase approach: familiarization, coding, theme development, theme review, theme definition and naming, and writing up [25]. Co-authors FD, SH, and SMH contributed to the review and development of themes. Themes were constructed inductively through engagement with the dataset, rather than pre-defined categories. QualCoder 3.5 [29] was used to support data management and coding. Its open-source and transparent structure enabled systematic documentation of coding decisions and analytic memos, which was particularly important as a first-cycle coding was conducted by a master student and second-cycle coding and initial theme development were undertaken by the first author [30]. To ensure transparency, examples of codes and theme development are included in S1 File.

Rigour and trustworthiness

Trustworthiness was enhanced through investigator triangulation and reflexive dialogue. The research team consisted of individuals with diverse professional backgrounds and genders, PHNs (ESO, SH), a psychologist and MSc (TS), and experienced qualitative researchers with PhDs (SH, FD, SMH). ESO, TS, SMH and SH are female, while FD is male, and FD, ESO and TS, ESO conducted the interviews and initial analysis. The interpretation of the findings was strengthened through collaborative discussions exploring multiple perspectives and assumptions. Memos were created during and after each interview to capture reflections and reduce bias, and these were regularly discussed within the research team. The team met frequently to review emerging themes and findings, supporting a transparent analytic process. The interviewer also kept a reflexive diary throughout the study to document personal reflections, expectations, and potential biases, including how her professional background, involvement in developing the training material, and beliefs about implementing the intervention in MCHCs might have influenced interactions with participants. Rather than seeking consensus, the team aimed to co-construct a rich and credible interpretation of the data.

Demographics

The six focus groups included 15 midwives, 14 public health nurses, and 3 nurses in public health nursing education. Participants from the same MCHC were interviewed together; however, due to limited staff numbers, two focus groups were conducted with participants from two different MCHCs. They were all female, with a mean age of 46 years (range 27–62 years). The mean years of experience in the current position of MCHCs was 6.8 years (range 0–23).

Theme 1: Broken Expectation – Navigating the Training-Practice Gap

Participants described initial enthusiasm and curiosity when introduced to Mamma Mia, but this optimism was quickly challenged during training and early implementation. A central source of frustration was a perceived mismatch between expectations of the training and its practical relevance. Participants had anticipated concrete, practice-oriented instruction on how to introduce, guide, and integrate the intervention within consultations. Instead, many experienced the training as abstract, overly complex, and insufficiently tailored to their clinical context. As one PHN explained: “I felt like those training days were somewhat unstructured... I spent two days without really understanding what we were doing. I think we had high expectations, but in the end, we were a bit disappointed.” (PHN, focus group 6). This disconnect undermined>participants’ sense of preparedness and shaped their early orientation toward the intervention. While the training covered technical and conceptual aspects of Mamma Mia, participants struggled to translate this knowledge into concrete clinical action. Several described uncertainty about how guidance was meant to look in practice, particularly when trying to balance structured techniques with their usual conversational style. As one midwife put it: “I was left thinking: am I really not doing anything of what I’m supposed to do? Because I don’t know what I’m doing. And then I have to choose between which four techniques… and I really feel like I’m just talking” (Midwife, focus group 4).

These accounts illustrate how the training-practice gap affected not only skill acquisition but also professional confidence. Participants felt responsible for delivering an intervention they did not yet feel competent to deliver, creating tension between professional expectations and perceived capability. This uncertainty, in turn, contributed to frustration, reduced motivation, and a hesitancy in promoting the intervention to women. Supervision, which participants had expected to compensate for these challenges, was often misaligned with their needs at this early stage. Several described supervision sessions as focused on implementation logistics rather than on developing conversational skills. One midwife said: “I expected supervision to go beyond just implementation—more like training us to be skilled conversation partners and effective support for women, not just focusing on how to apply the techniques. I was hoping for something more hands-on” (Midwife, focus group 6).

Timing further compounded these challenges. For many PHNs, primarily involved in postnatal care, there was a substantial delay between training and the opportunity to guide the use of Mamma Mia. This temporal gap weakened recall, reduced confidence, and limited opportunities to practice skills. As one PHN put it: “We have not started yet; I think that I agree with what was said earlier… that the training and supervision came a little early for us because we do not get very much out of it right now” (PHN, focus group 1). Midwives described related challenges among certain groups. Contextual and cultural factors also shaped implementation experiences. A midwife working with the Sámi population highlighted how local norms influenced engagement: “There’s a culture here of managing on your own… That might also be why recruitment is challenging; mental health remains a difficult topic for many.” (Midwife, focus group 3).

Taken together, these experiences illuminate how early misalignment between expectations and training content, and clinical realities weakened initial readiness for implementation and delivery of the guided Mamma Mia. This training-practice gap functioned not merely as a practical obstacle, but as an early interpretive lens through which participants evaluated the intervention’s feasibility and relevance. While this gap generated frustration and uncertainty, it also laid the groundwork for later reflection on whether and how digital interventions could be reconciled with relational models of care. This ongoing tension between belief in Mamma Mia’s potential and doubt about its fit with professional values is explored in the next theme.

Theme 2: Balancing Belief and Doubt – Navigating Digital Care in Relational Professions

This theme captures a value-based tension in how midwives and PHNs positioned Mamma Mia in relation to their professional identity. Participants’ accounts reflected not only assessments of the intervention itself but also deeper reflections on how digital care aligns with core professional values within MCHCs, such as relational presence, personal connection, and clinical judgment.

Several participants framed Mamma Mia as a useful supplement to existing services rather than a replacement for relational care. From this perspective, the intervention was seen as offering low-threshold, continuous support that could extend care beyond scheduled consultations and align with perinatal women’s everyday digital practices. As one PHN explained: “I imagine that Mamma Mia can be a supplement to our care at the MCHC... the app provides awareness... it supports continuity for those who use it.” (PHN, focus group 5). Others emphasized the app’s potential to promote emotional awareness and self-reflection: “It helps women recognize normal emotional fluctuations while also identifying when additional support may be needed” (PHN, focus group 6).

At the same time, participants’ endorsement was marked by ambivalence. Some questioned whether promoting a digital intervention was compatible with their identity as relational professionals, especially given their responsibility to address digital overuse and technoference in families. This created a perceived contradiction between advocating reduced screen use and simultaneously endorsing a digital intervention. This tension became more pronounced when participants felt expected to support an intervention they had not yet integrated into their clinical reasoning. One midwife reflected: “The app’s themes are fantastic, but I sometimes wonder—should we focus on strengthening midwifery-led support instead?” (Midwife, focus group 6).

Rather than indicating resistance to innovation, such reflections suggested an effort to safeguard professional values and ensure that digital tools did not displace relational, person-centred care. These concerns were further embedded in broader organisational realities. Participants described limited capacity to respond to women with mental health needs and a lack of clear referral pathways, which constrained their confidence in recommending the intervention: “We lack a stepped-care model, there’s no clear pathway for women who struggle.” (PHN, focus group 1)

In contrast, participants with a more integrative stance emphasized how Mamma Mia could complement their work by maintaining contact and support between consultations, particularly for women who might otherwise hesitate to seek help: “It can keep the door open for women between visits or for those who wouldn’t otherwise seek help.” (Midwife, focus group 2). Across accounts, participants did not reject digital care outright but called for clearer role definitions, shared reflection, and professional ownership of how digital interventions should be framed, introduced, and followed up. Taken together, this theme suggests that successful adoption depended less on the intervention’s content and more on whether its use could be reconciled with relational care models and professional identity.

Importantly, this tension between professional identity and innovation was significant, but not static. As participants gained experience with Mamma Mia and observed women’s responses, many described a shift from initial scepticism toward greater confidence and cautious optimism regarding the intervention’s role in everyday practice. This process of renegotiation is explored further in the next theme.

Theme 3: Learning by Doing and Support – Future Optimism

Despite initial uncertainty, participants described how practical experience, collaboration, and sustained implementation gradually fostered and contributed to confidence in using and guiding Mamma Mia. Repeated exposure and the ongoing interaction with the intervention made it easier for many to introduce the app, tailor its use to individual women’s needs, and integrate it into routine consultations without compromising the relational care. As one midwife said: “It was a bit overwhelming in the beginning, but I think it’s going very smoothly now.” (Midwife, focus group 6). Another added: “Once you find your rhythm, it becomes a valuable part of midwifery care” (Midwife, focus group 5).

This learning-by-doing process served as a mechanism for professional reassurance, enabling practitioners to test the intervention in practice, evaluate its relevance, and gradually develop a sense of ownership and competence. Confidence was not described as emerging from training alone, but from experiencing how Mamma Mia worked in real encounters with women.

Structured implementation support played a decisive role in sustaining this transition. Regular supervision, access to technical assistance, user manuals, and opportunities for peer exchange were described as critical, particularly in smaller clinics, with fewer colleagues or lower birth volumes. As one PHN noted: “If it feels overly complicated, motivation can start to fade. That’s why supervision and support are so important.” (PHN, focus group 3). Support structures appeared to function as stabilizing scaffolds, enabling professionals to persist through initial challenges rather than abandon the intervention.

With experience, Mamma Mia was increasingly reframed from a perceived burden to a meaningful supplement to care. Positive feedback from women using the program reinforced professional endorsement and strengthened confidence in its relational value. One midwife described how guided sessions altered the quality of consultations: “Now that I have had quite a few of the guidance sessions in week 28 and 32 with women who are part of Mamma Mia... it affects communication quite positively. We consciously enter a conversation about the app and their experiences. That’s the positive thing—and it can lead to very good conversations.” (Midwife, focus group 3).

The shift from scepticism to cautious acceptance was therefore grounded in experiential validation. Participants viewed Mamma Mia as filling gaps between consultations and extending support across pregnancy and early parenthood, without replacing core relational practices. Involvement in the study and implementation process was also perceived to enhance collaboration between midwives and PHNs by providing a shared intervention across care phases: “It ensures continuity—support doesn’t stop at birth but continues into early parenthood. Having something consistent throughout both stages fosters collaboration and ensures ongoing support” (Midwife, focus group 3).

While challenges remained, particularly related to recruitment and time constraints, participants expressed a forward-looking, yet conditional optimism. Their confidence appeared closely tied to continued opportunities for learning, reflection, and support, suggesting that sustained implementation may depend less on initial enthusiasm and more on the presence of enduring organizational and professional scaffolding.

Strengths and Limitations

A key strength of this study lies in its qualitative design and the use of reflexive thematic analysis, which allowed for a rich exploration of participants’ experiences and the nuanced complexities of implementing a guided version of Mamma Mia. The study involved both midwives and PHNs, offering a diverse perspective across the perinatal continuum. Moreover, the timing of the interviews, after initial implementation, provided insight into both the anticipatory and experiential aspects of integrating Mamma Mia into clinical practice. However, the findings should be interpreted within the context of certain limitations. First, the findings reflect experiences from a specific national context, potentially limiting transferability. Using an existing framework in implementation science is considered a significant strength, enabling deeper exploration of the implementation process and capturing contextual factors that influence the implementation of blended digital interventions [32]. Second, the participants were self-selected into the study, which may have resulted in the underrepresentation of those with lower levels of readiness and capacity to implement the intervention, and possibly more negative or passive experiences. The perceptions at this specific time point may change, and future studies are needed to explore fidelity, adaptation, and implementation over time. There is also an important role for future research in efforts to further understand the facilitators and barriers to developing strategies to promote sustainment. Finally, although the study aimed to capture a range of views, it is possible that organizational or structural influences were not fully explored due to the focus on individual experiences and the implementation of the specific intervention.