title: The bumpy road to implementing the Baby-Friendly Hospital Initiative in Austria: a qualitative study.
abstract: BACKGROUND
  The Baby-Friendly Hospital Initiative (BFHI) aims to promote and support breastfeeding. Globally, around 20,000 facilities have been designated Baby-Friendly. In Austria, however, only 16% of the maternity units have received BFHI-certification. Internationally, few studies have investigated facilitating or hindering factors for BFHI implementation. The need to extend BFHI-certification rates has been investigated previously, but little is known about why maternity units decide to become BFHI-certified, how BFHI is installed at the unit level, and which factors facilitate or impede the operation of the BFHI in Austria and how barriers are overcome.
  
  
  METHODS
  Using a qualitative approach, (health) professionals' perceptions of the selection, installation, as well as facilitators of and barriers to the BFHI were investigated. 36 semi-structured interviews with persons responsible for BFHI implementation (midwives, nurses, physicians, quality manager) were conducted in three Austrian maternity units. Data were analyzed using thematic analysis.
  
  
  RESULTS
  Interviewees mentioned several motives for selecting the BFHI, including BFHI as a marketing tool, improvement of existing services, as well as collaboration between different professional groups. In each hospital, "change agents" were identified, who promoted the BFHI, teamed up with the managers of other professional groups and finally, with the manager of the unit. Installation of BFHI involved the adoption of project management, development and dissemination of new standards, and training of all staff. Although multiple activities were planned to prepare for actually putting the BFHI into practice, participants mentioned not only facilitating, but also several hindering factors. Interpretations of what facilitated or impeded the operation of BFHI differed among and between professional groups.
  
  
  CONCLUSIONS
  Successful implementation of the BFHI in Austria depends on a complex interplay of multiple factors including a consensual "bottom-up" selection process, followed by a multifaceted installation stage. Even these activities may be perceived as a hindrance for non-BFHI-certified hospitals. Findings also suggest that despite active preparation, several barriers have to be overcome when BFHI is actually incorporated into routine practices. BFHI seems to pose a great challenge to health professionals' work routines and, thus, clear structural changes of such routines as well as ongoing monitoring and support activities are required.
authors.affiliation: Ludwig Boltzmann Institute Health Promotion Research, Ludwig Boltzmann Gesellschaft, Untere Donaustraße 47, 1020 Vienna, Austria.
authors.forename: Christina C
authors.initials: CC
authors.lastname: Wieczorek
authors.affiliation: Ludwig Boltzmann Institute Health Promotion Research, Ludwig Boltzmann Gesellschaft, Untere Donaustraße 47, 1020 Vienna, Austria.
authors.forename: Hermann
authors.initials: H
authors.lastname: Schmied
authors.affiliation: Institute of Social Medicine, Centre for Public Health, Medical University of Vienna, Kinderspitalgasse 15, 1090 Vienna, Austria.
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Dorner
authors.affiliation: Ludwig Boltzmann Institute Health Promotion Research, Ludwig Boltzmann Gesellschaft, Untere Donaustraße 47, 1020 Vienna, Austria.
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Dür
keywords: Baby-Friendly Hospital Initiative; Breastfeeding; Diffusion of innovation; Health services research