# Promoting and hindering factors for implementation of the Infant Stool Colour Card in Dutch youth health care organizations

## TL;DR

This study identifies factors that help or hinder the use of a tool to detect a rare but serious liver disease in infants within Dutch healthcare organizations.

## Contribution

The study maps implementation barriers and enablers for the Infant Stool Colour Card in Dutch youth health care.

## Key findings

- Positive attitudes and competence among professionals promote ISCC implementation.
- Limited knowledge and poor integration hinder ISCC adoption in youth health care.
- Interactive training and a designated professional are essential for successful implementation.

## Abstract

Biliary atresia is a rare life-threatening cholestatic disease of early infancy, and early treatment largely improves its prognosis. Currently, use of the Infant Stool Colour Card (ISCC) to improve early detection is implemented in several youth health care (YHC) organizations in the Netherlands. We aimed to map the promoting and hindering factors for implementation of the ISCC. We performed a qualitative study with semi-structured interviews among small and large Dutch YHC organizations. We included organizations that implemented the ISCC, and that did not. For both, we interviewed youth public health (YPH) physicians and nurses involved in the organizational policy regarding hyperbilirubinemia, using an interview topic guide based on the Consolidated Framework of Implementation Research. Ten of 17 approached YHC organizations participated (with 10 physicians and 3 nurses), among which all three organizations that implemented the ISCC. Major promoting factors were the positive attitudes of YPH professionals towards the ISCC, a sense of competence among YPH professionals, the ISCC’s simplicity, the compatibility with workflows, and the involvement of key stakeholders. Major hindering factors were limited knowledge and inadequate risk perception of biliary atresia among YPH professionals and general practitioners (GPs), insufficient ISCC integration within YHC organizations (lack of repeated training and lack of a designated responsible professional), and insufficient collaboration with GPs.

Conclusion: To implement use of the ISCC, comprehensive, interactive training and education on its rationale and use for YPH professionals and GPs are essential. The successful embedding of the ISCC into YHC organizations requires a designated professional.
What is Known:• There is a delay in diagnosing biliary atresia in the Netherlands.• The Infant Stool Colour Card led to earlier diagnosis and surgery in different countries, which largely improves the prognosis of biliary atresia.What is New:• The Infant Stool Colour Card is included in the new Dutch national guideline ‘Early detection and diagnosis of biliary atresia’ as a standard screening method in case of prolonged jaundice in youth health care organisations.• This study maps barriers and promoting factors of the ISCC to ensure successful implementation within Dutch youth health care organisations.

What is Known:

• There is a delay in diagnosing biliary atresia in the Netherlands.

• The Infant Stool Colour Card led to earlier diagnosis and surgery in different countries, which largely improves the prognosis of biliary atresia.

What is New:

• The Infant Stool Colour Card is included in the new Dutch national guideline ‘Early detection and diagnosis of biliary atresia’ as a standard screening method in case of prolonged jaundice in youth health care organisations.

• This study maps barriers and promoting factors of the ISCC to ensure successful implementation within Dutch youth health care organisations.

The online version contains supplementary material available at 10.1007/s00431-025-06212-7.