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Improving treatment of depression in primary health care: a case study of obstacles to perform a clinical trial designed to implement practice guidelines
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Medicine, Department of Clinical Sciences, Child and Adolescent Psychiatry.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Learning, Informatics, Management and Ethics, Medical Management Center, Karolinska Institutet, Stockholm, Sweden.ORCID iD: 0000-0003-2281-4622
2015 (English)In: Primary Health Care Research and Development, ISSN 1463-4236, E-ISSN 1477-1128, Vol. 16, no 2, 188-200 p.Article in journal (Refereed) Published
Abstract [en]

Aim The aim of this study is to investigate factors contributing to the failure of a randomized clinical trial designed to implement and test clinical practice guidelines for the treatment of depression in primary health care (PHC).

BACKGROUND: Although the occurrence of depression is increasing globally, many patients with depression do not receive optimal treatment. Clinical practice guidelines for the treatment of depression, which aim to establish evidence-based clinical practice in health care, are often underused and in need of operationalization in and adaptation to clinical praxis. This study explores a failed clinical trial designed to implement and test treatment of depression in PHC in Sweden.

METHOD: Qualitative case study methodology was used. Semi-structured interviews were conducted with eight participants from the clinical trial researcher group and 11 health care professionals at five PHC units. Additionally, archival data (ie, documents, email correspondence, reports on the clinical trial) from the years 2007-2010 were analysed.

FINDINGS: The study identified barriers to the implementation of the clinical trial in the project characteristics, the medical professionals, the patients, and the social network, as well as in the organizational, economic and political context. The project increased staff workload and created tension as the PHC culture and the research activities clashed (eg, because of the systematic use of questionnaires and changes in scheduling and planning of patient visits). Furthermore, there was a perception that the PHC units' management did not sufficiently support the project and that the project lacked basic incentives for reaching a sustainable resolution. Despite efforts by the project managers to enhance and support implementation of the innovation, they were unable to overcome these barriers. The study illustrates the complexity and barriers of performing clinical trials in the PHC.

Place, publisher, year, edition, pages
2015. Vol. 16, no 2, 188-200 p.
National Category
URN: urn:nbn:se:umu:diva-91488DOI: 10.1017/S1463423614000243PubMedID: 24969945OAI: diva2:736572
Available from: 2014-08-07 Created: 2014-08-07 Last updated: 2016-03-16Bibliographically approved
In thesis
1. Mind the Gap: exploring evidence-based policymaking for improved preventive and mental health services in the Swedish health system
Open this publication in new window or tab >>Mind the Gap: exploring evidence-based policymaking for improved preventive and mental health services in the Swedish health system
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: The challenges in the utilization of scientific findings in the fields of prevention and mental health are well documented. Scholars have found significant gaps between the knowledge available and the knowledge applied in healthcare. Studies have suggested that about half of the patients receive the recommended care for their medical condition. In order to address this gap, health systems at global, national, regional and local levels have made diverse efforts to facilitate the uptake of research for example through evidence-based health policy processes. In Sweden, government agencies and health policy actors such as the National Board of Health and Welfare support and control the health care system through evidence-based policies amongst other steering tools. The overall aim of this thesis is to explore evidence-based policy processes, and to further understand barriers to implementation of policies in the fields of preventive and mental health services.

Methods: A multiple case study approach was used, and data were collected from several sources. Qualitative content analysis methodology was used. Case 1 comprises the development and early implementation of national guidelines for methods of preventing disease managed by the National Board of Health and Welfare during 2007–2014. Case 2 covers the effort to improve health care for the older population that was undertaken through an agreement between the Swedish government and the Swedish Association of Local Authorities and Regions during 2009–2014. Case 3 involves an effort to implement an adapted version of a systematic review from the Swedish agency for health technology assessment and assessment of social services on treatment of depression in primary health care. Data was collected between 2007 and 2010.

In Paper 1, the policies from Case 1 and 2 were studied using a longitudinal, comparative case study approach. Data were collected through interviews, documents and observations. A conceptual model was developed based on prior frameworks. The model was used to organize and analyse the data. In Paper 2, the guideline development process (Case 1) was studied through interviews and the collection of documents. A prior framework on guideline quality was used in order to organize the data. Paper 3 investigated decision-making processes during guideline development using a longitudinal approach. Qualitative data were collected from questionnaires, documents and observations and analysed using conventional and summative content analysis. In Paper 4, the barriers to implementation were investigated through interviews and the collection of

documents. Data were analysed using qualitative content analysis with a conceptual model to structure the analysis.

Results: The sources and procedures for policy formulation differed in Case 1 and 2, as did the approaches to promote the implementation of the policies. The policy processes were cyclical, and phases overlapped to a large degree. The policy actors intended to promote implementation, both during and after the policy formulation process.

The thesis shows variation in how the key policy actors defined and used research evidence in the policy processes. In addition, other types of knowledge (e.g. politics, context, experience) served as alternative or multiple sources to inform the health policies. The composition of sources that informed the policies changed over time in Cases 1 and B. During the policy formulation and implementation process, efforts to integrate research evidence with clinical experiences and values were associated with tension and recurrent dilemmas. On the local level (i.e. primary health care centres), barriers to implementation were found related to the innovation and among health professionals, patients, in social networks as well as in the organizational, economic and political contexts.

Conclusion: The concept of evidence holds a key position in terms of goals and means for knowledge based policymaking in the Swedish health system. Broad definitions of evidence – including research and non-research evidence - were requested and to various extents utilized by the policy actors in the studied cases. An explicit terminology and systematic, transparent methodology to define, identify, and assess also non-research evidence in policy processes would potentially strengthen the clarity and validity of these processes and also enhance policy implementation.

Particular determinants to implementation, such as the interventions characteristic, are to a considerable degree established early in the policy process, during agenda setting and policy formulation. This early phase offers unique opportunities to assess and build capacity, initiate and facilitate implementation.

Early analysis and considerations of target populations and contexts and other implementation determinants related to the specific policy scope (e.g. disease preventive guidelines) could enhance the forth-coming implementation of the policy.

Place, publisher, year, edition, pages
Umeå: Umeå universitet, 2016. 82 p.
Umeå University medical dissertations, ISSN 0346-6612 ; 1788
Evidence-based policymaking, guidelines, implementation, prevention, depression
National Category
Medical and Health Sciences
Research subject
Public health
urn:nbn:se:umu:diva-118179 (URN)978-91-7601-432-5 (ISBN)
Public defence
2016-04-08, Målpunkt R, E04, Umeå, 09:00 (Swedish)
VINNOVA, A2008-025The Kempe FoundationsForte, Swedish Research Council for Health, Working Life and Welfare, 2014-1552Sven Jerring Foundation
Available from: 2016-03-17 Created: 2016-03-14 Last updated: 2016-05-02Bibliographically approved

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