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Mind the Gap: exploring evidence-based policymaking for improved preventive and mental health services in the Swedish health system
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.ORCID iD: 0000-0002-5517-0803
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.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1788
Keyword [en]
Evidence-based policymaking, guidelines, implementation, prevention, depression
National Category
Medical and Health Sciences
Research subject
Public health
Identifiers
URN: urn:nbn:se:umu:diva-118179ISBN: 978-91-7601-432-5 (print)OAI: oai:DiVA.org:umu-118179DiVA: diva2:911802
Public defence
2016-04-08, Målpunkt R, E04, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Funder
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
List of papers
1. Evidence-informed policy formulation and implementation: a comparative case study of two national policies for improving health and social care in Sweden
Open this publication in new window or tab >>Evidence-informed policy formulation and implementation: a comparative case study of two national policies for improving health and social care in Sweden
2015 (English)In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 10, no 1, 169-179 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Evidence has come to play a central role in health policymaking. However, policymakers tend to use other types of information besides research evidence. Most prior studies on evidence-informed policy have focused on the policy formulation phase without a systematic analysis of its implementation. It has been suggested that in order to fully understand the policy process, the analysis should include both policy formulation and implementation. The purpose of the study was to explore and compare two policies aiming to improve health and social care in Sweden and to empirically test a new conceptual model for evidence-informed policy formulation and implementation.

METHODS: Two concurrent national policies were studied during the entire policy process using a longitudinal, comparative case study approach. Data was collected through interviews, observations, and documents. A Conceptual Model for Evidence-Informed Policy Formulation and Implementation was developed based on prior frameworks for evidence-informed policymaking and policy dissemination and implementation. The conceptual model was used to organize and analyze the data.

RESULTS: The policies differed regarding the use of evidence in the policy formulation and the extent to which the policy formulation and implementation phases overlapped. Similarities between the cases were an emphasis on capacity assessment, modified activities based on the assessment, and a highly active implementation approach relying on networks of stakeholders. The Conceptual Model for Evidence-Informed Policy Formulation and Implementation was empirically useful to organize the data.

CONCLUSIONS: The policy actors' roles and functions were found to have a great influence on the choices of strategies and collaborators in all policy phases. The Conceptual Model for Evidence-Informed Policy Formulation and Implementation was found to be useful. However, it provided insufficient guidance for analyzing actors involved in the policy process, capacity-building strategies, and overlapping policy phases. A revised version of the model that includes these aspects is suggested.

Place, publisher, year, edition, pages
BioMed Central, 2015
Keyword
Policymaking, Policy analysis, Soft laws, Governance, Health policy, Implementation, Stakeholders, Advocacy Coalition Framework
National Category
Public Health, Global Health, Social Medicine and Epidemiology Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:umu:diva-112702 (URN)10.1186/s13012-015-0359-1 (DOI)000366455400001 ()26642783 (PubMedID)
Available from: 2015-12-14 Created: 2015-12-14 Last updated: 2017-12-01Bibliographically approved
2. Addressing implementation challenges during guideline development - A case study of Swedish national guidelines for methods of preventing disease.
Open this publication in new window or tab >>Addressing implementation challenges during guideline development - A case study of Swedish national guidelines for methods of preventing disease.
Show others...
2015 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 15, no 1, 19- p.Article in journal (Refereed) Published
Abstract [en]

BackgroundMany of the world¿s life threatening diseases (e.g. cancer, heart disease, stroke) could be prevented by eliminating life-style habits such as tobacco use, unhealthy diet, physical inactivity and excessive alcohol use. Incorporating evidence-based research on methods to change unhealthy lifestyle habits in clinical practice would be equally valuable. However gaps between guideline development and implementation are well documented, with implications for health care quality, safety and effectiveness. The development phase of guidelines has been shown to be important both for the quality in guideline content and for the success of implementation. There are, however, indications that guidelines related to general disease prevention methods encounter specific barriers compared to guidelines that are diagnosis-specific. In 2011 the Swedish National board for Health and Welfare launched guidelines with a preventive scope. The aim of this study was to investigate how implementation challenges were addressed during the development process of these disease preventive guidelines.MethodsSeven semi-structured interviews were conducted with members of the guideline development management group. Archival data detailing the guideline development process were also collected and used in the analysis. Qualitative data were analysed using content analysis as the analytical framework.ResultsThe study identified several strategies and approaches that were used to address implementation challenges during guideline development. Four themes emerged from the analysis: broad agreements and consensus about scope and purpose; a formalized and structured development procedure; systematic and active involvement of stakeholders; and openness and transparency in the specific guideline development procedure. Additional factors concerning the scope of prevention and the work environment of guideline developers were perceived to influence the possibilities to address implementation issues.ConclusionsThis case study provides examples of how guideline developers perceive and approach the issue of implementation during the development and early launch of prevention guidelines. Models for guideline development could benefit from an initial assessment of how the guideline topic, its target context and stakeholders will affect the upcoming implementation.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-98924 (URN)10.1186/s12913-014-0672-4 (DOI)000348429700001 ()25608684 (PubMedID)
Available from: 2015-01-28 Created: 2015-01-28 Last updated: 2017-12-05Bibliographically approved
3. Reaching beyond the review of research evidence: A qualitative study of decision-making during clinical guideline development
Open this publication in new window or tab >>Reaching beyond the review of research evidence: A qualitative study of decision-making during clinical guideline development
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: The judgment and decision-making process during guideline development is central for producing high-quality clinical practice guidelines, but the topic is relatively underexplored in the guideline research literature. We studied the development process of national guidelines with a disease-prevention scope produced by the National board of Health and Welfare (NBHW) in Sweden. The NBHW formal guideline development model states that guideline recommendations should be based on four decision-criteria: research evidence; severity of the condition; cost-effectiveness; and ethical considerations. A group of health profession representatives is assigned the task of ranking condition–intervention pairs for guideline recommendations, taking into consideration the multiple decision criteria. The aim of this study was to investigate the decision-making process during the two-year development of national guidelines for methods of preventing disease.

Methods: A qualitative longitudinal case study approach was used to investigate the decision-making process. Questionnaires, non-participant observations of nine two-day group meetings, and documents provided data for the analysis.

Results: The guideline development model was adapted ad-hoc as the group encountered three main types of dilemmas: high quality evidence vs low adoptability of recommendation; insufficient evidence vs high urgency to act; and incoherence in vertical and horizontal judgments. Decision-criteria added by the group were ‘clinical knowledge and experience’, ‘potential guideline consequences’ and ‘needs of vulnerable groups’. Gender, professional status, and interpersonal skills were perceived to affect individuals’ relative influence on group discussions. Decision criteria changed over time in the group discussions.

Conclusions: The study shows that guideline-development groups make compromises between rigour and pragmatism. The formal guideline-development model incorporated multiple aspects, but offered few details on how the different criteria should be merged. The guideline development model devoted little attention to the role of the decision-model and group-related factors. Guideline development models could benefit from incorporating more guidance on if and how to integrate research evidence with other types of decision criteria, such as clinical experience and socioeconomic evidence.

Keyword
Clincal practice guidelines, guideline development, evidence-based policymaking, group decision-making, prevention
National Category
Medical and Health Sciences
Research subject
Public health
Identifiers
urn:nbn:se:umu:diva-118178 (URN)
Available from: 2016-03-14 Created: 2016-03-14 Last updated: 2017-06-01
4. Improving treatment of depression in primary health care: a case study of obstacles to perform a clinical trial designed to implement practice guidelines
Open this publication in new window or tab >>Improving treatment of depression in primary health care: a case study of obstacles to perform a clinical trial designed to implement practice guidelines
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.

National Category
Psychiatry
Identifiers
urn:nbn:se:umu:diva-91488 (URN)10.1017/S1463423614000243 (DOI)24969945 (PubMedID)
Available from: 2014-08-07 Created: 2014-08-07 Last updated: 2017-12-05Bibliographically approved

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