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01.12.2012 | Research article | Ausgabe 1/2012 Open Access

BMC Health Services Research 1/2012

Challenges in identifying barriers to adoption in a theory-based implementation study: lessons for future implementation studies

BMC Health Services Research > Ausgabe 1/2012
Andria Hanbury, Katherine Farley, Carl Thompson, Paul Wilson, Duncan Chambers
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​1472-6963-12-422) contains supplementary material, which is available to authorized users.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

AH contributed to the design of this study and the questionnaire and interview schedule, contributed to data analysis and drafted the manuscript. KF contributed to the design of this study and the questionnaire and interview schedule, contributed to data analysis and commented on the manuscript. CT contributed to design of this study, advised on the questionnaire design and helped draft the manuscript. PW contributed to design of the study protocol, advised on the questionnaire design, and provided comments on the manuscript. DC contributed to qualitative data analysis and provided comments on the manuscript. All authors read and approved the final manuscript.



Exploring barriers to the uptake of research based recommendations into practice is an important part of the development of implementation programmes. Techniques to identify barriers can include use of theory-informed questionnaires and qualitative interviews. Conceptualising and measuring theory-informed factors, and engaging health professionals’ to uncover all potential barriers, can be a difficult task. This paper presents a case study of the process of trying to identify, systematically, the key factors influencing health professionals’ referrals for women diagnosed with mild to moderate postnatal depression for psychological treatment. The paper illustrates how the factors were conceptualised and measured and explores the real world challenges experienced, with implications for future implementation studies.


Theory-informed factors were conceptualised and measured using a questionnaire and interviews. The questionnaire was piloted, before being administered to general practitioners, practice nurses and health visitors working in general practices in one area of the UK NHS. The interviews were conducted with a small sample of general practitioners who had not completed the questionnaire, further exploring factors influencing their referral decisions in the local context.


The response rate to the questionnaire was low (19%), despite selecting the recommendation to target through engagement with local stakeholders and surveying local health professionals, and despite using two reminders, an incentive prize, and phone calls to practice managers to bolster response rates.


Two significant challenges to achieving higher response rates and successfully exploring local context were identified: the difficulties of developing a robust- but feasible- questionnaire to explore theory-informed factors, and targeting recommendations that are important to policy makers, but which health professionals view as unimportant. This case study highlights the “trade-off” between scientifically rigorous collection of data against the pragmatism and flexibility requirements of “real world” implementation. Future implementation studies should explore different ways of identifying factors influencing the adoption of recommendations to bridge this gulf.
Additional file 1: Paper copy of questionnaire.(PDF 200 KB)
Additional file 2: Summary of analyses and key findings.(PDF 392 KB)
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