title: Challenges in identifying barriers to adoption in a theory-based implementation study: lessons for future implementation studies.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Alcuin C, Department of Health Sciences, University of York, York, England, YO10 5DD, UK. andria.hanbury@york.ac.uk
authors.forename: Andria
authors.initials: A
authors.lastname: Hanbury
authors.forename: Katherine
authors.initials: K
authors.lastname: Farley
authors.forename: Carl
authors.initials: C
authors.lastname: Thompson
authors.forename: Paul
authors.initials: P
authors.lastname: Wilson
authors.forename: Duncan
authors.initials: D
authors.lastname: Chambers
mesh_terms: D019052:Depression, Postpartum / Q000628:therapy; D004059:Diffusion of Innovation; D004739:England; D055317:Evidence-Based Practice; D005260:Female; D058006:General Practice; D006801:Humans; D008962:Models, Theoretical; D009740:Nursing Staff; D010865:Pilot Projects; D036301:Qualitative Research; D012017:Referral and Consultation; D013222:State Medicine; D011795:Surveys and Questionnaires; D057170:Translational Research, Biomedical