title: Implementation of evidence-based rehabilitation for non-specific back pain and common mental health problems: a process evaluation of a nationwide initiative.
abstract: BACKGROUND
  Nationwide implementation of guaranteed access to evidence-based rehabilitation was established in Sweden in 2009, through an Act of the Swedish Government. The rehabilitation guarantee's primary goal was to increase the rate of return-to-work, reduce and prevent long-term absenteeism after diagnoses related to back pain and common mental health problems. This study aims to develop knowledge about factors influencing large-scale implementation of complex and extensive interventions in healthcare settings.
  
  
  METHODS
  Three different data sources questionnaires, interviews and documents were used in data collection and analysis. The data were analysed using iterative thematic analysis.
  
  
  RESULTS
  The following main facilitators contributed to realization of the rehabilitation guarantee: financial incentives, establishment of project organization, recruitment, in-service training and previous experiences of working in similar projects. Barriers were: the rehabilitation guarantee's short-term project-form, clinicians' attitudes to and competence in working towards return-to-work, lack of guidelines describing treatment modalities in multimodal rehabilitation, and lack of well-defined criteria for inclusion of patients. Documents revealed that the return-to-work goal became less pronounced during the implementation process. Instead, care and health were more often described in documents used to disseminate information about the rehabilitation guarantee. Intermediate outcomes found were: patients with rehabilitation needs were given more adequate priority, increased readiness for future implementation efforts, and increased general competence in psychotherapy, and team-work, which thus became available to patient groups other than those covered by the rehabilitation guarantee.
  
  
  CONCLUSIONS
  To facilitate implementation of established national policy goals in clinical practice, tools are needed that specifically aim at changing clinicians' attitudes and behaviours in relation to such goals. Our results underline the importance of investing both time and sufficient resources in the activities and in supporting the implementation process.
authors.affiliation: Division of Intervention and Implementation Research (IIR), Institute of Environmental Medicine (IMM), Karolinska Institute, SE 171 77, Stockholm, Sweden. elisabeth.bjork.bramberg@ki.se.
authors.forename: Elisabeth Björk
authors.initials: EB
authors.lastname: Brämberg
authors.affiliation: Department of Learning, Informatics, Management and Ethics (LIME), Medical Management Centre (MMC), Karolinska Institute, SE 171 77, Stockholm, Sweden. charlotte.klinga@ki.se.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Klinga
authors.affiliation: Division of Intervention and Implementation Research (IIR), Institute of Environmental Medicine (IMM), Karolinska Institute, SE 171 77, Stockholm, Sweden. irene.jensen@ki.se.
authors.forename: Irene
authors.initials: I
authors.lastname: Jensen
authors.affiliation: Division of Intervention and Implementation Research (IIR), Institute of Environmental Medicine (IMM), Karolinska Institute, SE 171 77, Stockholm, Sweden. hillevi.busch@ki.se.|The National Board of Health and Welfare, SE 106 30, Stockholm, Sweden. hillevi.busch@ki.se.
authors.forename: Hillevi
authors.initials: H
authors.lastname: Busch
authors.affiliation: Division of Intervention and Implementation Research (IIR), Institute of Environmental Medicine (IMM), Karolinska Institute, SE 171 77, Stockholm, Sweden. gunnar.bergstrom@ki.se.|Centre for Occupational and Environmental Medicine, Stockholm County Council, Stockholm, Sweden. gunnar.bergstrom@ki.se.
authors.forename: Gunnar
authors.initials: G
authors.lastname: Bergström
authors.affiliation: Department of Learning, Informatics, Management and Ethics (LIME), Medical Management Centre (MMC), Karolinska Institute, SE 171 77, Stockholm, Sweden. mats.brommels@ki.se.
authors.forename: Mats
authors.initials: M
authors.lastname: Brommels
authors.affiliation: Department of Learning, Informatics, Management and Ethics (LIME), Medical Management Centre (MMC), Karolinska Institute, SE 171 77, Stockholm, Sweden. johan.l.hansson@ki.se.
authors.forename: Johan
authors.initials: J
authors.lastname: Hansson
mesh_terms: D000328:Adult; D001290:Attitude; D001416:Back Pain / Q000534:rehabilitation*; D003695:Delivery of Health Care; D019317:Evidence-Based Medicine; D006295:Health Resources; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000534:rehabilitation*; D008603:Mental Health; D012046:Rehabilitation / Q000592:standards*; D011795:Surveys and Questionnaires; D013548:Sweden