Do Barriers and Facilitators Assessments Have to Be Resource-Intensive?
By Dr. Julia E. Moore, Executive Director
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Lately, one of the most common questions I get is: how do I assess barriers and facilitators, especially if I have limited resources?
It seems as though many people applying implementation science in practice have bought into the importance of assessing barriers and facilitators. They see the benefits of having a process model like the Knowledge to Action, they plan to use a theory of change, and they understand the value of assessing barriers and facilitators, but they get stuck on logistics. This is particularly true when working on a project that has limited resources.
Luckily there are very practical, inexpensive, and relatively quick ways that you can assess barriers and facilitators.
Assessing barriers and facilitators to select implementation strategies: The ideal scenario
First, let’s start with an ideal situation. If I had unlimited time and resources, I would have a very comprehensive 4 step process to understand the barriers and facilitators.
I would review the literature to find existing studies that assess barriers and facilitators to either the specific practice change or a similar practice change. I would then pull the relevant barriers and facilitators from the literature. These barriers and facilitators would provide a starting place to understand the local level barriers and facilitators.
Next, I would conduct interviews or focus groups, sharing the already identified barriers and facilitators and ask probing questions to get deeper into root causes and very unique barriers specific to that context.
After surveys and interviews, I might do observations, watching the people who are expected to change and making note of barriers and facilitators that people may not realize influence their behavior (e.g., workflows). The reality is humans are not great at understanding why we do and don’t do things, so asking us why we made a change or didn’t make a change is not always the best way to get at the true causes of our behavior.
After all of that, I may realize I have so many barriers and facilitators that I might want to prioritize them or at least get a sense of which ones are most important in this context, so you might conduct a survey.
There are similar examples in the published literature, like the one by Atkins and colleagues.
Unfortunately, almost no practical implementation project has the time and resources to do such a comprehensive barriers and facilitators assessment. So, where does that leave you?
Barriers and facilitators: The quick and low-resource way
The literature is often the easiest and fastest way to get information about barriers and facilitators. There are so many studies out there assessing barriers and facilitators to change on a wide range of topics. While you may not be able to find a study that specifically looks at the barriers and facilitators to your exact practice change, chances are you can find things that are conceptually similar. Focus on the literature that looks at the same target population and/or the same or similar practices. But don’t forget to go to some of the more generic literature on barriers and facilitators. There are existing systematic reviews, like the review by Cabana and colleagues, that has over 290 physician barriers and facilitators to guideline implementation. Chances are some of the barriers and facilitators you are facing are in that list.
Barriers and facilitators from the literature can provide a decent foundation understanding of potential barriers and facilitators. However, it is very important to get the perspective of the people who are being expected to change. If you have the time and resources to do formal interviews or focus groups, that’s great. If you don’t, through informal conversations, you can gain very valuable information about what is really happening and what factors are likely to hinder or support the implementation of the new practice.
Asking people questions directly can be hugely valuable, but there is one other method that I have found particularly helpful. If you are able to sit in on existing meetings, particularly if they are talking about the proposed practice change, you can learn so much about potential barriers and facilitators. When I have that kind of opportunity, I listen intently to what people are saying, to what is not said, and to reactions people have. I go into the meeting with a framework (like the theoretical domains framework or the consolidated framework for implementation research – if these are new terms for you, definitely check out the link to a previous bulletin where these are introduced), and I make a note about different barriers and facilitators that arise over the course of the discussion. During conversations with key team members afterwards, I ask probing questions to understand more about what was said.
If you are working on a resource-constrained project, there are inexpensive and relatively fast ways to understand the barriers and facilitators to change. It is important that you get this information, even if from less-than-rigorous methods – without it, you may select implementation strategies or develop an implementation plan that will be less effective.
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