What barriers are there to implementing each policy option?

The identification of potential barriers to implementing policy options is often done informally and in implicit and unsystematic ways. More structured approaches can help to ensure that important barriers are not overlooked and that unimportant barriers are not given undue attention. This requires the use of a framework to systematically consider potential barriers and the identification and appraisal of evidence of the extent of potentially important barriers.

Barriers to change and enablers of change are referred to in different ways, including ‘moderators and mediators’, ‘problems and incentives’ or ‘barriers and facilitators’ – terms which reflect subtle variations in meaning. In this guide, we have chosen to use the terms ‘barriers and enablers’ to describe all factors that might inhibit or facilitate the implementation of a policy option. Barriers and enablers are often the mirror image of each other. In this guide the term ‘barriers’ is used to describe ‘barriers and enablers’. It should be remembered that both enablers and barriers must be considered when implementing policy options.

Published lists of barriers for implementing changes in healthcare often show a high degree of overlap^2-9. A checklist for identifying barriers to implementing a policy option which is adapted to focus on barriers to implementing health systems changes is available in the ‘Additional resources’ section of this guide. This checklist can be used when considering different types of barriers and to flag those that warrant further consideration. For example, a team preparing a policy brief might choose to go through the list individually first and then discuss their assessments and the likelihood of potentially important barriers.

• Brainstorming – the bringing together of a group of people with relevant expertise and perspectives to generate ideas about barriers and their likely importance
• Contacting key informants – discussing potentially important barriers with individuals who understand and have insight into the problem or situation
• Searching for published or unpublished studies, including:
• • Case studies – descriptions and analysis of past efforts to implement similar options, usually involving a variety of data collection techniques
  • Qualitative studies, including those using:
  • Interviews – face-to-face or telephone discussions with individuals at relevant levels of the health system to ask specific questions and explore their perceptions of barriers and enablers in depth
  • Focus group discussions – facilitated discussions among groups in which a moderator uses open-ended questions to encourage a discussion of barriers and enablers
  • Direct observations – where interpersonal interactions, events, or activities in relevant settings are watched and listened to
  • Surveys – studies where participants are asked a standardised set of questions that assess, for example, their knowledge, attitudes, or self-reported behaviour

Efforts should be made to find local evidence whenever it is available, and strategies to find relevant studies are shown below. Links to materials for a workshop about how to find local evidence and a related PowerPoint presentation are located in the ‘Additional resources’ section of this guide. A SUPPORT tool providing guidance on how to find and use evidence about local conditions is also provided.

Strategies to find relevant studies include:

• Searching databases of published research papers, such as PubMed. Validated search strategies (or ‘hedges’) can be used to find qualitative research in the PubMed database and are available at  www.nlm.nih.gov/nichsr/hedges/search.html 
• Sources such as Google Scholar (http://scholar.google.com/schhp?hl=en&tab=ws) and the WHO Library Information System (http://dosei.who.int/uhtbin/cgisirsi/Mon+May++4+21:00:46+MEST+2009/0/49  to search for ‘grey’ or unpublished literature
• Contacting researchers in relevant universities, research institutes or health departments, or research networks

This page was last updated November 2011.