Table 4.
Examples of how barriers to changing professionals' behaviour or guideline adherence can be classified
| Revising Cabana et al.'s [12] system, Espeland and Baerheim [current study] related barriers to* | Oxman and Flottorp [22] related barriers to | Thompson et al. [24] related barriers to | Grol [21] related barriers to | Mäkelä and Thorsen [23] related barriers to |
| Knowledge | Knowledge and attitudes | Information management | Individual clinician | Professionals |
| Lack of knowledge of the guideline | Clinical uncertainty | Clinical uncertainty | Knowledge | Knowledge |
| Attitudes/feelings | Sense of competence | Sense of competence | Skills | Skills |
| Lack of agreement with its decision criteria | Compulsion to act | Standards of practice | Attitudes | Attitudes |
| Lack of outcome expectancy | Information overload | Financial disincentives | Habits | Patients |
| Lack of process expectancy | Prevailing opinion | Administrative issues | Social context | Knowledge |
| Lack of feelings expectancy | Standards of practice | Perception of liability | Patients | Skills |
| Lack of self-efficacy | Opinion leaders | Patient expectations | Colleagues | Attitudes |
| Lack of motivation/inertia of previous practice | Medical training | Authorities | Other resources | |
| External barriers related to | Advocacy | Organisational context | Environment | |
| Guideline (e.g., guideline unclear) | Practice environment | Available resources | Social factors | |
| Patient (e.g., patient pressure) | Financial disincentives | Organisational climate | Organisational factors | |
| Setting | Organisational constraints | Structures, etc. | Economic factors | |
| - lack of time | Perception of liability | |||
| - lack of other practice resources | Patient expectations | |||
| - increased costs | ||||
| - increased malpractice liability | ||||
| - pressures in the health care system | ||||
| - improper access to health care services |
* Possible strengths and weaknesses of this revised system: • Specifically concerns physicians' adherence to clinical practice guidelines [12] • Includes barriers actually reported by physicians in published studies [12] • Specifies several different types of attitude/feeling-related barriers • Separates these 'internal' barriers related to the physician from external barriers • Can be used to examine the relationship between internal and external barriers [40] • Includes lack of process expectancy in addition to lack of outcome expectancy • Explicitly lists guideline-related barriers, which guideline developers can prevent • Incorporates specific aspects of physicians' uncertainty, not a broad category (see text) • Lists attitudes that may underlie a 'compulsion to act', e.g., lack of process expectancy • Does not seem to have been used to classify barriers perceived by non-physicians, as opposed to for example Oxman and Flottorp's system [22,41] • Does not explicitly list specific reasons for internal barriers that can be directly addressed • Only implicitly incorporates medical training, advocacy and opinion leaders as sources of barriers • Concerns only barriers and not facilitators, as opposed to Mäkelä and Thorsen's [23] system, although lack of a barrier can also be a facilitator