Why aggregated data falls short: an exploratory survey study on barriers and facilitators in implementing the stepped care model for mental health in primary care

Abstract Background Implementing the stepped care model for mental health in primary care organizations is a complex process influenced by various barriers and facilitators. Identifying these barriers and facilitators at the appropriate level is crucial for developing effective implementation strategies. Traditionally, barriers and facilitators are identified at the aggregate level, which may not be optimal due to potential organizational and professional differences. The objectives of this study were to identify the barriers and facilitators to implementing the stepped care model across three primary care organizations in Sweden and to explore differences in barriers and facilitators at the aggregate, organizational, and professional levels. Methods An online self-report survey was conducted between January and May 2023 among healthcare professionals (n = 33) in three Swedish primary care organizations implementing the stepped care model for mental health. The survey included two open-ended questions regarding barriers and facilitators. Summative content analysis was used to identify frequent barriers and facilitators at the aggregate, organizational, and professional levels. Given the small sample size and early stage of implementation, the study was designed as an exploratory study. Results The findings revealed seven frequent barriers and facilitators to implementation: benefits of the model, information and communication, knowledge of the model, propensity to change, resources, support from management and time to work with implementation. At the aggregate level, two barriers (e.g., time to work on implementation) and five facilitators (e.g., resources) were prevalent. At the organizational level, some frequent barriers and facilitators corresponded with those identified at the aggregate level, but there were notable differences between the three organizations. At the professional level, some similarities were observed among psychologists, but no consistent trends were found across other professions. Conclusions The study provides three novel contributions to stepped-care implementation research. First, organizational-level analysis reveals context-specific barriers and facilitators that aggregated data overlook, making the organizational level the most informative for guiding implementation. Second, the time required to work on implementation emerges as a distinct barrier. Third, resources function not only as barriers when lacking but also as facilitators when available.