Victoria Loblay

Explorations of barriers and enablers (or barriers and facilitators) to a desired health practice, implementation process, or intervention outcome have become so prevalent that they seem to be a default in much health services and public health research. In this article, we argue that decisions to frame research questions or analyses using barriers and enablers (B&Es) should not be default. Contrary to the strengths of qualitative research, the B&Es approach often bypasses critical reflexivity and can lead to shallow research findings with poor understanding of the phenomena of interest. The B&Es approach is untheorised, relying on assumptions of linear, unidirectional processes, universally desirable outcomes, and binary thinking which are at odds with the rich understanding of context and complexity needed to respond to the challenges faced by health services and public health. We encourage researchers to develop research questions using informed deliberation that considers a range of approaches and their implications for producing meaningful knowledge. Alternatives and enhancements to the B&Es approach are explored, including using ‘whole package’ methodologies; theories, conceptual frameworks, and sensitising ideas; and participatory methods. We also consider ways of advancing existing research on B&Es rather than doing ‘more of the same’: researchers can usefully investigate how a barrier or enabler works in depth; develop and test implementation strategies for addressing B&Es; or synthesise the B&Es literature to develop a new model or theory. Illustrative examples from the literature are provided. We invite further discussion on this topic.

Background Climate change is impacting the health of individuals worldwide. At the same time, the healthcare sector contributes to carbon emissions. In Australia, healthcare contributes 7% of the country’s carbon footprint. Research into the environmental impact and mitigation of carbon emissions in primary care is an emerging area. Objective To explore staff perspectives on facilitators and barriers to environmental sustainability in 3 Australian general practices seeking to reduce their environmental impact. Methods We used a qualitative, case-study approach, conducting 23 semistructured interviews with staff across the 3 practices including nurses, administrative staff, and doctors. Observation of systems and staff behaviour relating to environmental sustainability was undertaken at 1 practice. Thematic analysis was conducted to determine themes relating to factors influencing the implementation of environmentally sustainable initiatives within practice settings. Results Climate mitigation efforts raised by participants were largely focussed on energy and waste reduction, rather than prescribing pharmaceuticals and staff and patient transport. Three main factors influencing change towards sustainable practice were identified: “Leadership,” “Staff Engagement and Workplace Culture,” and “Concomitant Benefits.” A leadership team and workplace culture that valued environmental sustainability were found to be important facilitators, as were concomitant benefits, in particular financial savings. Barriers included what interviewees described as a lack of knowledge about initiatives with the highest impact, lack of understanding described by staff of the evidence behind particular initiatives, waning staff engagement and infection control concerns. Conclusions Our research highlights several important factors that contribute to the implementation of intended environmentally sustainable initiatives in these 3 practices. Further education, research and high-level policy guidance on the potential environmental impact of prescribing pharmaceuticals, staff and patient transport and unnecessary tests and treatments are recommended to further promote environmental sustainability in primary care.

Summary Competitive grant funding is a well-established mechanism for generating activity and interventions in the field of chronic disease prevention. Yet grant competitions may be burdensome for organizations, and money may not be enough to bring about lasting change in communities. In this study, we explore the dynamics of awarding and receiving money in the context of a state-level government grant competition to support community organizations and promote community-driven action for health and well-being in Tasmania, Australia. Drawing on reflections of successful grant recipients and real-time observation of grant decision-making, we consider the role and value of grant competitions both for individual organizations and for generating broader change processes. We found that grant competitions operated according to an ‘icing-on-the-cake’ approach to funding, whereby money was provided for extra activities and new initiatives. In this way, the grant competition was valuable not only for stimulating new programme activities but also to effect broader organizational change, such as developing planning capacity, igniting new directions and pushing organizations towards ‘health’-focused activities. But for smaller organizations, grant funding was often stretched to support core work (i.e. cake rather than icing). Grants targeting specific focus areas could be a drain on resources if they diverted staff time away from core activities. We suggest an alternative approach to funding in which grants are able to be more responsive to the needs of community organizations and the support they require, as well as to desired outcomes. We describe the policy response to the results to date.