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Table 3 QIC factors influencing the achievement of the NPT constructs and depression propositions

From: Implementing a stepped-care approach in primary care: results of a qualitative study

NPT constructs
(May and Finch, 2009)
Corresponding propositions (Gunn et al., 2010) QIC factors
Coherence Depression work requires conceptualization of bounderies (who is depressed, who is not depressed). Depression work requires techniques for dealing with diffuseness. Facilitators:
      • The QIC stimulated multidisciplinary team discussions with open exchange of perspectives. The stepped-care model offered clinicians a technique for shared understanding on depression (who is severely and non severely depressed).
      • The BDI offered a framework for dealing with diffuseness of depressive symptoms.
   Barriers:
      • Different professional views on depression causing long discussions.
      • Disagreement of some clinicians with the medical model underlying the stepped-care model.
Cognitive participation Depression work requires engagement with a shared set of techniques that deal with depression as a health problem. Facilitators:
      • The new low intensity stepped-care treatment options fitted well into the primary care perspective.
      • The QIC meeting helped the exchange of the different views and come to agreements about the local depression care pathway and the task division.
      • Working with the stepped-care model improved the knowledge, skills and self confidence of primary care clinicians.
      • Treatment choices could be easily shared with the patients, leading to better working relationships.
   Barriers:
      • Unfamiliarity within the teams with each others skills and perspectives.
      • The negative attitude of some clinicians towards standardization of depression care.
      • The belief that (pro-active) monitoring is not a normal part of the PCP's work, and rather the patient's own responsibility.
Collective action Depression work requires agreement about how care is organized, who is required to deliver care, and their structural and human interactions. Facilitators:
      • The possibility to tailor the stepped-care model to the local setting.
      • Training was offered to apply the stepped-care interventions.
      • Regular team meetings to discuss individual treatment plans, helped to agree on how stepped care was delivered.
      • Competition between the different disciplines was not conceived as a problem because of the large amount of work to be divided.
      • Government policies have stimulated 'the stepped-care movement' over the last decade.
   Barriers:
      • Poor organizational infrastructures, such as the absence of links with specialty care.
      • A lack of funding of the new low intensive interventions, such as physical exercise.
      • A lack of patients opting for specific interventions.
Reflexive monitoring Depression work requires the ongoing assessment of how depression care is done. Facilitators:
      • Improved motivation because outcome measurement can structure and advance care for individual patients.
      • Positive reactions of patients and improved relationships, as a result of sharing the monitoring results.
      • Improved self-confidence of clinicians in making treatment decisions based on objective measurement.
   Barriers:
      • Multiple logistical problems for getting the questionnaires handed out and returned by the patients.
      • The absence of supportive systems (ICT, reminder systems) or staff.
      • The absence within the primary care teams of a culture and skills for process evaluation.