Clinician Attitudes Towards Adoption of Evidence-Based Practice: A Nationwide Multiprofessional Cross-Sectional Study of Child and Adolescent Mental Health Services in Sweden

doi:10.21203/rs.3.rs-4703011/v1

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Clinician Attitudes Towards Adoption of Evidence-Based Practice: A Nationwide Multiprofessional Cross-Sectional Study of Child and Adolescent Mental Health Services in Sweden

https://doi.org/10.21203/rs.3.rs-4703011/v1

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Background: Implementation of evidence-based practice (EBP) in child and adolescent mental health services (CAMHS) is a priority to improve service delivery and outcomes. Clinicians’ EBP attitudes are likely to play a crucial role in implementation but are poorly understood. This study aimed to assess variation in EBP attitudes in a large national sample of CAMHS clinicians in Sweden, and to compare these to findings from the United States of America (USA).

Methods: CAMHS clinicians (n = 799; 60% response rate) completed the Evidence-Based Practice Attitude Scale (EBPAS) and items from the Organizational Readiness for Change Scale (ORC) ahead of an EBP for depression implementation effort across Sweden. EBPAS scores were compared with the USA study. Predictors of global and specific attitudes (gender, age, working years, education, profession, perceived benefit of diagnosis and organizational readiness and type of service) were examined using simple and multiple linear regressions.

Results: Clinicians had positive attitudes towards EBP on the four-dimensional subscales of the EBPAS, somewhat more so than their American counterparts. Clinician and organizational characteristics were related to at least one attitudinal dimension in both models, with perceived utility of diagnosis being the strongest and most consistent predictor across dimensions and models.

Conclusions: Results from this large-scale national study underscore the need to consider cultural, contextual, and individual variations in attitudes towards EBP when planning implementation efforts. Such efforts may need to be tailored to the working contexts, needs, and values of CAMHS clinicians, particularly their views on the utility of diagnosis.

Evidence-Based Practice (EBP)

attitudes

Evidence-Based Practice Attitude Scale (EBPAS)

implementation

mental health

Child-and Adolescent Mental Health Service (CAMHS)

Despite years of research on their development and testing, empirically supported methods of assessment and treatment are not reaching enough of the youth seen in child and adolescent mental health services (CAMHS) across countries [1-3]. Consequently, governments, policymakers and healthcare providers have re-prioritized their efforts to disseminate, and improve the uptake of, empirically supported methods in CAMHS [4, 5]. Such efforts can be seen as part of a larger effort across child and adult mental health to improve clinical outcomes at the local level by helping clinicians to improve their decision making and practice by integrating the latest scientific findings, often summarized in national or local care guidelines, with the needs and values of their patients; referred to as Evidence-Based Practice (EBP) [6]. A key factor in the uptake of EBPs at the local level, is the readiness of the clinicians and organization to adopt “new” practices [7-9]. Clinicians are particularly important stakeholders, as their attitudes towards EBP broadly, and the adoption of particular methods, will influence their willingness to adopt new ways of working with patients [10, 11]. There is a small but growing body of evidence suggesting that positive EBP attitudes are significantly related to EBP adoption, but varying along individual (age, gender, educational attainment, experience), organizational (leadership, resources, levels of stress, support, service type), and patient characteristics (age, diagnosis, complexity) [5, 12, 13]. However, more research is needed to understand the interplay between these factors [5].

The Evidence-Based Attitude Practice Scale (EBPAS) is a widely used, 15-item measure of clinician’s EBP attitudes along four dimensions: the intuitive appeal of EBP; the likelihood of adopting EBP given requirements to do so; openness to new practices; and perceived divergence between research-based/academically developed interventions and current practice [8]. The scale has been shown to have satisfactory validity and reliability [8, 14-20]. Importantly, total and subscale scores have been found to be related to initial adoption, fidelity, and sustained use of EBP in mental health settings [5, 8, 21, 22]. National norms are available for the United States of America (USA) that can be used for benchmarking across countries [14, 16, 17].

Clinicians working in mental health settings are heterogenous in relation to background, roles, disciplines, positions, and workplace characteristics, all of which may influence their EBP attitudes [23]. Studies employing the EBPAS have found that women, younger, and less experienced, but more highly educated mental health providers tend to report more favourable EBP attitudes, although results are somewhat inconsistent across studies [8, 9, 14, 18, 19, 24]. The clinician’s discipline may be expected to influence EBP attitudes, as some disciplines place greater emphasis on combining research and practice during training and post-qualification [8, 14, 23]. Such variation has been found with social workers reporting more positive EBP attitudes [8, 9]. Differences between disciplines outside the USA remains poorly understood owing to few studies, sampling procedures or small sample sizes [18, 19, 25, 26].

Implementation frameworks suggest a complex interplay between organizational and individual implementation determinants [27]. More positive EBP attitudes are found in individuals working in more proficient, engaged, supportive and less stressful work environments, but varying between public vs. private, academic vs non-academic organizations and leadership style [7, 9, 25, 28, 29]. It is likely that organizational factors impact on clinician EBP use, interact with clinician characteristics, including knowledge of and attitudes towards EBP, with more research needed on this topic [30-32].

The EBPAS have been used in a variety of settings, countries, and cultures, most notably within the area of behavioural health, but no study outside the USA has surveyed a nationally representative sample [9, 18, 19, 25]. This includes Sweden, where no study has examined EBP attitudes in clinicians working in CAMHS. Results from a Norwegian study found significant differences in EBP attitudes when compared with normative data from the USA [18]. Given, the similarities between Norway and Sweden in terms of the healthcare training and delivery, similar differences may exist between Sweden and the USA for EBP attitudes in CAMHS clinicians. Partly consistent with such a view, a Swedish study of 345 clinicians working in inpatient and outpatient CAMHS in Stockholm were more positively disposed towards standardized assessments and diagnosis than normative data from the USA using the same questionnaires [33]. The authors also found a good deal of variability in attitudes towards assessment based on clinician and organizational characteristics.

In summary, there is preliminary evidence that clinicians’ attitudes towards EBP are a key factor in the success of EBP implementation efforts. These attitudes appear to vary according to clinician and workplace characteristics, but firm conclusions are limited by the number of studies and sampling procedure and sample size issues. The present study aimed to address a gap in the literature with respect to EBP attitudes among clinicians working in routine CAMHS in Sweden. To address some of the methodological limitations of previous studies, the EBPAS was administered to a nationally representative sample of CAMHS clinicians in Sweden and their responses compared to normative data from the USA. Based on the available literature, we hypothesized that: a) CAMHS clinicians would be positive towards EBP; b) would be more positive compared to normative data for the EBPAS from the USA; c) EBPAS scale scores would vary by sex, age, educational attainment, experience, profession, attitude toward diagnosis, organizational readiness, and service setting; and d) some of these background and organizational factors would remain significant predictors of EBP attitudes when controlling for sex, age, educational attainment, experience and attitude to diagnosis.

Design and setting

Data from the present cross-sectional study was collected at baseline in a large multi-CAMHS implementation study of child and adolescent depression guidelines in Sweden [20, 34, 35]. All Swedish publicly (state) funded CAMHS were invited and 16 of 31 eligible CAMHS, serving about 66% of Swedish youth participated. A web-based survey was administered to 1350 CAMHS clinicians from October 2014 to June 2018. Two to five reminders were sent. The survey included questions about the clinician’s age, gender, professional discipline, highest educational level, number of years worked in CAMHS, followed by the EBPAS, questions from the Organizational Readiness for Change (ORC) and a single question about the usefulness of psychiatric diagnosis [8, 36].

Participants

A total of 812 clinicians completed the survey (a 60% response rate). Of these, twelve were excluded because of missing all items on the EBPAS and one because all responses were the same, leaving 799 participants (Table 1). Missing data was less than 5% for demographic data (Table 1), EBPAS items (Supplemental table S1), and items from the Organizational Readiness for Change (ORC) [8, 36] (Supplemental table S2). The typical participant was female (84%), 35-45 years old (28%), a psychologist (33%) with less than 5 years’ experience of child and adolescent psychiatry (44%) (Table 1).

Measure/s

EBP Attitudes

EBP attitudes were measured with the Swedish version of the 15-item EBPAS [20]. Items are rated on a 5-point scale ranging from 0 (not at all) to 4 (to a very great extent) with four subscales measuring: 1) the intuitive appeal of EBP (Appeal, four items); 2) the likelihood of adopting EBPs given requirements to do so (Requirements, three items); 3) openness to new or more structured practices (Openness, four items); and 4) perceived clinical usefulness of and divergence between research-based developed interventions and current practice (Divergence, four items, reverse scored) [8]. Subscale means and a total scale score are computed, with higher total and subscale means indicating more positive EBP attitudes and less divergence between EBP and current practice. Previous studies report adequate internal consistency for the English language original [8, 14, 15]. Psychometric properties of the Swedish version were on par with the English language original [20]. In the present sample, the internal consistency values were as follows: EBPAS total scale α = .83; Requirements α = .89; Appeal α = .78; Openness α = .78; and Divergence α = .63.

Organizational Readiness

Items from the Organizational Readiness for Change (ORC) were used to assess clinicians’ perceptions of organizational readiness [36]. The ORC is comprised of 115 items scored on a 5-point scale (1 = strongly disagree, 5 = strongly agree), representing 18 content domains of organizational readiness for implementation. The ORC includes four subscales measuring motivational factors, program resources, and organizational climate at the organizational level and staff attributes at the individual practitioner level [36]. A validated Swedish-language version was used in this study [37]. To reduce the item load of the overall survey, participants completed nine OCR items assessing organizational readiness: one item from each of the six subscales of the Organizational Climate scale; two items from the Motivation for Change scale; and one item from the Resources scale (staff turnover). See supplemental table S2 for individual items. Internal consistency for the nine ORC items used in the present study was α = .71.

Data analysis

The reporting of results was guided by the Standards for reporting Implementation studies (STaRI) and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statements respectively [38, 39]. All statistical analyses were carried out using Version 27 of SPSS [40]. We applied a Bonferroni correction to all analyses to control for Type 1 error given multiple comparisons. Prior to analyses, we examined the accuracy of data entry, missing values, normality, nonlinearity, and heteroscedasticity and influential cases for grouped and ungrouped data. We used independent sample t-tests to compare means on the four subscales of the EBPAS to USA norms. To estimate the magnitude of observed relationships, we used Cohen’s d with d = .20 corresponding to small, d = .50 to medium, and d = .80 to large effect sizes [41]. Intra class coefficients (ICC’s) were used to estimate the variance in EPBAS and ORC scores that could be attributed to individual CAMHS. All ICCs were low indicating that EBPAS and ORC scores should represent clinician-level and not CAMHS-level constructs. The highest ICCs were .021 for the Requirement subscale of the EBPAS and .06 for the nine-items from the ORC used in this study.

Table 1 Background characteristics of respondents (n=799)
		N	%
Gender
	Male	128	16.2
	Female	660	83.8
Age Group
	<35 years	167	21.2
	35-44 years	216	27.4
	45-55 years	196	24.9
	>55 years	209	26.6
Education
	<University	21	2.7
	Bachelor	521	65.8
	Master	220	27.8
	PhD	30	3.8
Profession
	Auxiliary nurse	27	3.4
	Nurse	11	13.9
	Social Worker	207	26.0
	Psychologist	263	33.0
	Psychiatrist	104	13.0
	Other	85	10.7
Tenure Child Mental health
	<5 years	345	43.7
	5-10 years	138	17.5
	11-15 years	98	12.4
	16-20 years	82	10.4
	>20 years	126	16.0
Type of workplace /service
	Non academic	489	61.2
	Academic	310	38.8
Sample sizes vary slightly because of missing data. <University refers to secondary school (mandatory to age 16) or gymnasium (age 16-19 years). *Psychiatrists include Child Psychiatrists, residents, and MDs without any specialist training

We conducted simple regressions, with listwise deletion, using the EBPAS scales as the dependent variables (DV) and the following independent variables (IV’s) for all regressions: gender, age, experience, highest level of education, profession, attitude towards psychiatric diagnosis, type of workplace (academic-non-academic), and organizational readiness (total score on the 9-item ORC). Next, we conducted multiple regressions using the same IVs and DVs. Since the ICCs were low, we replicated Aarons et al (2004, 2010) multiple regression analyses, in line with the Norwegian and Dutch studies of the EBPAS [8, 14, 18, 19]. For the multiple regression analyses, squared semipartial correlation was used to estimate the unique relationship between IVs and DVs. The following benchmarks were used to estimate the strengths of the regression coefficients: R²= .02 - small: R²= .13 – medium, and R²= .26 – large [41].

Data preparation

Three univariate outliers (z scores > 3.0) on the EBPAS and ORC scales were replaced with one unit less extreme [42]. No influential cases (Cook’s distance < 1) were found. The following categorical predictors with three or more categories were dummy coded: age (< 45 years vs ≥ 45 years), educational attainment (bachelor’s degree and lower vs master’s degree and higher), and clinical experience (< 5 years vs ≥ 5 years). Scale scores were the means of test items, provided at least 50% of scale items had valid data.

Clinicians’ attitudes toward EBP and comparison with norms from the USA

Table 2 presents the means and standard deviations for the total and subscale scores on the EBPAS for the present sample and norms from the USA, t-test comparisons, and effect sizes. Overall, participants in this study expressed favourable EBP attitudes. Mean values were high for most of the positively phrased EBPAS items and generally lower for negatively phrased items (in the Divergence scale) (S1). Mean scores for the EBPAS scales (Divergence scale reversed) were all over a neutral score of 2; a higher score indicates more positive attitudes towards adopting EBP (Table 2). The Appeal subscale had the highest score followed by the Openness, Divergence (when reversed) and Requirement subscales. Compared to USA norms, participants in this study had significantly higher total and subscale scores, except for the Divergence subscale (Table 3). The effect size differences were small (Requirement and Openness) or moderate (Appeal and EBPAS total scale).

Table 2 Comparison between EBPAS scores in Swedish CAMHS and USA Norms¹.
Scale	Swedish		USA Norms¹		t	Df	Cohen’s d
Scale	M	SD	M	SD
Requirements	2.70	.80	2.41	.99	6.68***	1834.63	0.31
Appeal	3.23	.54	2.91	.68	10.90***	1851.93	0,49
Openness	2.91	.60	2.76	.75	4.81***	1862.04	0,22
Divergence	1.19	.62	1.25	.70	-1.63	1796.66	-0,08
EBPAS total	2.93	.44	2.73	.49	8.52***	1878	0.40
Note: EBPAS = Evidence Based Practice Assessment Scale; CAMHS = Child and Adolescent Mental Health Services. Scores range from 0 to 4. ¹Aarons [14], ***p<.0001

Differences in attitudes due to individual and organizational factors

Table 3 presents the means and standard deviations for the total and subscale scores on the EBPAS by groups defined by clinician characteristics. Significant between-group differences are indicated by values with different subscripts. These variables as well as attitude toward diagnosis, type of service and organizational readiness was studied as predictors of attitudes by simple and multiple regression models and are presented in Table 4. All differences between groups were in general small in relation to differences between individuals, explaining about 2.0 % of the variance in the unadjusted models (Table 4).

Females scored significantly higher than males on all EBPAS’s scales (Divergence scale scores are reversed) except Openness. However, when controlling for multiple comparisons, only the comparisons for Requirements, Appeal, and EBPAS total scales remained significant (Tables 3 and 4). Younger clinicians scored higher (lower for Divergence) than older clinicians on all scales except Requirements. Staff with a bachelor’s degree or lower scored significantly lower than those with a master’s degree or higher on the Openness, Divergence (when reversed), and EBPAS total scale. A significant difference between professional disciplines was observed only for the Requirement scale after controlling for multiple comparison. Nurses and others had higher Requirement scores than psychologists. Those with shorter experience in child psychiatry scored significantly higher on the Openness, lower on the Divergence, and higher on the EBPAS total scale (Table 4). Finally, attitude towards diagnosis correlated with attitude towards EBP adoption across all domains (Table 4).

Table 3 Means and standard deviations for Evidence Based Practice Assessment Scale by clinician characteristics.
EBPAS scales	Requirements		Appeal		Openness		Divergence		EBPAS total
	M	SD	M	SD	M	SD	M	SD	M	SD
All	2.69	0.81	3.22	0.55	2.90	0.60	1.20	0.62	2.92	0.46
Gender
Female	2.74_a	0.80	3.26_a	0.55	2.92_a	0.60	1.18_a	0.62	2.95_a	0.45
Male	2.43_b	0.83	3.04_b	0.52	2.53_a	0.60	1.31_a	0.60	2.76_b	0.46
Age
<45	2.66_a	0.79	3.31_a	0.52	3.03a	0.56	1.10_b	0.58	2.99_a	0.41
≥45	2.71_a	0.83	3.13_b	0.56	2.79_b	0.62	1.29a	0.65	2.85_b	0.48
Profession
Other*	2.79_b	0.87	3.18_a	0.57	2.83_a	0.66	1.28_a	0.65	2.89_a	0.51
Nurse	2.96_b	0.76	3.24_a	0.54	2.81_a	0.64	1.20_a	0.67	2.95_a	0.48
Social worker	2.66_a	0.74	3.23_a	0.54	2.88_a	0.59	1.21_a	0.62	2.91_a	0.43
Psychologist	2.58_a	0.85	3.27_a	0.56	2.99_a	0.58	1.17_a	0.60	2.95_a	0.45
Psychiatrist**	2.65_a	0.77	3.11_a	0.54	2.93_a	0.57	1.17_a	0.61	2.90_a	0.42
Education
Bach or lower	2.70_a	0.83	3.22_a	0.56	2.86_a	0.62	1.26_a	0.63	2.89_a	0.47
Master or higher	2.67_a	0.78	3.24_a	0.54	3.00_b	0.56	1.05_b	0.57	2.99_b	0.41
Tenure
<5 years	2.71_a	0.81	3.28_a	0.52	3.01_a	0.61	1.12_a	0.57	2.99_a	0.43
>5 years	2.68_a	0.81	3.18_a	0.57	2.83_b	0.59	1.26_b	0.65	2.87_b	0.46
Note: Scale scores are mean scores provided that at least 50 % of items had valid data. Means not sharing subscripts (a or b) differ significantly at p< 0.01. * Others are auxiliary nurse and others. ** Psychiatrists include child psychiatrists, residents, and MDs without any specialist training

Respondents working at academic services reported significantly higher Appeal scores than those working in non-academic services. Organizational readiness for change (ORC- short form scale) had weak and negative correlations with the Requirement and Total scales, respectively. All differences between groups were in general small in relation to differences between individuals, explaining about 2.0 % of the variance in the unadjusted models (Table 4).

Predictors of attitudes toward adopting EBP in the multiple regression models

Table 4 presents the results of multiple regressions to test whether sex, age, educational attainment, profession, experience, attitude to diagnosis, type of service, and organizational readiness would remain significant predictors of EBP attitudes, following the analytical plan of the original EBPAS studies (Aarons 2004, 2010), rather than the more complicated two-level analytic plan of Aarons 2012. Semipartial correlations (also called part correlations) indicate the “unique” contribution of an IV to the DV. Specifically, the squared semipartial correlation indicates how much R² will decrease if that variable is removed from the regression equation.

Table 4 Simple and multiple regression analyses of EBPAS scales

Requirements

Appeal

Openness

Divergence

Total

Simple

Multiple

R²=.099

Simple

Multiple

R²=.107

Simple

Multiple

R²=.115

Simple

Multiple

R²=.124

Simple

Multiple

R²=.172

Characteristics

R²

Unique

R²

Unique

Gender

.021

.145***

.015

.125***

.022

-.147***

.122***

.018

.007

-.081*

-.055

.024

.155***

.013

.117***

Age

.024

-.155***

-.122**

.04

-.205***

-.128**

.022

.148***

.118**

.026

-.161***

.008

-.109**

Educational level

-.040

.013

.113**

.046

.025

-.157***

-.118**

.010

.098**

Experience

.007

-.086*

-.041

.024

-.154***

-.117**

.011

.112**

.059

.017

-.129***

Profession’

.024

.013

Other

.092*

.008

.104**

-.017

-.091*

Nurse

.161***

.019

.157***

-.106**

Social worker

-.011.

-.085*

Psychiatrist

-.122**

Benefit of diagnosis

.045

.211***

.041

.212***

.038

.195***

.214***

.05

.228***

.220***

.09

-.293***

-.278***

.108

.329***

.106

.328**

Service

.015

.123***

.098**

.013

.112*

.092*

.018

.01

.102*

.002

.073*

Organizational readiness

.015

-.121***

.01

-.107**

.006

-.074*

.004

.011

-.113**

.007

-.083*

Note: Reference groups for dummy coded variable are as follows: gender =male, age= younger, educational level= low, Experience= short, Service= university clinic. Sr= semi partial correlations

*** p < .001 ** p < .01 * p < .05

The multiple regression model significantly predicted Requirement scores, R² =0.99, F (693, 11) = 6.90, p < .001, corresponding to a small effect size (Table 4). Gender (females scoring higher), profession (psychologists scored lower than nurses and others respectively), attitude toward diagnosis (more positive toward diagnosis scoring higher), and organizational readiness (more negative about readiness scoring lower) made significant contributions in the adjusted model as shown by the squared semipartial correlations. Appeal scale scores were significantly predicted by the full model, R²= .107, F (695, 11) = 7.53, p <.001. In line with results from the simple regression models, educational level and clinical experience did not make significant contributions. In contrast with the simple regression models, psychiatrists scored lower than psychologists on the Appeal scale; but the unique contribution to the full model was small (1.2 % of explained variance). Gender, age, attitude towards diagnosis, and type of service gave statistically significant contributions to the explained variance of the full model, unique contributions ranged from 4.2% to 4.9%. The full regression model explained 11.5% of the variance in Openness scores, R² = .115, F (699, 11) = 8.24, p < .001. The only predictors that remained statistically significant were age, experience, and benefit of diagnosis (unique contributions ranged from 1.0% to 4.5%), whereas educational level and profession did not give any significant contribution when controlling for the other predictors. Divergence subscale scores were significantly predicted by the full model, R² =.124, F (696, 11) = 8.94, p < .001. Age, educational attainment, and attitude towards diagnosis (but not level of experience) made unique contributions to the total variance of the Divergence scores (individual contributions ranging from 1.0% to 7.0%). The full model significantly predicted total scores on the EBPAS, R² = .172, F (699, 11) = 13.185, p < .001, a medium sized effect size. Gender (females scoring higher), age (younger scoring higher), and attitude toward diagnosis (more positive scoring higher) made significant unique contributions in the full model, whereas level of education or experience and perceptions about organizational readiness did not make any significant contribution when controlling for the other variables.

This study aimed to address several knowledge and methodological gaps in the literature about EBP attitudes among CAMHS clinicians, and how clinician and organizational characteristics might relate to these attitudes. To date, this is the first study carried out in Sweden of CAMHS clinician’s EBP attitudes towards both EBP interventions and assessment, and one of the largest studies of EBP attitudes among CAMHS clinicians in any country. Overall, we found that CAMHS clinicians across Sweden and from various disciplines (n = 799) reported generally favourable attitudes towards EBP, with subgroup differences mainly at the clinician rather than the organizational level (discussed below). EBP adoption attitudes in this sample were similar to those assessed by the EBPAS in a Norwegian study and somewhat more positive than USA norms for EBPAS [14, 18]. The best predictor of positive EBP attitudes was holding favourable views of the utility of psychiatric diagnosis. Before discussing the implications of the current findings, we briefly highlight the findings for clinician- and organizational-level variations in EBP attitudes.

Clinicians’ attitudes

Participants in this study reported favourable attitudes towards EBP overall and on all four EBPAS dimensions; they were ready to adopt an EBP when appealing (Appeal), they were open to new and research-based treatments (Openness), and they perceived relatively little divergence from EBP and their current practice (Divergence). Likewise, they were positive towards, but slightly less inclined to use, mandatory EBPs (Requirement). This pattern of attitudes across domains (subscales) was similar to that reported in a Norwegian study and in the USA norms study [14, 18]. However, broadly aligned with the Norwegian study, but in contrast with a Greek study, CAMHS clinicians in this study held more favourable EBP attitudes compared to their counterparts in the USA [14, 18, 26].

Differences in attitudes

Taken together, our results indicate group differences between professions related to gender, age, experience, and education, and to some extent profession, aligning with prior studies [9, 14]. While no differences emerged between CAMHS (according to the ICCs), we observed associations between service characteristics and specific attitudes: clinicians in academic settings found EBP more appealing than those in non-academic settings; and organizational readiness was uniquely linked to the Requirements scale. Our prediction models accounted for relatively small portions of the overall variance in each EBPAS scales. In that context, positive attitudes towards diagnosis were the best predictor across dimensions and models. This finding might reflect that most (if not all) evidence-based treatment protocols / care guidelines in CAMHS are diagnosed based [43].

Strengths and limitations

This first replication of Aarons study investigating clinician attitudes towards the adoption of EBP benefitted from a large and representative sample of front-line CAMHS clinicians from diverse professions from across Sweden. The robust response rate of 60% exceeded commonly viewed thresholds for e-mailed surveys and our sample size was sufficient to support the statistical analyses. Regarding limitations, we were unable to obtain data about non-respondents to the survey to investigate any potential selection bias, such that attitudes could be over- or underestimated. Reflecting the nature of the CAMHS outpatient workforce in Sweden, the professional groups differed as expected in size [44]. Generally, professions with a more positive view outnumbered the more negative ones resulting in a more positive view.

Participating CAMHS applied to join the implementation program for adopting clinical guidelines on depression in young people. Their staff may be more positive towards EBP compared to clinicians at CAMHS that did not participate. The voluntary participation may also explain the lack of significant differences between CAMHS (according to ICC). However, it is worth noting that a substantial number of publicly owned and operated CAMHS participated, while several of the non-participating CAMHS were in the process of joining.

Our study did not incorporate data from the USA, caution is therefore warranted when interpreting the observed EBP attitude differences between Sweden and the USA. The findings, beyond highlighting potential cultural distinctions, can also partly stem from variations in sample characteristics, data collection methods and the 15-year time span since the establishment of USA norms.

The regression models predicted 10–17% of the total variances, in line with previous studies [8, 9, 14], reflecting the complex mechanism involved in creating attitudes and that additional factors than those studied contribute to a large degree to attitudes towards adoption. One reason for weak results is that our study employed just a single item to assess perceived benefits of diagnosis and only nine items to gauge organizational readiness, which may decrease reliability of findings.

Implications

Our findings suggest a promising start for implementing evidence-based practice within Swedish CAMHS, particularly from the clinicians’ perspective. Clinicians generally value and are willing to adopt EBPs, and this positivity is remarkably consistent across professional groups and services. Nevertheless, our results indicate that early EBP educational efforts could be most effective when focused on enhancing the perceived benefit of psychiatric diagnosis. However, the extent of fine-tuning required will become clearer once utilization and satisfaction data with EBP are obtained through longitudinal investigations. Similarly, further research is needed to assess the ability of EBPAS scores to predict the adoption of, fidelity to, and sustainment of EBP compared with measures designed to assess barriers and facilitators to the adoption of evidence-based guidelines and specific EBPs. Finally, additional research is needed (and planned for) to investigate the relation between EBPAS scores and clinical outcome in Swedish CAMHS and other health care settings [45].

In this first, large-scale nationwide and interdisciplinary study outside the USA, CAMHS clinicians in Sweden held generally positive attitudes towards the adoption of evidence-based practice, and somewhat more so compared to USA norms. Positive attitudes towards the utility of psychiatric diagnoses emerged as the strongest predictor of positive attitudes towards EBP. The EPBAS can help identify clinician- and organizational-level factors that are important to EBP implementation efforts, and thus improving service delivery and outcomes in routine clinical care.

CAMHS: Child and adolescent mental health services

CI Confidence interval

EBI Evidence -Based Interventions

EBP: Evidence-based Practice

EBPAS: Evidence-based Practice Attitude Scale

ICC Intra Class correlation

NBHW Swedish National Board of Health and Welfare

ORC Organizational Readiness for Change Scale

StaRI Standards of Reporting Implementation Studies

STROBE The Strengthening the Reporting of Observational Studies in Epidemiology

USA United States of America

Ethics approval and consent to participate

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study received approval from the Regional Ethical Review Board in Umeå, Department of Medical Research (Regionala etikprövningsnämnden i Umeå avdelningen för medicinsk forskning); EPN 2015/186-31 and EPN 2016/502-32. In Sweden, the Regional Ethical Boards were previously affiliated with the faculty of medicine at regional universities until 2004. Between 2004 and 2019, the Regional Ethical Boards operated as independent authorities. However, starting from January 1, 2019, applications for ethical review of research are overseen by the new Swedish Ethical Review Authority.

Informed consent was obtained from all individual participants included in the study. The respondents were informed about the research project and that completion of the web-based survey was accepted as consent.

Consent for publication

Not applicable

Availability of data and materials

The dataset supporting the conclusions of this article is available in the Halland Hospital Halmstad repository. The dataset used and/or analysed during current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This study was funded by grants from the Halland county council.

Authors' contributions

HJ is the principal investigator, responsible for the design of the overall project, including this study. The initial concept of utilizing the EBPAS was proposed by SP, who also obtained the requisite authorization from Aarons to facilitate its translation to Swedish. AS, MB and PG conceptualized the specific research questions and the analytic approach for this manuscript. Analyses were conducted by AS. AS wrote the first draft of the manuscript; all authors (AS, RH, MB, PG, HJ, and SP) edited and revised the manuscript and provided critical commentary. All authors (AS, RH, MB, PG, HJ, and SP) read and approved the final manuscript.

Acknowledgements

Not applicable

Authors' information

Anna Helena Elisabeth Santesson, MD. PhD student^1,3; Robert Holmberg, PhD, Senior Lecturer²; Martin Bäckström, PhD, Professor²; Peik Gustafsson MD PhD¹; Håkan Jarbin, MD. PhD^1, ³, and, Sean Perrin, PhD Professor².

¹Department of Clinical Sciences, Faculty of Medicine, Lund University, BMC F12, S- 221 84 Lund, Sweden

²Department of Psychology, Faculty of Social Sciences, Lund University, Box 213, S-221 00, Lund, Sweden

³Child and Adolescent Psychiatry, Region Halland, S- 30185, Halland, Sweden

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No competing interests reported.

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Clinician Attitudes Towards Adoption of Evidence-Based Practice: A Nationwide Multiprofessional Cross-Sectional Study of Child and Adolescent Mental Health Services in Sweden

Status:

Version 1

Abstract

Background

Methods

Design and setting

Participants

Measure/s

EBP Attitudes

Organizational Readiness

Data analysis

Data preparation

Results

Clinicians’ attitudes toward EBP and comparison with norms from the USA

Differences in attitudes due to individual and organizational factors

Discussion

Clinicians’ attitudes

Differences in attitudes

Strengths and limitations

Implications

Conclusion

Abbreviations

Declarations

Ethics approval and consent to participate

Consent for publication

Availability of data and materials

Competing interests

Funding

Authors' contributions

Acknowledgements

Authors' information

References

Additional Declarations

Supplementary Files

Status:

Version 1