{"paper_id":"f2aa166d-dcb7-4144-841b-069e9ffd8fdf","body_text":"Mindfulness-Based Programs (MBPs) have in recent years gained a growing body of\nevidence for their use in clinical settings, primarily for the treatment and\nmanagement of Common Mental Disorders. A number of countries have included MBPs in\ntheir national guidelines for depression treatment and relapse prevention. For\nexample, the American Psychological Association, recommends Mindfulness-Based\nCognitive Therapy (MBCT) for depression treatment and relapse prevention among the\ngeneral adult population, \n 1 \n  and the Canadian Network for Mood and Anxiety Treatments, recommends MBCT as\na first line treatment for maintenance treatment of major depressive disorder. \n 2\nCrane et al \n 3 \n  aimed to develop a consensus (of the lead MBP developers internationally)\ndefinition of the key essential elements that define all MBPs: they are (1) informed\nby theories and practices that draw from a confluence of contemplative traditions,\nscience, and the major disciplines of medicine, psychology and education; (2)\nunderpinned by a model of human experience which addresses the causes of human\ndistress and the pathways to relieving it; (3) develop a new relationship with\nexperience characterized by present moment focus, decentering and an approach\norientation; (4) supports the development of qualities such as joy, compassion,\nwisdom, equanimity and greater attentional, emotional and behavioral\nself-regulation; and (5) engage participants in a sustained intensive training in\nmindfulness meditation practice, in an experiential, inquiry-based learning process\nand in exercises to understanding.” This definition has been adopted as an anchor\npoint to support integrity in research and implementation of MBPs worldwide,\nincluding by the International Mindfulness Integrity Network \n 4 \n  which disseminates good practice for MBP teaching practice. The most widely\nresearched and implemented MBPs are Mindfulness-Based Stress Reduction (MBSR) \n 5 \n  and MBCT. 6 , 7\nResearchers have detailed that these programs reduce illness and distress, and\npromote wellbeing and flourishing by improving metacognitive skills and\nself-regulation of attention and emotions. 8 - 10  The psychological mechanisms\nassociated with the clinical benefits of MBSR and MBCT include enhanced emotional\nregulation, higher self-compassion and metacognition, decreased rumination and\nworry, and decreased experiential avoidance. 11 - 13\nIn response to growing evidence for MBPs they have been included in the\ndepression treatment guidelines of the Swedish National Board of Health and\nWelfare in December 2017. \n 14 \n  The guidelines recommend MBCT for relapse prevention in depression, while\nstating that more research is needed for the use of MBCT or MBSR in treating\nmild-moderate depression or anxiety. \n 14 \n  However, there is a lack of systematized knowledge regarding the\nimplementation of MBPs—including the types of programs being provided, the level\nof training among MBP teachers, and the extent to which programs are\navailable—in the Swedish health care context. Furthermore, there is a lack of\nknowledge about what hinders and facilitates the uptake of MBPs, to inform how\nto best implement MBPs in the Swedish health care system. A recent qualitative\nstudy in Sweden, where MBP was provided for pregnant couples with increased risk\nfor stress and depression, has provided some useful preliminary understanding\nregarding possible sources of MBP participant motivation and skepticism. While a\nmajority of the participants experienced MBP as helpful in many ways, others\nfound that the mindfulness practices did not suit them and their skepticism\ntoward the practice clearly hindered them for experiencing MBCP as valuable. \n 15 \n  Implementation has been defined as the “act of putting a plan into action\nor of starting to use something in practice.” \n 16 \n  Implementation research is a broad field that addresses different aspects\nof implementation; including the processes of implementation, strategies that\nare needed for implementation as well as implementation outcomes. \n 17\nAs the implementation of MBPs in health care settings is increasing globally,\nmore research is needed to guide structures and guidelines for the\nimplementation journeys in various local context. This study, therefore,\nprovides an in-depth view of the implementation processes that have taken place\nin Sweden in order to illustrate some generalities and specificities of MBP\nimplementation in the light the particular context of Swedish health care. The\npresent study is thus part of a wider project which also includes a quantitative\nsurvey study, which aimed to map the provision of MBPs of in Swedish health\ncare.( 18 ) The\naim of this study is to add depth and detail to the understanding gleaned in the\nlinked survey study to better inform the next steps in the implementation\njourney both in Sweden and internationally. The specific aim of the present\nstudy is to explore how MBP teachers and other relevant stakeholders experience\nthe implementation of MBP in the Swedish health care setting.\n\nThe study is part of a larger project examining and exploring existing MBP\nprovision in Swedish health care systems with qualitative and quantitative\nmethods. The overall design of the project was inspired by a UK trial mapping\nthe uptake of Mindfulness-Based Cognitive Therapy in the national health service, \n 19 \n  and was informed and structured by the Promoting Action on Research\nImplementation in Health Services (PARIHS) framework. \n 20 \n  In this study, a qualitative approach is used to gain an in-depth\nunderstanding of different stakeholders’ experiences of the process of MBP\nimplementation. The participants in this study were identified through a survey\nused in the quantitative part of the project, in which existing MBP provision in\nSweden was systematically mapped using a survey developed within the context of\nthe UK study.( 21 )\n129 participants from 20 of the 21 regions in Sweden answered the survey and were\nasked if they were interested in participating in an interview. 39 participants\nfrom 15 regions in Sweden volunteered for a follow-up interview. All were MBP\nteachers, with various forms and levels of experience and education.\nParticipants for the qualitative interviews were selected to include\nparticipants from (1) different regions, (2) with an equal distribution of males\nand female and (3) a variation of mindfulness teacher training background, and\n(4) a variety of health care professions. Based on this selection, 19 survey\nrespondents were invited by e-mail to participate in an interview. A reminder\nwas sent to those who did not respond approximately two weeks after the first\ninvitation. Of those who were invited, 15 agreed to participate in the\ninterview, two declined, and another two did not respond to the invitation or\nthe reminder. In addition, all interview participants were asked to recommend a\nco-worker who could also give their view of MBP provision in the service. Two\nparticipants recommended co-workers. Two co-workers agreed to participate, two\ndeclined participation, and one did not respond.\nA semi-structured interview guide was constructed inspired by the PARIHS\nframework, and by themes arising through the analysis of the survey results (see\n Table 1 ). The\ninterview guide had open-ended questions to explore MBP teachers’ experiences of\nMBP implementation. The questions related to (1) the context for implementation\nof MBPs in their workplace (i.e., kinds of patients, referrals processes, and\nother characteristics of implementation), (2) the process of implementation,\nincluding the development of MBP over time and facilitators and barriers for\ndevelopment and (3) the evidence-base, including teacher training of MBP\nproviders and quality assessment of MBP delivery. The question guide for the\nco-workers contained similar questions adopted to explore their\nperspectives. Table 1. Question guide for mindfulness teachers. The context for implementation • Can you tell me how it came to be that\nyou started with mindfulness-based practice (MBP)? • Can you tell us more about MBP within\nyour workplace? • Who’s taking the courses? (staff,\npatients) • How do people come to the courses?\n(self-reporting, referred, how does it work) The process of implementation • What support do you think you need as an\nMBP teacher? • Looking back, how has the MBP developed\nover time? • Who (people) have been involved in the\ndevelopment of MBP at your workplace? • How do you feel that the MBP have been\nreceived by others at your workplace? • Are there any specific factors that have\nhindered development of MBP, can you describe\nthese? • Are there any specific factors that have\npromoted development of MBP, can you describe\nthese? • What would need to be adapted or changed\nto make it easier to work with MBP in your\nworkplace? • What policy decisions would be important\nfor developing MBP? The evidence base • What thoughts do you have about MBP\nteachers’ needs for education and training? • What are your thoughts and/or experiences\nabout quality assurance of MBP? • Are you conducting any evaluation of your\nMBP? If so, can you describe how? Abbreviation: MBP: mindfulness-based programs.\nQuestion guide for mindfulness teachers.\nAbbreviation: MBP: mindfulness-based programs.\nAll interviews were conducted by phone, due to the various geographical locations\nof the participants. The participants were informed about the study, first by\ne-mail, and then again by phone before the interview began, (see below for\ndetails on ethical issues). “The interviews with the MBP teachers lasted between\n40 and 71 minutes and those with the co-workers and managers lasted between 20\nand 27 minutes”…The interviewer aimed to be sensitive to the participants’\nnarrative, and asked follow-up questions to encourage the participants to\nelucidate further on issues of interest, in line with the interview guide. All\ninterviews were conducted in Swedish, audio-recorded and transcribed verbatim by\na professional typist. Quotes that are presented in this article were translated\nto English.\nThe data were analyzed using content analysis with a manifest approach. 22 , 23  First,\nthe transcripts were read several times by two of the authors (SA and MN) to get\nan initial understanding of the data. Thereafter, meaning units were abstracted\ninto condensed meaning units and codes by the two authors. After the analysis of\nthe first two interviews, the results were discussed with a focus on the\ndifferences and similarities to the interpretations. There was a high agreement\nin the analysis, including how meaning units were identified, condensed and\nabstracted into codes. The material was then divided into two parts and the two\nresearchers performed the condensation and coding of half the material each.\nAfter this, the analysis was discussed and codes with a similar content were\ngrouped into themes and sub-themes. In this process, both researchers were able\nto cross-check each other’s interpretations and discuss and adjust the preformed\ncoding. Themes, sub-themes, and a selection of quotes were translated to\nEnglish. Drafts of the results were initially written in both Swedish and\nEnglish by SA and MN, depending on their preferences. The Swedish parts of the\nresults, and specifically the quotes were translated and edited mainly by MN,\nwho is native to both languages. In addition, RC checked the quote translations\nin English, as she is a native English-speaker. The translations were discussed\nbetween SA and MN in order to maintain the initial meaning in the text. \n 24 \n  The emerging results were then discussed among all three researchers (SA,\nRC, and MN).\nThe researcher (SA), who conducted the interviews, has long-standing experience\nof qualitative methods, and asked open questions to allow for the participants\nto describe their experiences in their own words. SA has training in Public\nHealth, Anthropology, and Caring Science, an interest in MBPs and experience in\npracticing mindfulness but she is not an MBP teacher. MN has long-standing\nexperience of qualitative health care research. Two of the authors (MN and RC)\nare both experienced researchers in the field of MBPs. MN and RC are also\nqualified MBSR teachers and RC is a senior MBP teacher trainer.\nThe study was approved by the Regional Ethical Review Board in Stockholm\n(Approval number 2019-02952) and follows the ethical principles of the\nDeclaration of Helsinki 1964. All participants received verbal and written\ninformation about the study and gave written informed consent. All participants\nwere informed about the study, including how data were handled and stored as\nwell as that their participation was voluntary .\n\nThe study included 17 participants, of whom 15 were MBP teachers, one was a\nco-worker and one was a manager. The participants’ mean age was 51 years, range\n31–63 years. They worked in various health care settings including: primary\ncare, hospitals, private practice (with or without funding from publicly funded\nhealthcare), and specialist care units (such as psychiatry, rehabilitation\ncenters, a midwife clinic, ears, nose, and throat clinic, and a specialist care\nunit for brain damage). Three of the participants were nurses, and there were\ntwo each of the psychologists, social workers, midwives, and general therapists.\nThe others were a physiotherapist, an occupational therapist, a curator, an\neducator, a social educator, and a physician.\nThe MBP teachers experience of mindfulness practice varied greatly, some had\npracticed for decades and others had just begun practicing in parallel with\ntheir MBP teacher training. Eleven of the teachers had training in the\nSwedish-specific Here and Now program \n 25 \n  and four were trained in MBSR and/or MBCT (Appendix 1). The manager and\nco-worker did not have a teacher training. Of the teachers, seven were currently\ndelivering MBP groups in health care settings, five were not currently\ndelivering due to different factors, and three delivered either a modified\nprogram or integrated elements of MBPs into individual patient sessions. Of\nthose that had MBP groups, the majority were trained in the Here and Now\nprogram, and one was trained in MBSR ( Table 2 ). Table 2. Participant characteristics. Participants, n:17 MBP teachers (n) 15 Managers and co-workers (n) 2 Age, mean in years (range) 53 (31-63) Female, n (%) 14 (82) Male, n (%) 3 (18) Teacher training in  MBSR and/or MBCT, n (%) 11 (73)  Here and Now, n (%) 4 (27) Abbreviations: MBP, mindfulness-based programs; MBCT,\nmindfulness-based cognitive therapy; MBSR, mindfulness-based\nstress reduction.\nParticipant characteristics.\nAbbreviations: MBP, mindfulness-based programs; MBCT,\nmindfulness-based cognitive therapy; MBSR, mindfulness-based\nstress reduction.\nFour themes and nine sub-themes emerged in the analysis (see  Table 3 ). Table 3. Themes and Sub-Themes. Themes MBP teachers and their training Patients and patient referral pathways Organizational prerequisites to successful\nimplementation The need for structural changes Sub-themes A champion individual and the right\nconditions are key to success A variety of patients in different\nsettings The organizational and financial\nprerequisites for group activities Research, evaluation, and clear boundaries\nfor MBP are essential forms of quality assurance The importance of MBP teacher training Developing a collaboration with co-workers\nto enhance patient referral The importance of managers’ and colleagues’\nknowledge and acceptance Structures and guidelines are lacking and\nneeded Benefits and shortcomings of various forms\nof MBP\nThemes and Sub-Themes.\n\nThe reality that successful implementation relies on the presence of a key\nperson, who found themselves in the right conditions to drive the change\nprocess, was consistently expressed by the teachers. The teachers described a\nstrong personal drive to implement MBPs in their respective workplaces. They\nhave worked hard to convince their colleagues and leadership of the importance\nof implementing MBPs. A few teachers described that colleagues before them,,\nthat were described as enthusiastic champions had initiated the implementation\nof MBPs in their workplace. These teachers also emphasized how they themselves\ncommitted deeply to the continuing the work to implement MBPs, following in\ntheir colleagues’ foot-steps.\nEven though these teachers had a strong motivation, many of them were alone in\ndelivering MBPs within their working context and this could lead to an excessive\nworkload. One MBP teacher also described that there are two MBP teachers in her\nworkplace, but that the management does not allow them both to deliver MBP: “When I was employed by the region… I said that I would like to\nstart teaching MBSR groups ….. But they  [management]\n believe that one teacher is all that is needed. There\nare  [up to]  24 participants each half year and I\nknow that she always has a waiting list. So it is the management\nthat said no.”  (Participant 8)\n“When I was employed by the region… I said that I would like to\nstart teaching MBSR groups ….. But they  [management]\n believe that one teacher is all that is needed. There\nare  [up to]  24 participants each half year and I\nknow that she always has a waiting list. So it is the management\nthat said no.”  (Participant 8)\nThe teachers emphasized the importance of the quality of MBP teacher training.\nHaving a formal teacher training was perceived as a basic condition for success\nin MBP implementation. However, for those who did not have a teacher training\nprior to starting their employment, the opportunity to attend training was an\nimportant starting point. Some had the training paid for and could attend during\nworking hours, while others had to pay for themselves and attend the training in\ntheir spare time. In some cases, MBP teaching competence was a criterion for\nrecruitment to the role: “I was employed here […] at the end of 2017, and already …at the\njob interview, they saw that I had competence in teaching\nmindfulness and that this was something patients had been asking\nfor, … they currently did not have anyone skilled to deliver. So I\nstarted MBP implementation from scratch here when I started\nworking.”  (Participant 7)\n“I was employed here […] at the end of 2017, and already …at the\njob interview, they saw that I had competence in teaching\nmindfulness and that this was something patients had been asking\nfor, … they currently did not have anyone skilled to deliver. So I\nstarted MBP implementation from scratch here when I started\nworking.”  (Participant 7)\nThe main programs for which teacher training is available in Sweden are the Here\n& Now program, and MBSR. Teachers had mainly chosen the teacher training\nthat was most readily available in their region, or that they knew something\nabout. The visibility of the Here and Now teacher trainer in popular Swedish\nmedia have increased its credibility for patients, and therefore made it the\nobvious choice for some to train in. “I often take Ola Schenströms book with me when I teach groups,\nand I mention his mindfulness center sometimes, because it gives a\nclear anchoring into something that people recognize. I think that\nthis is important. That this isn’t something wishy-washy, but\nsomething that people know about, that they recognize his name and\nthey’ve seen Ola on TV and have read his book and so on.” \n(Participant 4)\n“I often take Ola Schenströms book with me when I teach groups,\nand I mention his mindfulness center sometimes, because it gives a\nclear anchoring into something that people recognize. I think that\nthis is important. That this isn’t something wishy-washy, but\nsomething that people know about, that they recognize his name and\nthey’ve seen Ola on TV and have read his book and so on.” \n(Participant 4)\nThe Here & Now program and MBSR differ in some respects, and some teachers\nweighed the benefits and shortcomings of these 2 programs against each other.\nSome, for example, reasoned that the teacher training pathway for MBSR is too\nlong, and that health care workers thus have a hard time taking all the stages\nof training. Others also thought that the length of home practices in MBSR are\nnot feasible for participants and thus preferred the shorter home practices\nassigned in the Here & Now program. Conversely, some others thought that the\nteacher training for Here & Now was too short and fell short of the depth\noffered by MBSR program and teacher training. In general, many emphasized the\nimportance of personally experiencing depth of engagement with mindfulness\npractices, and that this was something that most in the health care services had\nvery little knowledge about. “There’s a real lack of understanding in health care about\n[mindfulness] it’s not like you can just do a bit of mindfulness\njust like that. You are taking care of people who are ill and people\nwho are not feeling well … one should understand that and know what\ncan be brought up by the [meditation] practice and move slowly and\ncarefully through it. And for that, you need a lot of competence.\nIt’s not just about taking a short course and thinking you will just\nguide a meditation…the tough part with the MBSR program is holding\nthese dialogues around these central themes that are difficult\nthings to handle, and moving through it slowly with the group you\nhave.”  (Participant 17)\n“There’s a real lack of understanding in health care about\n[mindfulness] it’s not like you can just do a bit of mindfulness\njust like that. You are taking care of people who are ill and people\nwho are not feeling well … one should understand that and know what\ncan be brought up by the [meditation] practice and move slowly and\ncarefully through it. And for that, you need a lot of competence.\nIt’s not just about taking a short course and thinking you will just\nguide a meditation…the tough part with the MBSR program is holding\nthese dialogues around these central themes that are difficult\nthings to handle, and moving through it slowly with the group you\nhave.”  (Participant 17)\n\nThe MBP teachers worked in different settings and had patients with a large\nvariety of diagnoses and backgrounds participating at their MBP courses. Most\ncommonly, patients suffered from mental health problems such as exhaustion,\nstress, anxiety, and depression. “It’s very mixed and very fun, mostly I work with stress-related\nill-health; everything ranging from burnout to stress symptoms that\npeople experience for various reasons, difficulties in handling life\nas it is. But I also have quite a few patients who have depression,\nanxiety, sleep problems, and some even have more severe problems.\nBut worry, stress and anxiety I would say are the most common\nsymptoms, and depression.”  (Participant 4)\n“It’s very mixed and very fun, mostly I work with stress-related\nill-health; everything ranging from burnout to stress symptoms that\npeople experience for various reasons, difficulties in handling life\nas it is. But I also have quite a few patients who have depression,\nanxiety, sleep problems, and some even have more severe problems.\nBut worry, stress and anxiety I would say are the most common\nsymptoms, and depression.”  (Participant 4)\nHowever, there were also other patient groups including patients with tinnitus,\nendometriosis, brain damage, sexual health problems.\nThe MBP teachers emphasized the importance of good collaboration with co-workers\nto enhance patient referrals to MBP sessions. Patients most commonly came to\nMBPs through referrals from other healthcare providers, on their own initiative\nor through recommendation from MBP teachers. Some teachers worked actively to\nget more participants in their groups by putting up posters and informing\ncolleagues. Often, teachers described that it had been easy to recruit patients: “People are more interested nowadays, actually they call and sign\nup themselves. And also, this is a very small municipality compared\nto many other places, so the positive reputation spread here: “I\nhave a friend who has done this course and I myself have problems,\nand she tells me this would be good for me. Do you think there’s a\npossibility for me to get this too?” So there’s a lot of positive\nresponse.”  (Participant 10)\n“People are more interested nowadays, actually they call and sign\nup themselves. And also, this is a very small municipality compared\nto many other places, so the positive reputation spread here: “I\nhave a friend who has done this course and I myself have problems,\nand she tells me this would be good for me. Do you think there’s a\npossibility for me to get this too?” So there’s a lot of positive\nresponse.”  (Participant 10)\nMost of the teachers experienced that there were a couple of colleagues who\nreferred the main share of patients, while other colleagues referred only a few\nor no patients. This was thought to depend on their colleagues’ interest in and\nunderstanding of MBPs. A strategy that some teachers used to get more patients\non their courses was to develop collaborations with colleagues and increase\ntheir awareness of the benefits and applications of MBP. “In the beginning they were mainly my own patients, but then the\nword spread and I spoke to people at the clinic, made them aware\nthat this exists. So then there were doctors who referred patients\nto the courses. And then other caregivers had patients who they sent\nto the groups, so it became a complement to other psychological\ncare.”  (Participant 13)\n“In the beginning they were mainly my own patients, but then the\nword spread and I spoke to people at the clinic, made them aware\nthat this exists. So then there were doctors who referred patients\nto the courses. And then other caregivers had patients who they sent\nto the groups, so it became a complement to other psychological\ncare.”  (Participant 13)\nPatient satisfaction with the MBP courses and their experience of positive\neffects were seen as factors that motivated the teachers and promoted\nimplementation. The patients' positive response was described as an essential\nfactor that contributed to colleagues being made aware of the benefits of MBP\nimplementation.\n\nThe MBP teachers described a variation in the availability of organizational and\nfinancial prerequisites for conducting group activities. For some, it was\npossible to have groups as part of their defined job role. These teachers\njustified group activities from a cost perspective when they can meet several\npatients at the same time: Mindfulness-based programs teacher: “During the 8-week program the first\nsession I have is 3 ½ hours long, and then the following 7 times we meet\nfor 2 ½ hours, so they’re quite hefty sessions. Interviewer:  Yes indeed, and so you get reimbursement for those\nhours then? Mindfulness based programs teacher : Yes, well we get reimbursed\nwhen we have groups, we  [the health care company]\n get 300 kr  [36 USD]  per group participant.\nThat’s different when I meet patients for individual therapy, (…),\nso we end up on the plus side financially. So, I have increased the\neconomic gains here for the company and I’ve been able to shorten\nthe patient waiting lists and been able to offer methods that are\nalternatives to those we already offer, so it’s a win-win concept\nreally.”  (Participant 4)\nMindfulness-based programs teacher: “During the 8-week program the first\nsession I have is 3 ½ hours long, and then the following 7 times we meet\nfor 2 ½ hours, so they’re quite hefty sessions.\nInterviewer:  Yes indeed, and so you get reimbursement for those\nhours then?\nMindfulness based programs teacher : Yes, well we get reimbursed\nwhen we have groups, we  [the health care company]\n get 300 kr  [36 USD]  per group participant.\nThat’s different when I meet patients for individual therapy, (…),\nso we end up on the plus side financially. So, I have increased the\neconomic gains here for the company and I’ve been able to shorten\nthe patient waiting lists and been able to offer methods that are\nalternatives to those we already offer, so it’s a win-win concept\nreally.”  (Participant 4)\nHaving funding to conduct MBP classes was a crucial factor. Although some\nteachers described that they were able to give MBP classes without any budget\nconcerns, most teachers described that the lack of availability of funding\nnegatively affected MBP activities. Activities were sometimes financed though\nspecific, non-permanent efforts, such as research and development projects,\nwhich led to uncertainty and a lack of long-term sustainability. The\navailability of funding as well as the ways in which group activities were\nfunded could also change over time: “In the beginning … until 2016 or -17, group interventions were\nincluded in the selection of psychotherapy interventions that we\nhave available, but that changed from 2017 and then group\ninterventions weren’t included in the selection anymore.” \n(Participant 2)\n“In the beginning … until 2016 or -17, group interventions were\nincluded in the selection of psychotherapy interventions that we\nhave available, but that changed from 2017 and then group\ninterventions weren’t included in the selection anymore.” \n(Participant 2)\nOthers also described that no specific funding was available for MBP delivery.\nFor example, the organization’s protocols did not allow MBP teachers to register\nwhen patients participate in group meetings because the meetings were often\nlonger than standard individual sessions. In particular, it was a challenge to\norganize 2.5 hour long group sessions, as these could not be charged-for within\nthe existing funding system. However, other MBP teachers were able to find\nloopholes around these challenges: “They only participate in the group activities, and that means\nthat we can include many more patients in a meeting than is usually\npossible. This means that we gain more time in our schedules for\nadditional patients. And I think that we need to think a little bit\nabout this […] there’s great pressure on individual psychotherapy\nservices now and at the same time there’s this funding available, so\nwe need to plan this better. We need to help more people a little\nbit instead [of helping only a few in depth].”  (Participant\n16)\n“They only participate in the group activities, and that means\nthat we can include many more patients in a meeting than is usually\npossible. This means that we gain more time in our schedules for\nadditional patients. And I think that we need to think a little bit\nabout this […] there’s great pressure on individual psychotherapy\nservices now and at the same time there’s this funding available, so\nwe need to plan this better. We need to help more people a little\nbit instead [of helping only a few in depth].”  (Participant\n16)\nHowever, for others, these organizational bureaucratic challenges caused\nproblems, and drove reductions in the length of sessions. Some teachers reported\nthat they have resorted to only implementing mindfulness practices during\nindividual visits because of these factors. Adequate premises for organizing\ngroup activities were something that some, but not all, had access to.\nPositive support from managers and colleagues, such as knowledge and\nunderstanding, is described as an important factor for the implementation.\nMindfulness-based programs teachers who described their manager as supportive\nemphasized how important this has been as a factor for success. Other factors\nwere to get freedom as a MBP teacher to develop the MBP programs as well as to\nget the necessary prerequisites for it. Some teachers describe that they have\nfelt affirmed by the confidence the manager has placed in their activities.\nAnother MBP teacher described how an initially supportive manager changed in\napproach and suddenly decided that the MBP activities could not continue. The\nMBP teacher emphasized the importance of establishing contacts with varying\nlevels of leadership: “So the boss plays a central role in this, you need to establish\n[MBP understanding] with those above you, you need to have them on\nboard, and that’s where I didn’t do enough. I should have worked\nmuch more strategically to establish these activities with them, and\nto invite them in.”  (Participant 1)\n“So the boss plays a central role in this, you need to establish\n[MBP understanding] with those above you, you need to have them on\nboard, and that’s where I didn’t do enough. I should have worked\nmuch more strategically to establish these activities with them, and\nto invite them in.”  (Participant 1)\nMindfulness-based programs teachers also described how they have worked actively\nto increase the understanding of MBP among their managers and colleagues. Some\noffered taster sessions and opened up MBP classes for colleagues, which has led\nto an increased understanding and knowledge about MBPs in their work context: “I’ve been out and about and delivered talks (…), I’ve offered a\ncouple of lectures and we’ve had an open house (drop-in session)\nhere at the health care center where I’ve also delivered lectures\nand taster sessions in mindfulness.  (Participant 10)\n“I’ve been out and about and delivered talks (…), I’ve offered a\ncouple of lectures and we’ve had an open house (drop-in session)\nhere at the health care center where I’ve also delivered lectures\nand taster sessions in mindfulness.  (Participant 10)\nSome MBP teachers experience skepticism from colleagues about their MBP work.\nSome described that colleagues laugh behind their backs and disparage and\ndevalue their work. One teacher described that there is some fear and a\nresistance to mindfulness in her surroundings: “One thing I wanted to say is that one notices really how hard it\nis to implement [mindfulness] you know, there is this general fear\nthat it’s “New Age”. We live in a society where we follow facts and\nfigures and we’re happy with that. We’re a statistics society one\ncould say a materialist society. And people don’t take in new things\nand don’t think that the spirit also needs to be taken care of. And\nyeah, there’s so much of that in our society, and the doctors are\nnot receptive, and many don’t have knowledge about taking care of\ntheir patients from a psychological perspective.”\n (Participant 9)\n“One thing I wanted to say is that one notices really how hard it\nis to implement [mindfulness] you know, there is this general fear\nthat it’s “New Age”. We live in a society where we follow facts and\nfigures and we’re happy with that. We’re a statistics society one\ncould say a materialist society. And people don’t take in new things\nand don’t think that the spirit also needs to be taken care of. And\nyeah, there’s so much of that in our society, and the doctors are\nnot receptive, and many don’t have knowledge about taking care of\ntheir patients from a psychological perspective.”\n (Participant 9)\n\nMany teachers emphasized the importance of research—that which has already been\nconducted as well as the need for further studies on particular programs and\npatient groups – to underpin quality assurance of MBP delivery. In addition, the\nimportance of continuous evaluation of participant outcomes was emphasized by\nsome, in order to ensure high-quality delivery. Such evaluations might include\nself-assessment questionnaires as well as reports of patient feedback, and\nseveral teachers do indeed utilize these forms of evaluation. Some conducted\ntheir own research on the MBP delivery and highlighted this as an implementation\nfacilitator. Indeed, these various forms of participant outcome evaluation that\ncould be used to communicate MBP benefits to health care management were\nhighlighted as strong enabling factors for implementation.\nSome teachers voiced concerns about the lack of clear guidelines for patient\nreferral to MBPs. They highlighted that referrers as well as MBP teachers need\naccess to inclusion- and exclusion criteria for MBP that are guided by an\nawareness of possible adverse effects for example for those with trauma\nbackgrounds. Before patients joined MBP programs, many teachers assessed their\npatients’ health status, motivation, and expectations to emphasize that patients\nneed to be prepared for the engagement that is involved in taking the course.\nSome teachers also clarified that they did not include all patients: “I only include those with mild or moderate severity, not severe\nor high levels of anxiety or depression.”  (Participant\n9)\n“I only include those with mild or moderate severity, not severe\nor high levels of anxiety or depression.”  (Participant\n9)\nTo ensure quality, a recommendation to increasingly take these aspects into\naccount was voiced by some: “I think generally within heath care there is a romanticized view\nof mindfulness as if it’s something totally benign that doesn’t\ncause any harm to individuals. For me, that’s a problematic\nattitude… We, as teachers need to for example be attentive if a\nparticipant becomes hyperactivated.... We need to know how to help\nand guide the group to support them self-regulate […] and also if\nsomeone becomes a bit slumped and dissociated….. we need to have a\ncheck on hyper- and hypo-activation so they don’t become\ndysregulated.”  (Participant 3)\n“I think generally within heath care there is a romanticized view\nof mindfulness as if it’s something totally benign that doesn’t\ncause any harm to individuals. For me, that’s a problematic\nattitude… We, as teachers need to for example be attentive if a\nparticipant becomes hyperactivated.... We need to know how to help\nand guide the group to support them self-regulate […] and also if\nsomeone becomes a bit slumped and dissociated….. we need to have a\ncheck on hyper- and hypo-activation so they don’t become\ndysregulated.”  (Participant 3)\nOn the other hand, another teacher was of the opinion that the use of specific\nexclusion criteria would be unfortunate, as many patients who may have benefited\ngreatly from MBP may thus be excluded due to unnecessary precaution: “I’m really allergic toward this business of setting up of too\nmany criteria and that they start to do this with mindfulness as\nwell, as they do in health care in general. That ”you are excluded,\nyou are included”, I don’t like it. Rather, I would say, “come and\ntry it out“.”  (Participant 4)\n“I’m really allergic toward this business of setting up of too\nmany criteria and that they start to do this with mindfulness as\nwell, as they do in health care in general. That ”you are excluded,\nyou are included”, I don’t like it. Rather, I would say, “come and\ntry it out“.”  (Participant 4)\nAnother delineation that was described as important for quality assurance was\nthat teachers should be clear about the boundaries between secular mindfulness\nand mindfulness in Buddhist contexts or New Age philosophies: “I notice that there’s this thing, that people who do these\nthings sometimes are really interested in going on retreats, and\nthat there’s this whole “hallelujah” attitude around it. … they have\nthis deep personal engagement … they are fascinated by the Buddhist\nperspectives, […] for me this stuff is not so important because if I\nwere to do that, then my patients would wonder “are you Buddhist?”..\n“ (Participant 2)\n“I notice that there’s this thing, that people who do these\nthings sometimes are really interested in going on retreats, and\nthat there’s this whole “hallelujah” attitude around it. … they have\nthis deep personal engagement … they are fascinated by the Buddhist\nperspectives, […] for me this stuff is not so important because if I\nwere to do that, then my patients would wonder “are you Buddhist?”..\n“ (Participant 2)\nMany teachers voiced frustration about the lack of clear frameworks for good\npractice for MBP teachers in Sweden. This was an implementation hindering\nfactors as it resulted in lack of knowledge about MBPs within the organizations\nin which they worked relating to teacher training processes, and a lack of\nunderstanding and respect for the level of competence needed by MBP providers.\nAn MBP teacher said:  ”It seems like at my work place, it’s a bit like\nanyone can do it as long as you’ve read about it a bit.” (Participant\n17)  This lack of guidelines also applied to the commissioners at a\nregional level: “I think a dream scenario would be that they, the commissioners,\nat the regional level, would know the difference between different\nlevels of teacher training. That they would set a minimum level that\nis required, and that they would decide that now it’s good to send\npeople for training in […]MBSR-groups, or that they […] would have\nanother, say shorter training or group activity where you don’t do\nthe 8 weeks, but that they would know the difference. ‘Because in\ngeneral, people don’t know.’”  (Participant 8)\n“I think a dream scenario would be that they, the commissioners,\nat the regional level, would know the difference between different\nlevels of teacher training. That they would set a minimum level that\nis required, and that they would decide that now it’s good to send\npeople for training in […]MBSR-groups, or that they […] would have\nanother, say shorter training or group activity where you don’t do\nthe 8 weeks, but that they would know the difference. ‘Because in\ngeneral, people don’t know.’”  (Participant 8)\nSome teachers considered that the competence levels of MBP teachers should be\nclearly reflected in the levels of compensation that they get for their work: “I think for example that it should generate a higher level of\ncompensation if I am a certified teacher. I have reached a certain\nlevel for teaching MBSR and follow the curriculum which includes 2.5\nhour sessions and it would be fair if that gave me a higher level of\ncompensation than if I had say participated at a 5 day teacher\ntraining in mindfulness or if I teach a course that I myself have\nmade up.”  (Participant 3)\n“I think for example that it should generate a higher level of\ncompensation if I am a certified teacher. I have reached a certain\nlevel for teaching MBSR and follow the curriculum which includes 2.5\nhour sessions and it would be fair if that gave me a higher level of\ncompensation than if I had say participated at a 5 day teacher\ntraining in mindfulness or if I teach a course that I myself have\nmade up.”  (Participant 3)\n\nThis study included 15 providers and two managers of MBP services from a broad range\nof health care settings and regions in Sweden. The findings have shed light on the\nvarious ways in which MBPs are implemented in services, and how and why they are\nbeing modified to fit local contexts. This study provides insights into the\nimplementation process and factors that are crucial for facilitating or hindering\nMBP implementation in a variety of Swedish health care services and therefore add\nnuance and depth to the quantitative study findings.( 18 ) The themes that emerge though the\nqualitative analysis included the following: (1) MBP teachers and their training;\n(2) patients and patient referrals; (3) organizational prerequisites to successful\nimplementation; and (4) the need for structural changes.\nIn relation to the PARIHS framework, the implementation process can be understood as\na dynamic process of context, evidence, and facilitation. \n 20 \n  In terms of evidence, several forms of evidence were considered and used by\nthe MPB teachers, such as research, patients experiences, and the teachers own\nprofessional experiences. Some teachers wished for clearer governance for MBP\nprovision in health care, for example, in the form of national good practice\nguidelines such as are available in other countries—as detailed in the introduction.\nMindfulness-Based Cognitive Therapy is mentioned in the Swedish guidelines for\ndepression and anxiety healthcare which provides impetus for national roll out.\nCurrently, however, there is a lack of supporting structures such as quality\nstandards for teachers to support the quality of implementation efforts. By\ncontrast, with regard to Cognitive Behavioral Therapy and psychodynamic therapy, the\nSwedish National Board of Health and Welfare provides information about the scope\nand structure of treatment, and licensed practitioner training institutions are\nlisted. 26 , 27  National guidelines for MBPs could be inspired by those that\nare in place in the UK. There, MBCT is listed as a mandated intervention for anxiety\ndisorder and depression treatment within the Improving Access to Psychological\nTherapies Expansion Programme of the National Health Service. \n 28 \n  This inclusion is accompanied by a manual detailing the national MBCT teacher\ntraining curriculum and pathway. \n 29 \n  Indeed, such clearly stated guidelines would clarify which form of MBP should\nbe implemented for which context and population, with appropriate training pathways\ntailored to the Swedish context. This would provide guidance for those health\nworkers wishing to train as an MBP teacher, so that practitioners would need to stop\n“guessing” what the best training pathway is, as some of our participants indicate\nis necessary in the current situation. Indeed, as discussed by Dimidjian and Segal, \n 7 \n  “the thorny question of clinician training” (p. 605) has not yet been\nresolved by research, and recommendations differ widely across MBPs with respect to\nformal training for teachers. \n 30 \n  Empirical investigation of these issues is needed in order to develop\nclearer, evidence-based guidelines in this respect.\nAnother aspect that several our participants’ emphasized was the difficulty of\nfunding teacher training. Indeed, in Sweden, other psychological therapies such as\nCognitive Behavioral Therapy and Psychodynamic Therapy, that are mentioned in the\nnational guidelines for depression and anxiety guidelines, \n 14 \n  are taught at universities and thus financed by the government. As of yet,\nMBP teacher training is provided by private practitioners, and participation is\neither paid out-of-pocket or by some limited regional initiatives, as witnessed by\nour participants. By contrast, in countries such as the UK where MBP delivery has\nbecome more formalized in national guidance, training is provided by mainstream\ninstitutions such as universities, or by training providers within the health\nservice. The availability of all stages of teacher training and certification in\nSweden, and preferably available in local regions, are important. Teacher\ncredibility to participants was perceived as important and could be improved by\nincreasing public knowledge about the program through dissemination by public\nfigures in popular media. Another possible means of increasing public awareness is\nthe formation of national associations for MBPs, along the lines of the British\nAssociation for Mindfulness-Based Approaches \n 31 \n  and the European Association of Mindfulness-Based Approaches. \n 32 \n  Such associations can support the development of national good practice\nguidelines, and be a vehicle for communication with the public and\ndecision-makers.\nAnother important aspect of note, mentioned by some of participants in our study, is\nthe current development of research into possible harms of MBP for some patient\ngroups. 33 , 34  Indeed, some of our participants mentioned that they utilized\nvarious screening procedures for including participants to their programs. Some\nparticipants emphasized the importance of such procedures, referring to emerging\nevidence of possible adverse effects of MBPs for some groups of patients. \n 35 \n  Others had a more open approach to including participants, where they did not\napply any inclusion/exclusion criteria. This is yet another area that national\nguidance is required.\nAn important theme that was raised was the importance of delivering MBPs in ways that\nare clearly secular, without connotations to Buddhism, New Age, or other associated,\ncultural or religious practices. Indeed, Crane delineates the ways in which MBPs\noften have been caught in a cross current of divergent criticisms when attempting to\nmaintain their key tenet and ethic of teaching a form of mindfulness that is not\nBuddhist and thus universally accessible. Mindfulness-Based Programs have been\ncritiqued from two sides as either too Buddhist to be provided within tax-paying\nnational health services, while proponents from the Buddhist perspective have\nregarded MBPs as insufficiently Buddhist, thus risking watering down and losing the\nimportant essence and ethical underpinnings of mindfulness practice. \n 36 \n  According to the World Values Survey, \n 37 \n  Sweden is at the furthest extreme in being a society characterized by secular\nvalues, and this may imply that concerns regarding clear delineations from religious\npractices are of particular concern in the Swedish setting, which one of our\nparticipants referred to as a “statistics society”. In this sense, the\nimplementation of MBP in the Swedish health care was adjusted to contextual factors.\nContextual factors, such as culture, leadership and evaluation have been highlighted\nas important to promote successful implementation. In the PARHIS framework, learning\norganizations with transformational leaders are emphasized to have a key role in\nimplementation.\nIt is clear that a number of our findings from this qualitative study parallel those\nin the UK MBP implementation research. \n 19 \n  These include the importance of champion individuals driving implementation,\nand their engagement as facilitators for MBP in a range of proactive activities such\nas forming networks within and beyond the organization, and catalyzing interest\nthrough delivering taster sessions and talks. Also, our findings illustrate various\nways in which “stepped care” of MBP implementation in health care, as suggested by\nDemarzo and co-workers, \n 38 \n  and as suggested in our other study.( 18 ) Indeed, some interview participants\nwere proponents of providing shorter versions of MBPs, due to feasibility issues and\nthis may indeed be adequate in cases of milder health conditions.\n\nThis study has strengths and limitations. Strengths included that the participants\nrepresented a broad range of MBP providers from a variety of health care settings\nand region in Sweden, thus providing a multifaceted perspective of MBP\nimplementation; and that providers from a variety of MBP programs were represented,\nthus providing perspectives on the possible benefits and shortcomings of the variety\nof different program models. This allowed us to gain understandings that could seem\ncontradictory at first sight: that is, some of our teachers were proponents of\nshorter programs due to concerns of accessibility, while others were proponents of\nfull MBP programs due to concerns of fidelity. However, these views need not\nnecessarily be contradictory, but may also complement each other to inform the\nimplementation efforts of MBP in Sweden in the future, by for example as suggested\nabove, developing a stepped-care implementation model. A limitation of the study\nwas, however, that most teachers were trained in the same training center.\nAll interviews provided rich material for analysis. The length of the interviews with\nthe co-workers and the managers was shorter than those with MBP teachers, mainly due\nto time limits in their schedule. A methodological strength of the study was that\ntwo researchers conducted the qualitative analyses, thus increasing reliability. The\ntwo researchers had complementary perspective in the analysis (one as an MBSR\nprovider and one not) which enabled a beneficial triangulation of various\nperspectives in the analysis and interpretation of results. Furthermore, during data\ncollection, the interviewer was unfamiliar with some aspects of MBPs that the\nparticipants brought up, and handled this by asking follow-up questions to clarify\nwhat the participants meant. This approach contributed to providing a rich\nmaterial.\nA weakness of the study was the lack of inclusion of referrers and managers who would\nhave provided additional beneficial insights. Attempts to recruit this group were\nunsuccessful. Future studies in Sweden would preferably also address the view of\nother health professionals and managers in regard to MBP implementation. Financial\nand time restrictions constrained us from extending the study recruitment further,\nand some of those who were approached declined participation due to time constraints\ninflicted by the Covid-19 pandemic and its impact on health services. Therefore, our\nstudy does not provide a more complete “case study” perspective as is presented in\nthe UK MBCT implementation trial. \n 19\n\nOur aim in this study was to hear various perspectives on MBP implementation,\nincluding those of providers, managers, and referrers to programs. This shed light\non the important factors hindering or facilitating implementation. In summary,\nparticipants clearly voiced the need for national guidelines for MBP provision and\nteacher training pathways, as well as improved availability of teacher training.\nAlso, the various and sometimes contradictory participant perspectives can be added\nup to indicate the benefit of a stepped-care model of MBP provision. In the light of\nvarious factors that limit the possibilities for full program implementation in a\nnumber of health care settings, stepped-care models could imply full programs being\ndelivered for those with more severe conditions, where adequate screening procedures\nshould be put in place in order to ensure safe provision of MBP. On the other hand,\nshorter or in other ways less intensive programs may be of benefit for those with\nless severe conditions. Increasing awareness of MBPs among referrers, managers as\nwell as the public was voiced as an important concern by our participants and may\nenable more targeted implementation for patient groups for whom MBPs are most\nsuitable. A national Association for Mindfulness-Based Approaches could provide a\nvehicle for communication with the public and decision-makers.","source_license":"CC-BY-4.0","license_restricted":false}