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Qual Prim Care. 2008;16(1):17-26.

Utilising theories of change to understand the engagement of general practitioners in service improvement: a formative evaluation of the Lewisham Depression Programme.

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  • 1Lewisham PCT, London, UK.



Mental health issues such as depression are commonly treated within primary care. In accordance with new UK National Institute for Health and Clinical Excellence (NICE) guidance, primary care practitioners have increased responsibilities to manage mild depression in primary care. This paper reports on an evaluation of a depression programme marketing strategy, and factors contributing towards practitioner engagement or non-engagement.


The main aims of the study were to conduct an evaluation that was programme specific, to immediately feed results back iteratively through early development and engagement of general practitioners (GPs) and nurses and their practices in a multifaceted programme, and to investigate decisions to participate or not participate in the depression recognition audit as a first point of engagement, in order to gain a better understanding of what motivates GPs and nurses to be involved and what prohibits involvement, in order to address any future potential barriers to improvement.


The methods for this formative evaluation can be categorised in three distinct ways: firstly, the iterative development of 'theories of change' (programme-based assumptions) using ethnographic techniques, which led to the development of a list of predefined theories of change and formed the basis of two questionnaires; secondly, questionnaires were sent to engaged GPs and nurses and a separate questionnaire was sent to a matched sample of GPs and nurses not engaged; finally, results were fed back on an ongoing basis to inform the ongoing programme development and evaluation and to produce final theories of change for engagement.


The response rate to the questionnaire was 54%. Those involved in the audit reported individual motivation, team working, wider networks and method of engagement, all as positively influencing their decision to take part. Those not involved focused on practice organisational issues leading to non-participation, such as not having enough time, or being understaffed or busy with other initiatives.


The 'theories of change' method helped explore and shape assumptions around the Lewisham Depression Programme's marketing strategy as a basis for future marketing of programme activity. It also helped to develop a joint programme-evaluation forum by which programme team members were empowered to lead aspects of future research within the programme. There are some key messages for future programme makers to help engage GPs and nurses, such as the importance of having face-to-face practice meetings with a trained facilitator, the positive engagement of practice managers, and a launch meeting for the programme. The results also support targeted strategies to support poorly performing individuals and practice teams.

[PubMed - indexed for MEDLINE]
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