The implementation of mindfulness in healthcare systems: a theoretical analysis
Introduction
One of the main challenges faced by all types of psychotherapies, including mindfulness-based interventions (MBIs), is the conversion of studies on their efficacy, developed under controlled conditions, to routine clinical practice within national healthcare systems. It has now been more than three decades since MBIs were proposed to improve symptoms of chronic pain, depression and anxiety symptoms among patients and the general population, and exponential evidence-based data have built a scientific foundation for the use of these interventions in healthcare [1]. However, no healthcare system seems to offer suitable and equitable access for MBIs to patients and the general population who could benefit from these interventions. In this opinative narrative review article [2], we provide a conceptual framework for the implementation of MBIs in healthcare systems based on available theoretical and empirical data that address key issues such as the training of professionals, funding and costs of interventions, cost effectiveness and innovative delivery models. We discuss innovative approaches based on “complex interventions,” “stepped-care” and “low intensity–high volume” concepts that may prove fruitful in the evolution and implementation of MBIs in national healthcare systems, particularly in Primary Care (PC). This conceptual framework may bring about scholarly dialog [2] and support health managers and practitioners with the implementation of MBIs and others types of psychosocial interventions in healthcare systems.
Section snippets
Implementing mindfulness in the healthcare system: the case of United Kingdom
Although mindfulness interventions designed for clinical settings were originally developed in the United States (US), and currently there is a widespread interest for them in many countries (mainly in mindfulness-based stress reduction — MBSR — the original program designed by Jon Kabat-Zinn in 1979 at the University of Massachusetts), the United Kingdom (UK) is apparently the most developed country in terms of the formal implementation of MBIs in an integrated national healthcare system [3],
PC: the gateway for mindfulness in healthcare systems
PC is the main gateway for patients in a healthcare system and is essential for the proper prevention and management of chronic mental illnesses [6]. The characteristics of PC (equitable access; services close to people’s residence; continuous, lifelong, person-centered care; focus on preventive actions and people’s health needs) may enhance the accessibility of and adherence (motivation and compliance) to MBIs.
However, there are barriers to the implementation of mindfulness in PC services that
MBIs are “complex interventions” in healthcare systems
Complex interventions are defined as those comprising several interrelated components. These present a challenge for researchers and managers of health services. The challenges involved in the evaluation of these interventions include the following: difficulties in standardizing designs and modes of application for various existing programs; the influence of ethnocultural and political contexts; organizational, logistical and political difficulties in evaluating an intervention in health
Professional qualifications to teach and deliver MBIs
There are three key aspects to ensuring the quality of professional MBI training: (a) the content, method and process of development and training; (b) training standards; and (c) the definition of skills needed to teach mindfulness groups and/or train other instructors [14].
At present, there are still no accepted international standards or professional qualifications with regard to MBI training [5]. However, professional training guidelines for teaching MBIs and training new mindfulness
Funding, costs and number of instructors
The issue of financing MBIs is also key to implementing them in national healthcare systems. In the case of the UK, as already mentioned, MBIs are supported by governmental clinical guidelines [4].
In universal healthcare systems, MBIs should be part of interventions that are formally recommended by the system to allow funding, including payment for groups and professionals’ hours of labor. To save on long-term costs in countries where there is a relevant role for health insurance companies,
Cost effectiveness of MBIs
Appropriate cost effectiveness is essential in order for MBIs to be accepted and implemented in healthcare systems. Studies on the cost effectiveness of MBIs are still scarce, but the results of some of the existing studies are encouraging. For example, in 2002, Roth and Stanley [17] showed that an 8-week MBSR group at a primary care center in the US decreased the number of visits to the health center for chronic illnesses among the patients who attended the group, suggesting that MBIs may be
“Stepped-care” and “low intensity–high volume”: key concepts for the large-scale implementation of mindfulness
When we discuss the implementation of MBIs in healthcare systems, we consider high-volume interventions. A large-scale strategic implementation plan for mindfulness may benefit from concepts such as “stepped-care” and “low intensity–high volume” interventions [22], [23], [24], thereby making the models of these types of MBIs more flexible and increasing access to MBIs.
The “stepped-care” intervention model is based on the notion that there is a gap between population demand for these therapies
Conclusion and agenda for future studies
In evidence-based terms, different MBIs may have distinct approaches and barriers in order to be implemented in highly diverse healthcare systems worldwide, and thus many questions regarding the implementation of mindfulness interventions in health systems remain unanswered. A good theoretical framework for researchers and managers is to follow a progressive development and assessment model for MBIs, based on the approach for “complex interventions” (see Table 3) [8], [9]. This general
Conflict of Interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Author Contributions
M.M.P.D. and J.G.C. presented the initial concept, drafted the first version and organized subsequent versions until the final format of the manuscript. All authors contributed to the development and improvement of the manuscript until its final version.
Acknowledgments
M.M.P.D. is grateful to the National Council for Scientific and Technological Development — Brazilian National Council for Research and Technological Development — for a postdoctoral fellowship under supervision of Professor Javier García-Campayo (“Science without Borders Program”). The authors thank Rebecca S. Crane, Centre for Mindfulness Research and Practice, Dean Street Building, Bangor University, LL571UT, UK, for the revision of previous drafts of this paper, as well as Mari Cruz
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