Barriers and facilitators for the implementation of primary prevention and health promotion activities in primary care: a synthesis through meta-ethnography

Maria Rubio-Valera, Mariona Pons-Vigués, María Martínez-Andrés, Patricia Moreno-Peral, Anna Berenguera, Ana Fernández, Maria Rubio-Valera, Mariona Pons-Vigués, María Martínez-Andrés, Patricia Moreno-Peral, Anna Berenguera, Ana Fernández

Abstract

Background: Evidence supports the implementation of primary prevention and health promotion (PP&HP) activities but primary care (PC) professionals show resistance to implementing these activities. The aim was to synthesize the available qualitative research on barriers and facilitators identified by PC physicians and nurses in the implementation of PP&HP in adults.

Methods and findings: A systematic search of three databases was conducted and supported by manual searches. The 35 articles included were translated into each other and a new interpretation of the concepts extracted was generated. The factors affecting the implementation of PP&HP activities in PC according to professionals were fitted into a five-level ecological model: intrapersonal factors, interpersonal processes, institutional factors, community factors and public policy. At the intrapersonal level we find professionals' beliefs about PP&HP, experiences, skills and knowledge, and selfconcept. The attitudes and behavior towards PP&HP of patients, specialists, practice managers and colleagues (interpersonal factors) affect the feasibility of implementing PP&HP. Institutional level: PC is perceived as well-placed to implement PP&HP but workload, lack of time and referral resources, and the predominance of the biomedical model (which prioritizes disease treatment) hamper the implementation of PP&HP. The effectiveness of financial incentives and tools such as guidelines and alarms/reminders is conditioned by professionals' attitudes to them. Community factors include patients' social and cultural characteristics (religion, financial resources, etc.), local referral resources, mass-media messages and pharmaceutical industry campaigns, and the importance given to PP&HP in the curriculum in university. Finally, policies affect the distribution of resources, thus affecting the implementation of PP&HP.

Conclusions: Research on barriers and facilitators in the implementation of PP&HP activities in multirisk management is scarce. The conceptual overview provided by this synthesis resulted in the development of practical recommendations for the design of PP&HP in PC. However, the effectiveness of these recommendations needs to be demonstrated.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Figure 1. Flow-chart of the systematic review.
Figure 1. Flow-chart of the systematic review.
Figure 2. Ecological model of the factors…
Figure 2. Ecological model of the factors affecting the implementation of PP&HP activities by primary care professionals.

References

    1. Shaw K, Gennat H, O'Rourke P, Del MC (2006) Exercise for overweight or obesity. Cochrane Database Syst Rev CD003817.
    1. Rees K, Dyakova M, Ward K, Thorogood M, Brunner E (2013) Dietary advice for reducing cardiovascular risk. Cochrane Database Syst Rev 3: CD002128.
    1. Costa B, Barrio F, Cabre JJ, Pinol JL, Cos X, et al. (2012) Delaying progression to type 2 diabetes among high-risk spanish individuals is feasible in real-life primary healthcare settings using intensive lifestyle intervention. Diabetologia 55: 1319–1328.
    1. Rasmussen SR, Thomsen JL, Kilsmark J, Hvenegaard A, Engberg M, et al. (2007) Preventive health screenings and health consultations in primary care increase life expectancy without increasing costs. Scand J Public Health 35: 365–372.
    1. Brotons C, Soriano N, Moral I, Rodriguez-Artalejo F, Banegas JR, et al. (2012) Prevention in primary care. the example of the program for prevention and health promotion. SESPAS report 2012. Gac Sanit 26 Suppl 1: 151–157.
    1. Starfield B (1992) Primary care: Concept, evaluation and policy. New York: Oxford University Press.
    1. World Health Organization (2008) The world health report: Primary health care (now more than ever).
    1. Fairhurst K, Huby G (1998) From trial data to practical knowledge: Qualitative study of how general practitioners have accessed and used evidence about statin drugs in their management of hypercholesterolaemia. BMJ 317: 1130–1134.
    1. Lambe B, Collins C (2010) A qualitative study of lifestyle counselling in general practice in ireland. Fam Pract 27: 219–223.
    1. Fixsen DL, Naoom SF, Blase KA, Friedman RM, Wallace F (2005) Implementation Research: A Synthesis of the Literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network (FMHI Publication #231).
    1. Campbell M, Fitzpatrick R, Haines A, Kinmonth AL, Sandercock P, et al. (2000) Framework for design and evaluation of complex interventions to improve health. BMJ 321: 694–696.
    1. Campbell NC, Murray E, Darbyshire J, Emery J, Farmer A, et al. (2007) Designing and evaluating complex interventions to improve health care. BMJ 334: 455–459.
    1. Noblit GW, Hare RD. (1988) Meta-ethnography: Synthesizing qualitative studies. Newbury Park, California: Sage.
    1. Britten N, Campbell R, Pope C, Donovan J, Morgan M, et al. (2002) Using meta ethnography to synthesise qualitative research: A worked example. J Health Serv Res Policy 7: 209–215.
    1. Pope C, Mays N, Popay J (2007) Synthesizing qualitative and quantitative health evidence: A guide to methods. Maidenhead: Open University Press.
    1. Mays N, Pope C (2000) Qualitative research in health care. assessing quality in qualitative research. BMJ 320: 50–52.
    1. Calderon C (2002) Quality criteria in qualitative research in health: Notes for a necessary debate]. Rev Esp Salud Publica 76: 473–482.
    1. Dixon-Woods M, Sutton A, Shaw R, Miller T, Smith J, et al. (2007) Appraising qualitative research for inclusion in systematic reviews: A quantitative and qualitative comparison of three methods. J Health Serv Res Policy 12: 42–47.
    1. Lamb J, Bower P, Rogers A, Dowrick C, Gask L (2012) Access to mental health in primary care: A qualitative meta-synthesis of evidence from the experience of people from ‘hard to reach’ groups. Health (London) 16: 76–104.
    1. Pound P, Britten N, Morgan M, Yardley L, Pope C, et al. (2005) Resisting medicines: A synthesis of qualitative studies of medicine taking. Soc Sci Med 61: 133–155.
    1. Blaxter M (1996) Criteria for the evaluation of qualitative research papers. Medical Sociology News 22: 68–71.
    1. McLeroy KR, Bibeau D, Steckler A, Glanz K (1988) An ecological perspective on health promotion programs. Health Educ Q 15: 351–377.
    1. Carlfjord S, Lindberg M, Andersson A (2012) Staff perceptions of addressing lifestyle in primary health care: A qualitative evaluation 2 years after the introduction of a lifestyle intervention tool. BMC Family Practice 13: 99 Available: . Accessed 29 July 2013.
    1. Sondergaard A, Christensen B, Maindal HT (2012) Diversity and ambivalence in general practitioners' attitudes towards preventive health checks - a qualitative study. Bmc Family Practice 13: 53 Available: . Accessed 29 July 2013.
    1. Badertscher N, Rossi N, Rieder A, Herter-Clavel C, Rosemann T, et al. (2012) Attitudes, barriers and facilitators for health promotion in the elderly in primary care. A qualitative focus group study. Swiss Med Wkly 142: 13606 Available: . Accessed 29 July 2013.
    1. Hernandez J, Anderson S (2012) Storied experiences of nurse practitioners managing prehypertension in primary care. J Am Acad Nurse Pract 24: 89–96.
    1. Gunther S, Guo F, Sinfield P, Rogers S, Baker R (2012) Barriers and enablers to managing obesity in general practice: A practical approach for use in implementation activities. Quality in primary care 20: 93–103.
    1. Nolan C, Deehan A, Wylie A, Jones R (2012) Practice nurses and obesity: Professional and practice-based factors affecting role adequacy and role legitimacy. Prim Health Care Res Dev 1–11.
    1. Boase S, Mason D, Sutton S, Cohn S (2012) Tinkering and tailoring individual consultations: How practice nurses try to make cardiovascular risk communication meaningful. J Clin Nurs 21: 2590–2598.
    1. Calderon C, Balague L, Cortada JM, Sanchez A (2011) Health promotion in primary care: How should we intervene? A qualitative study involving both physicians and patients. BMC Health Serv Res 11: 62 Available: . Accessed 29 July 2013.
    1. Gale NK, Greenfield S, Gill P, Gutridge K, Marshall T (2011) Patient and general practitioner attitudes to taking medication to prevent cardiovascular disease after receiving detailed information on risks and benefits of treatment: A qualitative study. BMC Family Practice 12: 26 Available: . Accessed 29 July 2013.
    1. Muller-Riemenschneider F, Holmberg C, Rieckmann N, Kliems H, Rufer V, et al. (2010) Barriers to routine risk-score use for healthy primary care patients: Survey and qualitative study. Arch Intern Med 170: 719–724.
    1. Walter U, Flick U, Neuber A, Fischer C, Hussein RJ, et al. (2010) Putting prevention into practice: Qualitative study of factors that inhibit and promote preventive care by general practitioners, with a focus on elderly patients. BMC Fam Pract 11: 68 Available: Accessed 29 July 2013.
    1. Heymann AD, Bentur N, Valinsky L, Lemberger J, Elhayany A (2010) The perceived performance, barriers and solutions for the good preventive care of elderly people in israel. Qual Prim Care 18: 173–179.
    1. Ampt AJ, Amoroso C, Harris MF, McKenzie SH, Rose VK, et al. (2009) Attitudes, norms and controls influencing lifestyle risk factor management in general practice. BMC Fam Pract 10:59.: 59 Available: Accessed 29 July 2013.
    1. Leverence RR, Williams RL, Sussman A, Crabtree BF, Rios NC (2007) Obesity counseling and guidelines in primary care - A qualitative study. Am J Prev Med 32: 334–339.
    1. Graham RC, Dugdill L, Cable NT (2005) Health professionals' perspectives in exercise referral: Implications for the referral process. Ergonomics 48: 1411–1422.
    1. Ribera AP, McKenna J, Riddoch C (2005) Attitudes and practices of physicians and nurses regarding physical activity promotion in the catalan primary health-care system. Eur J Public Health 15: 569–575.
    1. Jacobsen ET, Rasmussen SR, Christensen M, Engberg M, Lauritzen T (2005) Perspectives on lifestyle intervention: The views of general practitioners who have taken part in a health promotion study. Scand J Public Health 33: 4–10.
    1. Johansson K, Akerlind I, Bendtsen P (2005) Under what circumstances are nurses willing to engage in brief alcohol interventions? A qualitative study from primary care in sweden. Addict Behav 30: 1049–1053.
    1. Williams R, Rapport F, Elwyn G, Lloyd B, Rance J, et al. (2004) The prevention of type 2 diabetes: General practitioner and practice nurse opinions. Br J Gen Pract 54: 531–535.
    1. Van Steenkiste BT, Stoffers HE, Grol R (2004) Barriers to implementing cardiovascular risk tables in routine general practice. Scandinavian Journal of Primary Health Care 22: 32–37.
    1. Hudon E, Beaulieu MD, Roberge D (2004) Integration of the recommendations of the canadian task force on preventive health care - obstacles perceived by a group of family physicians. Fam Pract 21: 11–17.
    1. Kedward J, Dakin L (2003) A qualitative study of barriers to the use of statins and the implementation of coronary heart disease prevention in primary care. Br J Gen Pract 53: 684–689.
    1. Fuller TL, Backett-Milburn K, Hopton JL (2003) Healthy eating: The views of general practitioners and patients in scotland. Am J Clin Nutr 77: 1043S–1047S.
    1. Mirand AL, Beehler GP, Kuo CL, Mahoney MC (2002) Physician perceptions of primary prevention: Qualitative base for the conceptual shaping of a practice intervention tool. BMC Public Health 2: 16 Available: Accessed 29 July 2013.
    1. Beich A, Gannik D, Malterud K (2002) Screening and brief intervention for excessive alcohol use: Qualitative interview study of the experiences of general practitioners. BMJ 325: 870 Available: Accessed 29 July 2013.
    1. Lock CA, Kaner E, Lamont S, Bond S (2002) A qualitative study of nurses' attitudes and practices regarding brief alcohol intervention in primary health care. J Adv Nurs 39: 333–342.
    1. Coleman T, Murphy E, Cheater F (2000) Factors influencing discussion of smoking between general practitioners and patients who smoke: A qualitative study. British Journal of General Practice 50: 207–210.
    1. Makrides L, Veinot PL, Richard J, Allen MJ (1997) Primary care physicians and coronary heart disease prevention: A practice model. Patient Education & Counseling 32: 207–217.
    1. Kerse NM, Murphy MJ, Flicker L, Young D (1997) Health promotion and older people: A qualitative study of general practitioners' views. Med J Aust 167: 423–427.
    1. Swinburn BA, Walter LG, Arroll B, Tilyard MW, Russell DG (1997) Green prescriptions: Attitudes and perceptions of general practitioners towards prescribing exercise. British Journal of General Practice 47: 567–569.
    1. Swinburn BA, Walter LG, Arroll B, Tilyard MW, Russell DG (1997) Green prescriptions: Attitudes and perceptions of general practitioners towards prescribing exercise. British Journal of General Practice 47: 567–569.
    1. Rush BR, Powell LY, Crowe TG, Ellis K (1995) Early intervention for alcohol-use - family physicians motivations and perceived barriers. Can Med Assoc J 152: 863–869.
    1. Williams SJ, Calnan M (1994) Perspectives on prevention: The views of general practitioners. Sociol Health Ill 16: 372–393.
    1. Ajzen I (1991) The theory of planned behavior. Organizational Behavior & Human Decision Processes 50: 179–211.
    1. Albert D, Fortin R, Lessio A, Herrera C, Riley B, et al. (2013) Strengthening chronic disease prevention programming: The toward evidence-informed practice (TEIP) program assessment tool. Prev Chronic Dis 10: E88 Available: Accessed 29 July 2013.
    1. Bosch-Capblanch X, Lavis JN, Lewin S, Atun R, Rottingen JA, et al. (2012) Guidance for evidence-informed policies about health systems: Rationale for and challenges of guidance development. PLoS Med 9: e1001185 Available: Accessed 29 July 2013.
    1. Epstein RM, Fiscella K, Lesser CS, Stange KC (2010) Why the nation needs a policy push on patient-centered health care. Health Aff (Millwood) 29: 1489–1495.
    1. Brandling J, House W (2009) Social prescribing in general practice: Adding meaning to medicine. Br J Gen Pract 59: 454–456.
    1. Blumenthal DS (2007) Barriers to the provision of smoking cessation services reported by clinicians in underserved communities. J Am Board Fam Med 52: 272–279.
    1. Ribera AP, McKenna J, Riddoch C (2006) Physical activity promotion in general practices of Barcelona: a case study. Health Educ Res 21: 538–548.
    1. Campbell R, Pound P, Morgan M, Daker-White G, Britten N, et al. (2011) Evaluating meta-ethnography: Systematic analysis and synthesis of qualitative research. Health Technol Assess 15: 1–164.
    1. Vázquez ML, da Silva MRF, Mogollon AS, Fdez Sanmamed MJ, Delgado ME, et al... (2006) Introduccion a las t‚cnicas cualiativas de investigaci¢n aplicadas en salud. Barcelona: UAB Servei de publicacions.

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