Modelling innovative interventions for optimising healthy lifestyle promotion in primary health care: "prescribe Vida Saludable" phase I research protocol

Barriers and facilitators in the implementation of an evidence-based health promotion intervention in a primary care setting: a qualitative study

PURPOSE

This study aims to elucidate the health care organization, management and policy barriers and facilitators associated with implementation of an evidence-based health promotion intervention in primary care centers in the Basque Country, Spain.

DESIGN/METHODOLOGY/APPROACH

Seven focus groups were conducted with 49 health professionals from six primary care centers participating in the Prescribing Healthy Life program. Text was analyzed using the Consolidated Framework for Implementation Research (CFIR) focusing on those constructs related to health care organization, management and policy.

FINDINGS

The health promotion intervention was found to be compatible with the values of primary care professionals. However, professionals at all centers reported barriers to implementation related to: (1) external policy and incentives, (2) compatibility with existing workflow and (3) available resources to carry out the program. Specific barriers in these areas related to lack of financial and political support, consultation time constraints and difficulty managing competing day-to-day demands. Other barriers and facilitators were related to the constructs networks and communication, culture, relative priority and leadership engagement. A set of six specific barrier-facilitator pairs emerged.

ORIGINALITY/VALUE

Implementation science and, specifically, the CFIR constructs were used as a guide. Barriers and facilitators related to the implementation of a health promotion program in primary care were identified. Healthcare managers and policy makers can modify these factors to foster a more propitious implementation environment. These factors should be appropriately monitored, both in pre-implementation phases and during the implementation process, in order to ensure effective integration of health promotion into the primary care setting.

Effectiveness of physical exercise for people with chronic diseases: the EFIKRONIK study protocol for a hybrid, clinical and implementation randomized trial

Background

Chronic illnesses are the leading cause of morbidity and mortality and threaten the sustainability of healthcare systems worldwide. There is limited evidence in terms of the best modality and intensity of physical activity for improving cardiorespiratory capacity and quality of life in patients with chronic conditions. The objective of the EfiKroniK study is to estimate the common effect of innovative, individualized and supervised physical exercise, on cardiorespiratory functional capacity and quality of life across people with different chronic conditions.

Methods/design

This is a multicentre clinical trial with a type I hybrid effectiveness-implementation design, including 370 patients each with one of four different chronic illnesses: solid cancer, blood cancer, chronic obstructive pulmonary disease or schizophrenia. Patients will be randomly divided into two parallel groups, stratified by illness type. Patients in both groups will receive a standard healthy life prescription (PVS, from the Spanish “Prescribe Vida Saludable”) and additionally, the EfiKroniK group will be prescribed a physical exercise programme tailored to each patient in terms of intensity in each session. The primary outcome variables will be cardiorespiratory functional capacity and quality of life. The secondary outcome variables will be signs and symptoms, psychological and social factors and specific laboratory parameters. We will also analyse the dose-response effect of the physical exercise programme. Qualitative variables will describe patients’ perception of the utility and suitability of the EfiKroniK programme, as well as their expectations and satisfaction, identifying barriers to and facilitators of the EfiKroniK implementation process through discussion groups. The study will be carried out on an intention-to-treat basis, comparing changes throughout the 1-year follow-up between groups, adjusting for baseline, by performing mixed-effect analysis of covariance. We will estimate the effect of time on repeated measures in each subject and changes in the EfiKroniK and PVS groups over time.

Discussion

The study will provide the data necessary to allow us to prescribe physical exercise in a similar way to a drug and as a key part of the treatment of chronic illnesses within our healthcare system.

Trial registration

NCT03810755.

Date and version identifier: October 9, 2020. Version2.0.

Collaborative modeling of an implementation strategy: a case study to integrate health promotion in primary and community care

Background

Evidence-based interventions are more likely to be adopted if practitioners collaborate with researchers to develop an implementation strategy. This paper describes the steps to plan and execute a strategy, including the development of structure and supports needed for implementing proven health promotion interventions in primary and community care.

Results

Between 10 and 13 discussion and consensus sessions were performed in four highly-motivated primary health care centers involving 80% of the primary care staff and 21 community-based organizations. All four centers chose to address physical activity, diet, and smoking. They selected the 5 A’s evidence-based clinical intervention to be adapted to the context of the health centers. The planned implementation strategy worked at multiple levels: bottom-up primary care organizational change, top-down support from managers, community involvement, and the development of innovative e-health information and communication tools. Shared decision making and practice facilitation were perceived as the most positive aspects of the collaborative modeling process, which took more time than expected, especially the development of the new e-health tools integrated into electronic health records.

Conclusions

Collaborative modeling of an implementation strategy for the integration of health promotion in primary and community care was feasible in motivated centers. However, it was difficult, being hindered by the heavy workload in primary care and generating uncertainty inherent to a bottom-up decision making processes. Lessons from this experience could be useful in diverse settings and for other clinical interventions. Two companion papers report the evaluation of its feasibility and assess quantitatively and qualitatively the implementation process.

Feasibility of an implementation strategy for the integration of health promotion in routine primary care: a quantitative process evaluation

BACKGROUND

Process evaluation is recommended to improve the understanding of underlying mechanisms related to clinicians, patients, context and intervention delivery that may impact on trial or program results, feasibility and transferability to practice. The aim of this study was to assess the feasibility of the Prescribe Healthy Life (PVS from the Spanish "Prescribe Vida Saludable") implementation strategy for enhancing the adoption and implementation of an evidence-based health promotion intervention in primary health care.

METHODS

A descriptive study of 2-year implementation indicators for the PVS clinical intervention was conducted in four primary health care centers. A multifaceted collaborative modeling implementation strategy was developed to enhance the integration of a clinical intervention to promote healthy lifestyles into clinical practice. Process indicators were assessed for intervention reach, adoption, implementation, sustainability and their variability at center, practice, and patient levels.

RESULTS

Mean rates of adoption by means of active collaboration among the three main professional categories (family physicians, nurses and administrative personnel) were 75% in all centers. Just over half of the patients that attended (n = 11650; 51.9%) were reached in terms of having their lifestyle habits assessed, while more than a third (33.7%; n = 7433) and almost 10% (n = 2175) received advice or a printed prescription for at least one lifestyle change, respectively. Only 3.7% of the target population received a repeat prescription. These process indicators significantly (p < 0.001) varied by center, lifestyle habit and patient characteristics. Sustainability of intervention components changed thorough the implementation period within centers.

CONCLUSIONS

The implementation strategy used showed moderate-to-good performance on process indicators related to adoption, reach, and implementation of the evidence-based healthy lifestyle promotion intervention in the context of routine primary care. Sources of heterogeneity and instability in these indicators may improve our understanding of factors required to attain adequate program adoption and implementation through improved implementation strategies.

The implementation of health promotion in primary and community care: a qualitative analysis of the 'Prescribe Vida Saludable' strategy

BACKGROUND

The impact of lifestyle on health is undeniable and effective healthy lifestyle promotion interventions do exist. However, this is not a fundamental part of routine primary care clinical practice. We describe factors that determine changes in performance of primary health care centers involved in piloting the health promotion innovation 'Prescribe Vida Saludable' (PVS) phase II.

METHODS

We engaged four primary health care centers of the Basque Healthcare Service in an action research project aimed at changing preventive health practices. Prescribe Healthy Life (PVS from the Spanish "Prescribe Vida Saludable) is focused on designing, planning, implementing and evaluating innovative programs to promote multiple healthy habits, feasible to be performed in routine primary health care conditions. After 2 years of piloting, centers were categorized as having high, medium, or low implementation effectiveness. We completed qualitative inductive and deductive analysis of five focus groups with the staff of the centers. Themes generated through consensual grounded qualitative analysis were compared between centers to identify the dimensions that explain the variation in actual implementation of PVS, and retrospectively organized and assessed against the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Of the 36 CFIR constructs, 11 were directly related to the level of implementation performance: intervention source, evidence strength and quality, adaptability, design quality and packaging, tension for change, learning climate, self-efficacy, planning, champions, executing, and reflecting and evaluating, with -organizational tracking added as a new sub-construct. Additionally, another seven constructs emerged in the participants' discourse but were not related to center performance: relative advantage, complexity, patients' needs and resources, external policy and incentives, structural characteristics, available resources, and formally appointed internal implementation leaders. Our findings indicate that the success of the implementation seems to be associated with the following components: the context, the implementation process, and the collaborative modelling.

CONCLUSIONS

Identifying barriers and enablers is useful for designing implementation strategies for health promotion in primary health care centers that are essential for innovation success. An implementation model is proposed to highlight the relationships between the CFIR constructs in the context of health promotion in primary care.

Metric properties of the "prescribe healthy life" screening questionnaire to detect healthy behaviors: a cross-sectional pilot study

Background

Feasible and valid assessment of healthy behaviors is the first step for integrating health promotion in routine primary care. Therefore, the aim of this study was to develop and evaluate the validity and reliability of the “prescribe healthy life” screening questionnaire, a brief tool for detecting physical activity levels, consumption of fruit and vegetables, tobacco use and patients’ compliance with minimal recommendations.

Methods

An observational cross-sectional study to determine the reliability and validity of this questionnaire by means of mixed (qualitative and quantitative) methods. Thirteen healthcare professionals designed the questionnaire. One hundred and twenty-six patients from three primary care health centers within Osakidetza (Basque Health Service, Spain) filled in the “Prescribe Healthy Life” Screening Questionnaire and completed an accelerometry record, the PREDIMED Food Frequency Questionnaire and a co-oximetry as gold standards for physical activity, dietary intake and tobacco use, respectively. Correlations, sensitivities, specificities, likelihood ratios and test-retest reliability were calculated. Additionally, the feasibility and utility of the questionnaire were evaluated.

Results

Both reliability and concurrent validity for the consumption of fruit and vegetables (r_spearman = 0.59, r_spearman = 0.50) and tobacco use (r_spearman = 0.76, r = 0.69) as their overall performance in the detection of unhealthy diet (accuracy = 76.8%, LR + = 3.1 and LR- = 0.31) and smokers (accuracy = 86.8%, LR + = 6.1 and LR- = 0.05) were good. Meanwhile, the reproducibility (0.38), the correlation between the minutes of physical activity (0.34) and LR+ (1.00) for detection of physical activity were low. On average the questionnaire was considered by patients easy to understand, easy to fill in, short (5–6 min) and useful.

Conclusion

The “Prescribe Healthy Life” Screening Questionnaire, PVS-SQ, has proved to be a simple and practical tool for use in the actual context of primary care, with guarantees of validity and reliability for the diet and tobacco scales. However, the physical activity scale show unsatisfactory results, and alternative questions ought to be tested.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3898-8) contains supplementary material, which is available to authorized users.

Organizational Capabilities for Integrating Care: A Review of Measurement Tools

The success of integrated care interventions is highly dependent on the internal and collective capabilities of the organizations in which they are implemented. Yet, organizational capabilities are rarely described, understood, or measured with sufficient depth and breadth in empirical studies or in practice. Assessing these capabilities can contribute to understanding why some integrated care interventions are more effective than others. We identified, organized, and assessed survey instruments that measure the internal and collective organizational capabilities required for integrated care delivery. We conducted an expert consultation and searched Medline and Google Scholar databases for survey instruments measuring factors outlined in the Context and Capabilities for Integrating Care Framework. A total of 58 instruments were included in the review and assessed based on their psychometric properties, practical considerations, and applicability to integrated care efforts. This study provides a bank of psychometrically sound instruments for describing and comparing organizational capabilities. Greater use of these instruments across integrated care interventions and studies can enhance standardized comparative analyses and inform change management. Further research is needed to build an evidence base for these instruments and to explore the associations between organizational capabilities and integrated care processes and outcomes.

Basic concepts in the taxonomy of health-related behaviors, habits and lifestyle

Background: Health-related Habits (HrH) are a major priority in healthcare. However there is little agreement on whether exercise, diet, smoking or dental hygiene are better described as lifestyles, habits or behaviors, and on what is their hierarchical relationship. This research is aimed at representing the basic concepts which are assumed to constitute the conceptual framework enabling us to interpret and organize the field of HrH. Methods: A group of 29 experts with different backgrounds agreed on the definition and hierarchy of HrH following an iterative process which involved framing analysis and nominal group techniques. Results: Formal definitions of health-related behavior, habit, life-style and life-style profile were produced. In addition a series of basic descriptors were identified: health reserve, capital, risk and load. Six main categories of HrH were chosen based on relevance to longevity: diet/exercise, vitality/stress, sleep, cognition, substance use and other risk. Attributes of HrH are clinical meaningfulness, quantifiability, temporal stability, associated morbidity, and unitarity (non-redundancy). Two qualifiers (polarity and stages of change) have also been described. Conclusions: The concepts represented here lay the groundwork for the development of clinical and policy tools related to HrH and lifestyle. An adaptation of this system to define targets of health interventions and to develop the classification of person factors in ICF may be needed in the future.

[Smoking intervention in patients with cardiovascular diseases]

Smoking tobacco is the main cardiovascular risk factor and has a dose-dependent response. It has been shown that an aggressive policy, not only against consumption, achieves a significant decrease in cardiovascular deaths. Thus, we must provide and carry out activities to prevent or decrease the incidence of smoking (primary prevention), and to the early detection of the smoker and to reduce the prevalence (secondary prevention), and lastly to act on the effects of tobacco smoke, preventing complication and remissions (tertiary prevention). Thus, all health care levels must act in order that smokers do not develop cardiovascular disease when they quit smoking, both from Primary, as well as specialist care.

A refined taxonomy of behaviour change techniques to help people change their physical activity and healthy eating behaviours: the CALO-RE taxonomy

BACKGROUND

Current reporting of intervention content in published research articles and protocols is generally poor, with great diversity of terminology, resulting in low replicability. This study aimed to extend the scope and improve the reliability of a 26-item taxonomy of behaviour change techniques developed by Abraham and Michie [Abraham, C. and Michie, S. (2008). A taxonomy of behaviour change techniques used in interventions. Health Psychology, 27(3), 379-387.] in order to optimise the reporting and scientific study of behaviour change interventions.

METHODS

Three UK study centres collaborated in applying this existing taxonomy to two systematic reviews of interventions to increase physical activity and healthy eating. The taxonomy was refined in iterative steps of (1) coding intervention descriptions, and assessing inter-rater reliability, (2) identifying gaps and problems across study centres and (3) refining the labels and definitions based on consensus discussions.

RESULTS

Labels and definitions were improved for all techniques, conceptual overlap between categories was resolved, some categories were split and 14 techniques were added, resulting in a 40-item taxonomy. Inter-rater reliability, assessed on 50 published intervention descriptions, was good (kappa = 0.79).

CONCLUSIONS

This taxonomy can be used to improve the specification of interventions in published reports, thus improving replication, implementation and evidence syntheses. This will strengthen the scientific study of behaviour change and intervention development.

Two-year longitudinal analysis of a cluster randomized trial of physical activity promotion by general practitioners

BACKGROUND

We evaluate the effectiveness of a physical activity promotion programme carried out by general practitioners with inactive patients in routine care.

METHODS AND FINDINGS

Pragmatic, cluster randomised clinical trial conducted in eleven public primary care centres in Spain. Fifty-six general practitioners (GPs) were randomly assigned to intervention (29) or standard care (27) groups. They assessed the physical activity level of a systematic sample of patients in routine practice and recruited 4317 individuals (2248 intervention and 2069 control) who did not meet minimum physical activity recommendations. Intervention GPs provided advice to all patients and a physical activity prescription to the subgroup attending an additional appointment (30%). A third of these prescriptions were opportunistically repeated. Control GPs provided standard care. Primary outcome measure was the change in self-reported physical activity from baseline to six, 12 and 24 months. Secondary outcomes included cardiorespiratory fitness and health-related quality of life. A total of 3691 patients (85%) were included in the longitudinal analysis and overall trends over the whole 24 month follow-up were significantly better in the intervention group (p<0.01). The greatest differences with the control group were observed at six months (adjusted difference 1.7 MET*hr/wk [95% CI, 0.8 to 2.6], 25 min/wk [95% CI, 11.3 to 38.4], and a 5.3% higher percentage of patients meeting minimum recommendations [95% CI: 2.1% to 8.8%] NNT = 19). These differences were not statistically significant at 12 and 24 months. No differences were found in secondary outcomes. A significant difference was maintained until 24 months in the proportion of patients achieving minimum recommendation in the subgroup that received a repeat prescription (adjusted difference 10.2%, 95% CI 1.5% to 19.4%).

CONCLUSIONS

General practitioners are effective at increasing the level of physical activity among their inactive patients during the initial six-months of an intervention but this effect wears off at 12 and 24 months. Only in the subgroup of patients receiving repeat prescriptions of physical activity is the effect maintained in long-term.

TRIAL REGISTRATION

clinicaltrials.gov NCT00131079.

Methodology for the development of a taxonomy and toolkit to evaluate health-related habits and lifestyle (eVITAL)

Background

Chronic diseases cause an ever-increasing percentage of morbidity and mortality, but many have modifiable risk factors. Many behaviors that predispose or protect an individual to chronic disease are interrelated, and therefore are best approached using an integrated model of health and the longevity paradigm, using years lived without disability as the endpoint.

Findings

This study used a 4-phase mixed qualitative design to create a taxonomy and related online toolkit for the evaluation of health-related habits. Core members of a working group conducted a literature review and created a framing document that defined relevant constructs. This document was revised, first by a working group and then by a series of multidisciplinary expert groups. The working group and expert panels also designed a systematic evaluation of health behaviors and risks, which was computerized and evaluated for feasibility. A demonstration study of the toolkit was performed in 11 healthy volunteers.

Discussion

In this protocol, we used forms of the community intelligence approach, including frame analysis, feasibility, and demonstration, to develop a clinical taxonomy and an online toolkit with standardized procedures for screening and evaluation of multiple domains of health, with a focus on longevity and the goal of integrating the toolkit into routine clinical practice.

Trial Registration

IMSERSO registry 200700012672