If health promotion is so important, why is it not systematically integrated into primary care and community organizations? Scoping Review on Implementation Strategies

Abstract

Introduction: Reinforcing integrated healthcare systems requires systematic adoption of health promotion interventions by primary care professionals to reduce chronic disease burden caused by inadequate diet, physical inactivity, tobacco smoking and alcohol consumption. Despite the effectiveness of health promotion interventions and the strategic position of primary care professionals for optimistic health behaviour change interventions, health promotion is not systematically integrated into routine practice owing to the existence of multiple barriers. The purpose of this Scoping Review (SR) is to identify and describe implementation strategies used to increase adoption and maintenance of health promotion interventions into primary care and community organizations. Theory / Methods: Five steps guided this SR (two independent reviewers involved): Systematic bibliographic search. Inclusion criteria for study selection (implementation strategy; health promotion intervention to modify risk habits; primary care and community organizations; evaluation of implementation strategy). Quality assessment. Data extraction of each implementation strategy (analytical unit). Qualitative narrative synthesis. SR fits well with our aim of identifying and synthesizing emerging evidence related to implementation strategies and to detect the most relevant research questions in this field. Results: After screening 1641 titles and assessing 118 full-texts, 45 publications on 35 implementation projects were included. Most of them used dissemination strategies (i.e. “conduct educational meetings”) to change clinical practice, focusing more on individual characteristics than on inner and outer settings. Projects published after 2010 applied more complex strategies -combining at least 4 discrete components- to operate at multiple levels (see attached graphic). Implementation researchers focused more on adoption than on maintenance. Discussion: Integration of health promotion into primary care organizations is an unsolved implementation problem despite the sound evidence of these interventions and their potential impact to reduce chronic disease burden in general population. The spread use of dissemination strategies is insufficient to guarantee a sustainable change. The advance toward an integrated primary care system constitutes an opportunity to act over structural barriers located in inner and outer settings thought implementation research. Conclusions: This SR highlights the need of more consistent and transparent reporting of implementation strategies to rigorously evaluate their effectiveness and to understand how they exert their effects. The lack of specification of strategies, the weak use of theory and the moderate quality of evaluations make difficult replication and generalization. We recommend the application of the StaRI (Standards for Reporting Implementation Studies) guidelines for improving reporting. Lessons learned: Improving the design of implementation strategies requires some conditions: use of theory, previous identification of barriers, stakeholders’ active engagement (patients and community agents) and application of methods for selecting and adapting implementation strategies. Limitations: The small number of projects identified, the different designs and the diverse range of outcomes have made impossible to conduct a systematic review and a meta-analysis to estimate the effectiveness of implementation strategies. SR fits well with this immature research field. Suggestions for future research: We will conduct a Qualitative Comparative Analysis with implementation projects of this SR to identify which combinations of strategies are more effective to change clinical practice.

Keywords

• implementation science
• implementation strategy
• health promotion
• primary and community organizations