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01.12.2017 | Systematic review | Ausgabe 1/2017 Open Access

Implementation Science 1/2017

Behavior change interventions and policies influencing primary healthcare professionals’ practice—an overview of reviews

Zeitschrift:
Implementation Science > Ausgabe 1/2017
Autoren:
Bhupendrasinh F. Chauhan, Maya Jeyaraman, Amrinder Singh Mann, Justin Lys, Becky Skidmore, Kathryn M. Sibley, Ahmed Abou-Setta, Ryan Zarychanksi
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​s13012-016-0538-8) contains supplementary material, which is available to authorized users.
An erratum to this article is available at http://​dx.​doi.​org/​10.​1186/​s13012-017-0568-x.

Introduction

Approximately one in six Canadians aged 20 years or older suffer from chronic diseases such as diabetes, cardiovascular diseases, chronic respiratory diseases, arthritis, osteoporosis, mental illness, and cancer [1]. Combining direct medical costs ($38.9 billion) and indirect productivity losses ($54.4 billion), the total economic burden of chronic illness exceeds Canadian $93 billion a year [2]. Despite this enormous expenditure, 12 to 15% of Canadians feel they receive inadequate chronic disease care [3, 4]. The major unmet needs include long waiting periods for medical services [5] and unavailability of essential services [4]. Compared with people in other developed nations, Canadians today are less satisfied with their access to and quality of care [6] and have worse health outcomes for several medical conditions [7]. The numbers of patients with chronic diseases and the existing gap in quality of care present a significant challenge for public health policy-makers [8, 9].
With the objective of closing gaps in quality of care and managing patients with chronic diseases, the implementation of patient-centred treatment has recently gained attention from policy-makers [1012]. Patient-centered medical centres may become the future backbone of the Canadian healthcare system [13]. These teams may include family physicians, physician assistants, nurses, pharmacists, social workers, mental health counselors/psychologists, dieticians, and midwives among others. To achieve efficient and effective patient-centered medical homes, some changes in the way healthcare is delivered will be required. To do so, effective behavior change interventions and supporting policies are required [14, 15]. However, it is unclear which intervention(s) and policies are appropriate, sustainable, and sufficiently safe to support practice change and improve patient-relevant outcomes in primary healthcare settings. Despite extensive published literature including randomized controlled trials [16, 17], observational studies [18, 19], and systematic reviews [2022], no recent comprehensive review classifying or evaluating the feasibility or effectiveness of interventions and policies in terms of patients’ and professionals’ outcomes exists. The objectives of this overview of reviews were to identify, classify, and critically appraise reviews evaluating behavior change interventions and policies influencing primary healthcare professionals working at primary healthcare centers.

Methods

Data sources and searches

The search strategy was developed and tested through an iterative process by an experienced medical information specialist in consultation with the review team. We searched MEDLINE (Ovid), Embase (Ovid), CINAHL (EbscoHost), and the Cochrane Library (Wiley). Strategies utilized a combination of controlled vocabulary (e.g., “Physicians", "Primary Care”, “Physician’s Practice Patterns”, “Quality Improvement”) and keywords (e.g., family practitioner, home clinic, policy adherence). Vocabulary and syntax were adjusted across databases. Results were restricted to the English language and the dates from January 2005 to July 2015 (Additional file 1). We used DistillerSR (Version 2, Evidence Partners Inc. ON, Canada) for study selection, data extraction, and project management.

Study selection

We included (1) systematic reviews, overview of reviews, scoping reviews, rapid reviews, or health technology assessments that (2) evaluated behavior change interventions or policies on primary healthcare professionals (including general practitioners/family physicians, physician assistants, nurses, pharmacists, social workers, mental health counselors/psychologists, dieticians, and midwives) (3) working at primary healthcare settings (4) reporting any outcomes of primary healthcare professionals’ practice change, and (5) published in the English language as full-text articles. Primary healthcare settings were defined as the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community [23, 24]. Considering the application of outcomes in the Canadian context, reviews that exclusively included studies conducted in either underdeveloped or developing countries were excluded.
The abstracts and titles of relevant citations were independently screened by two reviewers to determine eligibility. The same two reviewers independently assessed the eligibility of full-text reports of relevant citations using a standardized pre-piloted form outlining the inclusion and exclusion criteria. Disagreements were resolved by consensus or with the involvement of a third reviewer, if needed.

Data extraction and quality assessment

Two reviewers independently abstracted data from the included reviews using standardized piloted forms. The following data were extracted from each included review: review type, number and study designs that the review included, types of professionals evaluated, interventions, outcomes, therapeutic domains, and authors’ conclusions.
All behavior change interventions and policies were classified into nine categories of interventions and seven categories of policies following the behavior change wheel framework proposed by Michie et al. [15]. This framework consists of a behavior system at the hub, encircled by nine intervention functions and then by seven policy categories. The nine behavior change interventions include (1) education (increasing knowledge or understanding): e.g., continuous medical education; (2) persuasion (using communication to induce positive or negative feelings or stimulate action): e.g., reminders; (3) incentivization (creating expectation of reward): e.g., payment for performance; (4) coercion (creating expectation of punishment or cost): e.g., punishment or fines; (5) training (imparting skills): e.g., communication skills training; (6) restriction (using rules to reduce the opportunity to engage in the target behavior): e.g., rules for prohibiting the use; (7) environmental restructuring (changing the physical or social context): e.g., shared decision-making; (8) modeling (providing an example for people to aspire to or imitate): e.g., local opinion leaders; (9) enablement (increasing means/reducing barriers to increase capability or opportunity): e.g., clinical decision support systems. While the seven policies include: (1) communication/marketing (using print, electronic, telephonic or broadcast media): e.g., advertising media; (2) guidelines (creating documents that recommend or mandate practice): e.g., management guidelines; (3) fiscal (using the tax system to reduce or increase the financial cost): e.g., financial provisions from policy-makers; (4) regulation (establishing rules or principles of behavior or practice): e.g., rules and regulations; (5) legislation (making or changing laws): e.g., law amendments; (6) environmental/social planning (designing and/or controlling the physical or social environment): e.g., social support; (7) service provision (delivering a service): e.g., service or facilitation.
Two reviewers independently, and in duplicate, evaluated the methodological quality of the included reviews using the assessing the methodological quality of systematic reviews (AMSTAR) scoring system [25]. Conflicts were resolved by consensus or discussion with a third reviewer, if needed. Reviews with AMSTAR score ≥8, 4 to 7, ≤3 were considered as high, moderate, or low-methodological quality, respectively.
We summarized the findings that emerged from the subjective judgment matrix, which was based on the authors’ conclusions, qualitative data, quantitative data with statistically significant group differences in terms of patients’ and primary healthcare providers’ outcomes, and the methodological quality of included reviews [2528]. The protocol for this overview of reviews has been developed prior to conduct the review and provided to the Primary Health Care Branch, Manitoba Health, Seniors and Active Living, Government of Manitoba, Canada. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting the systematic review were followed.

Results

We screened 2771 citations and included 138 reviews representing 3502 individual studies (Fig. 1). The characteristics of the included reviews are presented in Table 1. Of the included studies, three were overviews of reviews [2931]. Most reviews (91%) investigated behavior change interventions and policies among family physicians primarily managing chronic diseases at primary healthcare centers. We classified the included reviews into eight of nine categories of behavior change interventions including education (n = 28, 20%), enablement (n = 16, 12%), environmental restructuring (n = 18, 13%), incentivization (n = 7, 5%), modeling (n = 2, 2%), multiple interventions (n = 42, 30%), persuasion (n = 4, 3%), training (n = 11, 8%), and three of seven categories of policies including service provision (n = 5, 4%), communications (n = 3, 2%), and guidelines (n = 2, 2%). Major chronic diseases evaluated were mental disorders (n = 12, 9%), diabetes (n = 10, 7%), respiratory diseases (n = 8, 6%), cancer (n = 5, 4%), cardiovascular diseases (n = 4, 3%), arthritis/osteoporosis (n = 3, 2%), and hypertension (n = 2, 2%); some reviews reported more than one chronic disease. Total of 36 (26%) reviews exclusively included randomized controlled trials. The remaining reviews included systematic reviews, observational studies, interrupted time series studies, and controlled before-after studies (Table 1). Of the total included reviews, 68 (49%) reviews were of high quality, 60 (44%) reviews were of moderate quality, and 11 (8%) reviews were of low quality (Additional file 1: Table S1).
Table 1
Key features of included reviews
Study
Type of review
Study design included
Number of included studies
Professionals evaluated
Intervention(s)
Type of disease(s)
Funding
Behavior change interventions
 Education (increasing knowledge or understanding)
  Chhina et al. [32] 2013
SR
Any study design
15
FPs
Academic detailing
NR
No
  Mostofian et al. [29] 2015
Overview
Reviews
14
FPs
Any interventions
NR
No
  Velden et al. [33] 2012
SR
Any study design
58
FPs, others
Any interventions
RTIs
Yes
  Thepwongsa et al. [20] 2014
SR
RCTs, non-RCTs, ITS
11
FPs
CME
NR
Yes
  Thomas et al. [34] 2006
SR
Any study design
13
FPs
CME
NR
Yes
  Ginige et al. [21] 2007
SR
Any study design
4
FPs
CME, video, text
Chlamydia
No
  Brody et al. [35] 2013
SR
Any study design
16
FPs, nurses, SWs, pharmacists
Dementia educational/dissemination intention
Dementia
Yes
  Schichtel et al. [36] 2013
SR
RCTs, cluster RCTs
21
FPs, Nurses, PAs
Education
Cancer
Yes
  Hardy et al. [37] 2011
SR
Any study design
0
FPs
Education
Mental illness
No
  Miller et al. [38] 2010
SR
Any study design
16
FPs
Education
NR
No
  Lineker et al. [39] 2010
SR
Any study design
7
FPs, nurses
Education
Arthritis
No
  Alvarez et al. [40] 2006
SR
Any study design
18
FPs
Education
Pallative care
No
  Howe et al. [41] 2006
SR
RCTs
18
FPs
Education
NR
No
  Kamarudin et al. [42] 2013
SR
Any study design
47
FPs
Education
NR
No
  Thepwongsa et al. [43] 2014
SR
Any study design
13
FPs
Education
T2DM
Yes
  Perry et al. [44] 2011
SR
Any study design
5
FPs
Educational meetings, audit-feedback, reminders, mass media, local opinion leaders
Dementia
Yes
  Vodicka et al. [45] 2013
SR
Any study design
17
FPs, nurses
Educational or behavior change interventions
RTIs, otitis media
Yes
  Guldberg et al. [46] 2009
SR
RCTs
10
FPs
Feedback
T2DM
Yes
  Cheraghi-Sohi et al. [47] 2008
SR
RCTs
9
FPs
Feedback or training or both
NR
No
  Ring et al. [48] 2007
SR
RCTs
14
FPs
Interactive educational seminar, QI learning collaborative for general practice teams
Asthma
Yes
  Rourke et al. [49] 2015
MA
Any study design
37
FPs
Lecture, audit-feedback, computer based learing, multicomponent intervention
Skin lesions
No
  Reinders et al. [50] 2011
SR
RCTs
10
FPs
Patient feedback
NR
Yes
  Gijbels et al. [51] 2010
SR
Any study design
61
Nurses, midwives
Education
NR
Yes
  Zaher et al, [52] 2012
SR
Any study design
13
FPs
Practice-based small group learning programs
NR
No
  Curti et al. [53] 2015
SR, MA
RCTs, cluster-RCTs, CBA
12
FPs
Educational materials, meetings, CME, audit-feedbacks, reminders
Occupational diseases
No
  Goulart et al. [54] 2011
SR
Any study design
20
FPs
Education
Skin cancer
Yes
  Omidvari et al. [55] 2013
SR
RCTs
3
FPs
Guidelines
NR
Yes
  Benthem et al. [56] 2009
SR
RCTs, CBA or ITS
27
FPs
Education
Psychiatric disorders
No
 Enablement (increasing means/reducing barriers to increase capability or opportunity)
  Adaji et al. [57] 2008
SR
Any study design
29
FPs
Information technology
Diabetes
Yes
  de Lusignan et al. [58] 2014
SR
Any study design
143
FPs
Access to electronic health records
NR
Yes
  Pires et al. [59] 2014
SR
Any study design
18
FPs
Communication skills training for FPs
NR
No
  Holstiege et al. [60] 2015
SR
RCTs; cluster RCTs
7
FPs
CDSSs
NR
No
  Dixon et al. [61] 2013
SR
Any study design
10
FPs, others
Computer-based interventions
NR
Yes
  Robertson et al. [62] 2010
SR
Any study design
21
Pharmacists
CDSSs
NR
Yes
  Curtain et al. [63] 2014
SR
Any study design
8
Pharmacists
CDSSs
Allergic rhinitis, stroke
No
  Souza et al. [64] 2011
SR
RCTs
41
FPs
CDSSs
Dyslipidaemia, cancer, mental illnesses
Yes
  Fathima et al. [65] 2014
SR
RCTs
16
FPs, nurses, pharmacists, PAs
CDSSs
Asthma, COPD
No
  Cleveringa et al. [66] 2013
SR
RCTs
20
FPs
CDSSs, feedback on performance
T2DM
Yes
  Calabretto et al. [67] 2005
SR
RCTs
4
Pharmacists
Elecronic decision support system
NR
Yes
  Boyle et al. [68] 2010
SR
Any study design
12
FPs
Electronic medical records
Tobacco dependence
Yes
  Lainer et al. [69] 2013
SR
RCTs
10
FPs, pharmacists
Information technology
NR
Yes
  Huang et al. [70] 2013
SR, MA
Any study design
13
FPs
Point of care testing
RTIs
No
  Gialamas et al. [71] 2010
SR
RCTs, quasi-RCTs
6
FPs, others
Point of care testing
Diabetes, hyperlipedemia, coagulation disorders
Yes
  Motulsky et al. [72] 2013
SR
Any study design
19
FPs, pharmacists
Second-generation electronic prescriptions
NR
No
 Environmental restructuring (changing the physical or social context)
  Damiani et al. [73] 2013
SR
Any study design
26
FPs
Group versus single handed practice, information and communication technology
NR
No
  Riley et al. [74] 2010
SR
Any study design
12
Others
Group visits
Diabetes
No
  Unverzagt et al. [75] 2014
SR
RCTs
84
FPs
Multiple interventions
Cardiovascular
Yes
  Gilbody et al. [76] 2008
MA
RCTs
16
FPs
Screening and case-finding instruments
Depression
Yes
  Legare et al. [77] 2010
SR
Any study design
39
FPs, nurses, pharmacists, SWs, midwives
Shared decision-making
NR
Yes
  Smith et al. [78] 2007
SR, MA
RCTs, CBA, ITS
20
FPs
Shared-care interventions
Chronic diseases
No
  Mitchell et al. [79] 2008
SR
Any study design
18
FPs
Multidisciplinary primary care team
Stroke
Yes
  Page et al. [80] 2005
SR
RCTs, non-RCTs, CBA
6
FPs, Nurses
Any interventions in nurese-led care
Coronary heart disease
No
  Kuethe et al. [81] 2013
SR
RCTs
5
FPs, nurses, PAs
Nurse-led care
Asthma
No
  Carey et al. [82] 2007
SR
RCTs
22
Nurses
Nurse-led care
Diabetes
Yes
  Desborough et al. [83] 2012
SR
Any study design
13
FPs, Nurses
Nurse-led care
NR
Yes
  Urquhart et al. [84] 2009
SR
RCTs, CBA, ITS
9
Nurses
Nursing record system
NR
Yes
  Martelly et al. [85] 2014
SR, MA
RCTs
24
FPs, Nurses
Nurse-led care
NR
No
  Laurant et al. [86] 2005
SR
RCTs, CBA, ITS
16
FPs, Nurses
Nurse-led care
NR
Yes
  Courtenay et al. [87] 2008
SR
Any study design
21
Nurses
Nurse-led care
Pain
Yes
  Dennis et al. [88] 2009
SR
Any study design
46
FPs, nurses, pharmacists
Task shifting
Chronic diseases
Yes
  Health, [89] 2013
SR
RCTs, SRs
6
FPs, nurses
Task shifting
Chronic diseases
Yes
  Proia et al. [90] 2014
SR
Any study design
80
FPs, nurses, pharmacists
Team based care
Blood pressure
No
  Schadewaldt et al. [91] 2011
SR
RCTs
7
Nurses
Multiple interventions
Coronary artery disease
No
 Incentivization (creating expectation of reward)
  Scott et al, [92] 2011
SR
RCTs, CBA, ITS
7
FPs
Financial incentives
NR
Yes
  McDonald et al. [93] 2008
SR
Any study design
23
FPs
Funding initiatives or incentives
NR
Yes
  Langdown et al. [94] 2014
SR
Any study design
11
FPs
P4P
Asthma, coronary heart disease, diabetes
No
  Eijkenaar et al. [30] 2013
Overview
SRs
22
FPs
P4P
NR
No
  Houle et al. [95] 2012
SR
Any study design
30
FPs
P4P
Chronic diseases
No
  Gillam et al. [96] 2012
SR
Any study design
94
FPs
P4P
Chronic diseases
No
  Vahidi et al. [97] 2013
SR
Any study design
11
FPs
Payment mechanisms to FPs
NR
Yes
 Modeling (providing an example for people to aspire to or imitate)
  Flodgren et al. [98] 2011
SR
RCTs
18
FPs
Local opinion leaders
NR
Yes
  Harkness et al. [99] 2009
SR, MA
RCTs, CBA, ITS
42
FPs, others
Mental health workers involvement
Mental health
Yes
 Multiple interventions
  Zou et al. [115] 2012
SR
Any study design
8
FPs
Any interventions
STDs
Yes
  Dwamena et al. [116] 2012
SR
RCTs, CBA, CCTs, ITS
43
FPs, nurses
Any interventions
General medical problems
Yes
  Castelino et al. [117] 2009
SR
RCTs
12
Pharmacists
Interventions for prescribing
NR
No
  Mansell et al. [118] 2011
SR
Any study design
22
FPs
Multiple interventions
Cancer
Yes
  Guy et al. [119] 2011
SR
Any study design
16
FPs
Multiple interventions
Chlamydia screening
Yes
  Laliberte et al. [120] 2011
SR, MA
Any study design
13
FPs, pharmacists
Multiple interventions
Osteoporosis
No
  Jacobson et al. [121] 2011
SR
Any study design
15
FPs, nurses
Multiple interventions
Childhood obesity
No
  Dennis et al. [122] 2008
SR
Any study design
164
FPs, nurses
Any interventions
NR
Yes
  Grindrod et al. [31] 2006
Overview
SRs
34
Pharmacists
Any interventions
NR
No
  Arnold et al. [123] 2005
SR
RCTs, quasi-RCT, CBA, ITS
39
FPs
Any interventions
NR
Yes
  Moe-Byrne et al. [125] 2014 [124]
SR
SRs, studies
23
FPs
Any interventions
NR
Yes
  McMillan et al. [125] 2013
SR
RCTs
30
FPs, nurses, others
Any interventions
NR
Yes
  Loganathan et al. [126] 2011
SR
Any study design
16
FPs, nurses, Others
Any interventions
NR
Yes
  Kaur et al. [127] 2009
SR
Any study design
24
FPs, pharmacists, others
Any interventions
NR
No
  Okelo et al. [128] 2013
SR
Any study design
73
FPs, nurses, Pharmacists, others
Any interventions
Asthma
Yes
  Huijg et al. [129] 2014
SR
Any study design
59
FPs, nurses, others
Any interventions
NR
Yes
  Fahey et al. [130] 2005
SR
RCTs
72
FPs, nurses, pharmacists
Educational and organizational strategies
Hypertension
No
  McKinstry et al. [131] 2006
SR
RCTs, quasi-RCTs, CBA, ITS
10
FPs
Informative, educational, multiple interventions
NR
No
  Akbari et al. [132] 2008
SR
Any study design
17
FPs
Multiple interventions
NR
Yes
  Gunten et al. [133] 2007
SR
Any study design
43
FPs, nurses, pharmacists
Pharmacists’ interventions
NR
No
  Beach et al. [134] 2006
SR
RCTs
27
FPs
Provider and organization interventions
NR
No
  Smit et al. [135] 2007
SR
RCTs
12
FPs, nurses, psychologists, others
Psychological and supportive interventions
Depression
No
  Newhouse et al. [136] 2011
SR
Any study design
69
FPs, nurses, others
Advanced practice nurse care
NR
No
  Lau et al. [137] 2012
SR, MA
Any study design
77
FPs, nurses
QI
Vaccination
Yes
  Saxena et al. [138] 2007
SR
Any study design
9
FPs, nurses, others
Case management
Diabetes
No
  Majka et al. [139] 2014
SR, MA
Any study design
15
FPs, nurses, dieticians, others
Care coordination and/or team approach methods; multiple simultaneous strategies
Patients with long term enteral tube feeding
No
  Archer et al. [140] 2012
SR, MA
RCTs
79
FPs, nurses, pharmacists, psychologists
Colloborative care
Anxiety, depression
Yes
  Thota et al. [141] 2012
SR, MA
RCTs
69
FPs
Collaborative care models
Depressive disorders
No
  Christensen et al. [142] 2008
SR
RCTs, controlled trials
55
FPs, nurses, pharmacists, psychologists
Community models of care
NR
Yes
  Phillips et al. [143] 2010
SR
Any study design
19
FPs
Different models using various interventions
NR
Yes
  De Belvis et al. [144] 2009
SR
RCTs
13
FPs, nurses, PAs
Evidence based medicine tools
Diabetes
Yes
  Sandall et al. [145] 2013
SR, MA
RCTs, cluster RCTs
13
FPs, midwives
Mid-wife led continuity model
NR
Yes
  Baishnab et al. [146] 2012
SR
RCTs
3
FPs, Nurses
Organized asthma care
Asthma
Yes
  Jackson et al. [147] 2013
SR
Any study design
19
FPs
PCMH
NR
Yes
  Van Cleave et al. [148] 2012
SR
Any study design
23
FPs
QI initiatives, electronic records
NR
Yes
  Shojania et al. [149] 2006
SR
RCTs, quasi-RCTs, CBA studies
58
FPs
QI strategies
T2DM
Yes
  Tory et al. [150] 2015
SR
Any study design
7
FPs, pharmacists
QI measures
Osteoporosis
No
  Gallagher et al. [151] 2010
SR
Any study design
9
Nurses, pharmacists
QI strategies
Hypertension, chronic kidney disease
Yes
  Ranji et al. [152] 2008
SR
RCTs, CBA, ITS
43
FPs
QI strategies
NR
Yes
  Gask et al. [153] 2011
SR
RCTs, CBA
13
FPs
Reattribution model
Medically unexplained symptoms
No
  Rolfe et al. [154] 2014
SR
RCTs, quasi-RCTs, CBA
10
FPs
Interventions (informative, educational, behavioral, organizational)
NR
No
 Persuasion (using communication to induce positive or negative feelings or stimulate action)
  Jenkins et al. [100] 2015
SR
Any study design
7
FPs
Audit-feedback, reminders, clinical decision support on imaging
Lower back pain
No
  Holt et al. [101] 2012
SR, MA
CCTs
42
FPs
Reminders
NR
No
  Siddiqui et al. [102] 2011
SR
RCTs
5
FPs
Reminders
Colorectal cancer screening
No
  Lu et al. [103] 2008
SR
RCTs
164
FPs, pharmacists
Any interventions
Asthma, depression, Helicobacter pylori infection
Yes
 Training (imparting skills)
  Moore et al. [104] 2013
SR, MA
RCTs, CBA
15
FPs, nurses, others
Communication skills training
Cancer
Yes
  Eggenberger et al. [105] 2013
SR
RCTs, CCTs, CBA
12
FPs, nurses, SWs, psychologists, others
Communication skills training, education
Dementia
Yes
  Horvat et al. [106] 2014
SR
RCTs, cluster RCTs, CCTs
5
FPs, nurses, PAs, psychologists, others
Cultural competence training
NR
No
  Lie et al. [107] 2011
SR
Any study design
7
FPs, nurses, PAs
Cultural competency training
Blood pressure, diabetes
Yes
  Henderson et al. [108] 2011
SR
RCTs, controlled studies
24
FPs
Cultural competency training
Chronic diseases
Yes
  Soderlund et al. [109] 2011
SR
Any study design
10
FPs, nurses, PAs, SWs, psychologists, others
Motivational interviewing training
NR
Yes
  Rashid et al. [110] 2010
SR
Any study design
8
Nurses
Nurse training
NR
No
  Mesquita et al. [111] 2010
SR
Any study design
15
Pharmacists
Simulated patient methods
NR
Yes
  Xu et al. [112] 2012
SR
Any study design
30
Pharmacists
Simulated-patient methods
Headache, abdominal pain
No
  Sikorski et al. [113] 2012
SR, MA
RCTs
11
FPs
Training
Depression
Yes
  Paskins et al. [114] 2014
SR
Any study design
28
FPs
Video stimulated recall
NR
Yes
Policy
 Service provision (delivering a service)
  OHTA [160] 2012
Report
SRs, MA, RCTs
7
FPs
Specialized community-based care
T2DM
Yes
  Wilson et al. [156] 2006
SR
SRs, RCTs, CCTs, CBA
4
FPs
Any interventions altering consultation time
NR
Yes
  McNaughton et al. [157] 2009
SR
RCTs
9
FPs
Brief non-pharmacological interventions
Depression
No
  Wilson et al. [158] 2006
SR
RCTs, CCTs
7
FPs
Consultation time
NR
Yes
  Bhanbhro et al. [159] 2011
SR
Any study design
17
FPs, nurses, pharmacists
Non-medical prescribing
NR
No
 Communications (using print, electronic, telephonic or broadcast media)
  Jiwa et al. [161] 2014
SR
Any study design
18
FPs, others
Communications
NA
Yes
  Cant et al. [162] 2011
SR
Any study design
20
FPs, dieticians
Dietitians’ correspondence practices
NR
No
  Sawmynaden et al. [163] 2012
SR, MA
RCTs, quasi-RCTs, CBA, ITS
6
FPs
Email communication
NR
Yes
 Guidelines (creating documents that recommend or mandate practice)
  Ramsaroop et al. [164] 2007
SR
Any study design
18
FPs
Advance Directive
NR
Yes
  Clarke et al. [165] 2010
SR
Any study design
24
FPs
Guidelines
NR
Yes
BP blood pressure; CBA controlled before-after sudy; CCTs controlled clinical trails; CME continuing medical education; COPD chronic obstructive pulmonary disease; FP family physician; ITS interrupted time series study; MA meta-analysis; NA not applicable; OR odds ratio; PAs physician assistants; P4P pay-for-performance; PCMH patient-centered medical home; PCPs primary care providers; RCTs randomized clinical trails; RD risk difference; RTIs respiratory tract infections ; SMD standardized mean difference; STD sexually transmitted disease; SR systematic review; SWs social workers; T2DM type 2 diabetes mellitus; WMD weighted mean difference

Behavior change interventions (Additional file 1: Table S1)

Education (increasing knowledge/understanding)

Twenty-eight reviews [20, 21, 29, 3256] (n = 509 studies) evaluated educational interventions. Evidence from moderate- to high-quality reviews demonstrated that education to improve knowledge and skills [3742, 48, 49, 5156], continuing medical education [20, 21, 29, 34, 43], and academic detailing [32] were found to be effective in professional development to increase knowledge, optimize prescriptions, screening rate, and improve patient outcomes [20, 29, 3236, 41, 44, 45, 50, 54]. Certain education interventions were evaluated as components of multifaceted education interventions, including interactive educational methods, reminder systems, audit and feedback, academic detailing, computer-based learning, lecture, as well as pamphlet in several reviews [29, 33, 36, 43, 44, 49]; which reported improvement in implementing guidelines into general practice [29], improved antibiotic prescribing [33], improved detection of cancer, dementia, and skin lesions [36, 44, 49]. Conflicting evidence exists on patient feedback. One review [50], based on ten studies, reported some evidence for the effectiveness of using feedback from real patients to improve knowledge and primary healthcare professionals’ practice change exists while other reviews [34, 46, 47] failed to reach the same conclusion.

Enablement (increasing means/reducing barriers to increase capability or opportunity)

Sixteen reviews [5772] (n = 377 studies) evaluated the use of information technologies including interactive analysis systems [5759, 69], clinical decision support systems [60, 6266], electronic health records and prescriptions [61, 68, 72], and point of care testing [67, 70, 71] to increase capability and facilitate practice change of primary healthcare professionals. Evidence from moderate- to high-quality reviews demonstrated that enablement interventions improved communication between healthcare professionals and patients [59, 63], augmented knowledge [61], facilitated the appropriate antibiotic prescriptions [60], increased quality of service, reduced potential adverse events (drug interactions, contraindications, dose monitoring, and adjustment) [62], and improved several patient outcomes [64].

Environmental restructuring (changing the physical or social context)

Nineteen [7391] (n = 470 studies) evaluated the impact of environmental restructuring including the use of collaborative or shared care practices or the institution of specialized nurses or other allied healthcare professionals [73, 74, 7783, 8591], or guideline implementation [75, 76] in primary healthcare settings. Evidence from poor- to high-quality reviews indicate organizational changes to increase collaboration among pharmacists, nurses, prevention coordinators, and other primary healthcare professionals led to increased physicians’ adherence to guidelines [75]. Nurse-led care was found to be as equally effective as general practitioners in patient satisfaction, asthma, cardiovascular, and diabetes management. However, weak study designs and restricted interventional scopes mean that further evaluation is required [8082, 84], especially in the context of other chronic diseases.

Incentivization (creating an expectation of reward)

Seven reviews [30, 9297] (n = 198 studies) evaluated the impact of financial incentives on family physicians. All reviews [30, 9297] of poor- to high-quality failed to provide supportive evidence of any significant improvement in family physicians’ behavior change. One high-quality review [96] observed modest improvements in quality of care for chronic diseases, albeit, the impact on costs, professional behavior, and patient experience remained uncertain.

Modeling (providing an example for people to aspire or imitate)

Two reviews [98, 99] (n = 60 studies) evaluated modeling using local opinion leaders [98], or mental health workers [99] in primary healthcare settings. Evidence from moderate- to high-quality reviews demonstrated that involving local opinion leaders or subject experts to promote evidence-informed practices decreased the rates of consultations and prescriptions [98, 99].

Persuasion (using communication to induce positive or negative feelings or stimulate action)

Four reviews [100103] (n = 218 studies) reported on interventions categorized as persuasion. Evidence from moderate- to high-quality reviews indicates that reminders [100103] worked well to reduce unnecessary imaging for lower back pain [100] while improving the rate of screening [101] and vaccination [101].

Training (imparting skills)

Eleven reviews [104114] (n = 165 studies) focused on training. Evidence from moderate- to high-quality reviews [104114] reported that training on communication skills and cultural competency improved knowledge and professional expertise, which resulted in improved clinical outcomes including quality of life, well-being of patients with dementia, and reduced chronic disease in culturally and linguistically diverse communities [104106, 108, 109, 113, 114].

Multiple interventions

Several reviews were focused on how to better manage chronic diseases using any behavior change interventions. To avoid misclassification, we classified these reviews under an umbrella term, multiple interventions. Forty-one reviews [31, 115154] (n = 1375 studies) of poor- to high-quality focused on multiple interventions. The use of computer alerts within electronic medical records increased screening for sexually transmitted diseases [115]. Interventions in pharmacy services reduced suboptimal prescribing [117, 127, 133], and educational interventions improved primary healthcare providers’ identification, assessment, prevention and/or management of obesity in children and adolescents to achieve weight loss [121]. No review focused exclusively on audit and feedback, but multifaceted audit/feedback, reminders, educational outreach visits, and patient-mediated interventions [31, 116, 118, 119] were found to be effective in influencing health professionals’ prescribing practice. Financial incentives combined with educational interventions and audit/feedback have been found to be effective in increasing the practice of generic prescribing [124]. Multifaceted interventions where educational interventions occurred at many levels may be successfully incorporated into established medical communities after addressing local barriers to change [120, 123, 130, 153]. Advance practice nurse care [136], quality improvement strategies [137, 148152], case management [138], collaborative care [140], evidence-based medicine practice strategies [144], midwife-led continuity services [145], comprehensive asthma care [146], and patient-centered medical home [125, 147] have all been evaluated. Moderate- to high-quality reviews demonstrated improved safety, quality care, increased vaccination rate, and improved management of patient with depression and anxiety in primary healthcare settings [135137, 139142, 144, 147, 148, 150, 151]. Few reviews failed to provide any conclusive outcomes [122, 126, 129, 131, 134, 143, 154, 155].

Policies (Additional file 1: Table S1)

Service provision (delivering a service)

Five reviews [156160] (n = 44 studies) of poor- to high-quality evaluated effects of consultation time [156, 158], brief non-pharmacological interventions (computer-based cognitive-behavioral therapy) [157], and non-medical prescribing [159] (drug prescriptions by nurses, pharmacists, and allied health professionals) on behavioral change of primary healthcare professionals. While a health technology report [160] assessed evidence on specialized community-based care and concluded that specialized community-based care effectively improves outcomes in patients with heart failure, chronic obstructive pulmonary disease, and diabetes. Bibliotherapy, cognitive behavioral therapy-based websites, and cognitive behavioral therapy-based computer programs [157] found to be effective in improving management of patients with depression. Other reviews [156, 158, 159] were not found to be effective.

Communication (using print, electronic, telephone, or broadcast media)

Three reviews [161163] (n = 44 studies) of moderate- to high-quality evaluated communication as an intervention reporting inconclusive results. One review [161] uniquely assessed whether patients benefit from improved communication between primary healthcare practitioners and nephrologists. The review found little evidence of benefit from enhancing the quality of letters from specialists to primary healthcare practitioners.

Guidelines (creating documents that recommend practice standards)

Two reviews [164, 165] (n = 42 studies) of moderate- to high-quality evaluated the impact of guidelines on the improvement of healthcare professionals’ practice. None of the interventions found to be effective method for increasing advance directive completion rates in the primary healthcare setting [164, 165].

Discussion

In our overview of reviews, we identified, classified, and evaluated the behavior change interventions and policies influencing practice change of primary healthcare professionals who primarily manage patients with chronic diseases at primary healthcare centers. Interactive and multifaceted continuous medical education programs including training with audit and feedback, and clinical decision support systems were found to be of benefit in improving knowledge, optimizing prescriptions, increasing screening rate, enhancing patient outcomes, and reducing adverse events. Limited evidence on environmental restructuring and modeling were found to be effective in improving collaboration and adherence to treatment guidelines. Collaborative team-based approaches involving primarily family physicians, nurses, and pharmacists were found to be effective. Limited evidence on nurse-led care approaches were found to be promising and warrant further evaluation using better study designs for different chronic diseases. Evidence clearly does not support the use of financial incentives to family physicians, especially for long-term sustained behavior and practice change.
To the best of our knowledge, so far this is the largest comprehensive overview of reviews evaluating authors’ reported efficacy of behavior change interventions and policies influencing primary healthcare professionals’ practice change and classified according to the behavior change wheel proposed by Michie et al. [15]. Our outcomes support the inferences reported by other overview reviews [166] and review [167] focused on individual interventions. Grimshaw and colleagues [166] reported that educational outreach (for prescribing) and reminders were found to be most promising approaches. Multifaceted interventions targeting different barriers to change are more likely to be effective than single interventions. We reported that education intervention found to be effective, especially when used as multifaceted interventions to achieve primary healthcare professionals’ practice change to improve quality of care and better manage patients with chronic diseases. Ivers and colleagues [167] reported audit and feedback generally leads to small but potentially important improvements in professional practice. We did not find any review exclusively evaluating audit and feedback on primary healthcare professionals; however, it was used with other interventions (e.g., education and training) and provided mixed results. With regards to financial incentives, Flodgren and colleagues have reported that financial incentives may be effective in changing healthcare professional practice [168]. In contrast, we found that financial incentives were not effective in practice change of family physicians working at primary healthcare centers.
This review did identify limited evidence on a few promising interventions, including nurse-led approaches and use of opinion leaders or specialists. Further, thorough evaluation in specific areas of interest should be performed before they are widely implemented in a healthcare setting.
To reduce the gap in quality of care and better manage patients with chronic diseases, behavioral interventions and supporting policies are essential. Through this overview of reviews, we attempted to provide an evidence to improve our understanding on which behavioral interventions and policies are effective to influence practice of primary healthcare professionals working in primary health care settings. This review is heavily weighted by evidence on family physicians, thus indicating the need for studies on other primary healthcare professionals. We excluded reviews that either evaluated these interventions and policies on specialists and hospital settings or included studies conducted exclusively in low- to middle-income countries, where the functionality of healthcare systems is different than Canada. Behavior change interventions or policies were classified based on the framework proposed by Michie and colleagues [15] and no other frameworks were explored or compared. Considering this is an overview of reviews and we have not performed a meta-analysis, we did not attempt to review individual studies from included reviews; there is a possibility of few studies might have been included by multiple reviews or might be a chance of over representation of outcomes. Evidence ranged from poor- to high-quality as well the high heterogeneity in interventions, study population, and outcomes prevented to generalize the conclusion to specific category of primary healthcare professionals or interventions and policies.

Conclusion

Behavior change interventions including interactive and multifaceted continuous medical education, training with audit and feedback, enablement through advanced information technology-based systems, and collaborative team-based interventions can effectively modify healthcare professionals’ practice and patient outcomes. Limited evidence exists to support environment restructuring and modeling. Nurse-led systems of care warrant further evaluation. Financial incentives to family physicians do not influence long-term behavior and practice change.

Acknowledgements

We sincerely thank Kristin Anderson, Lindsay Story, and Nathan Hoeppner from Manitoba Health, Seniors and Active Living for their suggestions and comments on the subject, as well as the protocol of the overview.

Funding

None. Dr. Zarychanski is a recipient of the New Investigator Salary Award from the Canadian Institutes of Health Research.

Availability of data and materials

For the additional information on data and material presented in this manuscript, please contact the corresponding author.

Authors’ contributions

Dr. BFC played a role in the conceptualization of the project, wrote the protocol, led and coordinated this overview, screened citations, assessed studies for eligibility, extracted data, performed quality assessments, drafted and revised the manuscript, approved the final version of the manuscript as submitted, and agrees to be accountable for all aspects pertaining to the overview. Drs. MJ, ASM, and JL screened citations, assessed studies for eligibility, extracted data, and performed methodological quality assessments. Drs. KMS, AA-S, and RZ and played a key role in the conceptualization of the project and provided methodological expertise during the protocol development and conduct of the overview. They critically reviewed and provided expert comments on the manuscript and approved the final version of the manuscript. BS played an important role in designing and executing the search strategy, provided relevant comments on the manuscript, and approved the final version.

Competing interests

The authors declare that they have no competing interests.
This article is based on research conducted by the Knowledge Synthesis Platform, George and Fay Yee Centre for Healthcare Innovation, Winnipeg, Canada under the request made from the Primary Health Care Branch, Manitoba Health, Seniors and Active Living, Government of Manitoba, Canada. The authors of this article are responsible for its contents, including the conclusion and any inference derived from the included evidence. Results and conclusions are those of the author(s) and no official endorsement by Manitoba Health, Seniors and Active Living is intended or should be inferred.

Consent for publication

Not applicable.

Ethics approval and consent to participate

Not applicable.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://​creativecommons.​org/​licenses/​by/​4.​0/​), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://​creativecommons.​org/​publicdomain/​zero/​1.​0/​) applies to the data made available in this article, unless otherwise stated.
Zusatzmaterial
Additional file 1: Table S1. Outcomes and methodological quality assessment of included reviews. (DOC 662 kb)
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