An exploration of how clinician attitudes and beliefs influence the implementation of lifestyle risk factor management in primary health care: A grounded theory study

Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, University of New South Wales, Sydney NSW 2052, Australia.
Implementation Science (Impact Factor: 4.12). 10/2009; 4(1):66. DOI: 10.1186/1748-5908-4-66
Source: PubMed


Despite the effectiveness of brief lifestyle intervention delivered in primary healthcare (PHC), implementation in routine practice remains suboptimal. Beliefs and attitudes have been shown to be associated with risk factor management practices, but little is known about the process by which clinicians' perceptions shape implementation. This study aims to describe a theoretical model to understand how clinicians' perceptions shape the implementation of lifestyle risk factor management in routine practice. The implications of the model for enhancing practices will also be discussed.
The study analysed data collected as part of a larger feasibility project of risk factor management in three community health teams in New South Wales (NSW), Australia. This included journal notes kept through the implementation of the project, and interviews with 48 participants comprising 23 clinicians (including community nurses, allied health practitioners and an Aboriginal health worker), five managers, and two project officers. Data were analysed using grounded theory principles of open, focused, and theoretical coding and constant comparative techniques to construct a model grounded in the data.
The model suggests that implementation reflects both clinician beliefs about whether they should (commitment) and can (capacity) address lifestyle issues. Commitment represents the priority placed on risk factor management and reflects beliefs about role responsibility congruence, client receptiveness, and the likely impact of intervening. Clinician beliefs about their capacity for risk factor management reflect their views about self-efficacy, role support, and the fit between risk factor management ways of working. The model suggests that clinicians formulate different expectations and intentions about how they will intervene based on these beliefs about commitment and capacity and their philosophical views about appropriate ways to intervene. These expectations then provide a cognitive framework guiding their risk factor management practices. Finally, clinicians' appraisal of the overall benefits versus costs of addressing lifestyle issues acts to positively or negatively reinforce their commitment to implementing these practices.
The model extends previous research by outlining a process by which clinicians' perceptions shape implementation of lifestyle risk factor management in routine practice. This provides new insights to inform the development of effective strategies to improve such practices.

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    • "As limited clinician time is cited as a barrier to providing preventive care in general primary care settings [13,43,44] and mental health care settings [45,46], it has been recommended that the 5A’s (ask, advise, assess, assist and arrange) model of preventive care be shortened to ‘2As and an R’, whereby clinicians ask, advise and refer clients on for specialized further care [13,44,47,48]. This approach emphasizes referral of clients to specialist services rather than clinicians providing the extended care themselves, thereby limiting the demand on clinicians’ time, and encouraging client access to specialized health behavior change interventions. "
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    ABSTRACT: People with a mental illness experience substantial disparities in health, including increased rates of morbidity and mortality caused by potentially preventable chronic diseases. One contributing factor to such disparity is a higher prevalence of modifiable health risk behaviors, such as smoking, inadequate fruit and vegetable intake, harmful alcohol consumption, and inadequate physical activity. Evidence supports the effectiveness of preventive care in reducing such risks, and guidelines recommend that preventive care addressing such risks be incorporated into routine clinical care. Although community-based mental health services represent an important potential setting for ensuring that people with a mental illness receive such care, research suggests its delivery is currently sub-optimal. A study will be undertaken to evaluate the effectiveness of a clinical practice change intervention in increasing the routine provision of preventive care by clinicians in community mental health settings.Methods/design: A two-group multiple baseline design will be utilized to assess the effectiveness of a multi-strategic intervention implemented over 12 months in increasing clinician provision of preventive care. The intervention will be implemented sequentially across the two groups of community mental health services to increase provision of client assessment, brief advice, and referral for four health risk behaviors (smoking, inadequate fruit and vegetable consumption, harmful alcohol consumption, and inadequate physical activity). Outcome measures of interest will be collected via repeated cross-sectional computer-assisted telephone interviews undertaken on a weekly basis for 36 months with community mental health clients. This study is the first to assess the effectiveness of a multi-strategic clinical practice change intervention in increasing routine clinician provision of preventive care for chronic disease behavioral risk factors within a network of community mental health services. The results will inform future policy and practice regarding the ability of clinicians within mental health settings to improve preventive care provision as a result of such interventions.Trial registration: Australian and New Zealand Clinical Trials Registry (ANZCTR) ACTRN12613000693729.
    Full-text · Article · Aug 2013 · Implementation Science
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    • "Clinical guidelines that recommend routine, opportunistic clinician delivery of preventive care to all clients regarding multiple risks represent one strategy for reducing this preventable disease burden [12-15]. Such recommendations include assessment, and for those ‘at risk’, the provision of brief advice and referral or follow-up [12-19]. Further, both international and national guidelines [15,18,20] state that such care should be provided across the whole health system as a component of all ‘curative’ visits and interventions, regardless of the age or health status of the client. "
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    ABSTRACT: Background Smoking, poor nutrition, risky alcohol use, and physical inactivity are the primary behavioral risks for common causes of mortality and morbidity. Evidence and guidelines support routine clinician delivery of preventive care. Limited evidence describes the level delivered in community health settings. The objective was to determine the: prevalence of preventive care provided by community health clinicians; association between client and service characteristics and receipt of care; and acceptability of care. This will assist in informing interventions that facilitate adoption of opportunistic preventive care delivery to all clients. Methods In 2009 and 2010 a telephone survey was undertaken of 1284 clients across a network of 56 public community health facilities in one health district in New South Wales, Australia. The survey assessed receipt of preventive care (assessment, brief advice, and referral/follow-up) regarding smoking, inadequate fruit and vegetable consumption, alcohol overconsumption, and physical inactivity; and acceptability of care. Results Care was most frequently reported for smoking (assessment: 59.9%, brief advice: 61.7%, and offer of referral to a telephone service: 4.5%) and least frequently for inadequate fruit or vegetable consumption (27.0%, 20.0% and 0.9% respectively). Sixteen percent reported assessment for all risks, 16.2% received brief advice for all risks, and 0.6% were offered a specific referral for all risks. The following were associated with increased care: diabetes services, number of appointments, being male, Aboriginal, unemployed, and socio-economically disadvantaged. Acceptability of preventive care was high (76.0%-95.3%). Conclusions Despite strong client support, preventive care was not provided opportunistically to all, and was preferentially provided to select groups. This suggests a need for practice change strategies to enhance preventive care provision to achieve adherence to clinical guidelines.
    Full-text · Article · May 2013 · BMC Health Services Research
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    • "Our previous work has demonstrated that there is a significant need for brief lifestyle interventions among the clients of GCHNs, as they carry a large burden of chronic disease and associated risk factors and these clients may also be open to changing their risk-related lifestyle practices [20]. In our previous research, we argued that to increase the implementation of brief interventions, an intervention needed to be developed to build positive attitudes, skills and self-efficacy with regard to brief interventions as well as provide organisational level support with decision support tools, improved access to referral services, and resource materials for nurses and clients [21]. An intervention designed around these principles was tested in the Community Nurse SNAP Trial. "
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    ABSTRACT: Lifestyle risk factors like smoking, nutrition, alcohol consumption, and physical inactivity (SNAP) are the main behavioural risk factors for chronic disease. Primary health care is an appropriate setting to address these risk factors in individuals. Generalist community health nurses (GCHNs) are uniquely placed to provide lifestyle interventions as they see clients in their homes over a period of time. The aim of the paper is to examine the impact of a service-level intervention on the risk factor management practices of GCHNs. The trial used a quasi-experimental design involving four generalist community nursing services in NSW, Australia. The services were randomly allocated to either an intervention group or control group. Nurses in the intervention group were provided with training and support in the provision of brief lifestyle assessments and interventions. The control group provided usual care. A sample of 129 GCHNs completed surveys at baseline, 6 and 12 months to examine changes in their practices and levels of confidence related to the management of SNAP risk factors. Six semi-structured interviews and four focus groups were conducted among the intervention group to explore the feasibility of incorporating the intervention into everyday practice. Nurses in the intervention group became more confident in assessment and intervention over the three time points compared to their control group peers. Nurses in the intervention group reported assessing physical activity, weight and nutrition more frequently, as well as providing more brief interventions for physical activity, weight management and smoking cessation. There was little change in referral rates except for an improvement in weight management related referrals. Nurses’ perception of the importance of ‘client and system-related’ barriers to risk factor management diminished over time. This study shows that the intervention was associated with positive changes in self-reported lifestyle risk factor management practices of GCHNs. Barriers to referral remained. The service model needs to be adapted to sustain these changes and enhance referral. Trial registration
    Full-text · Article · Feb 2013 · BMC Health Services Research
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