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

  • Bhupendrasinh F. Chauhan1, 2, 3Email author,
  • Maya Jeyaraman3,
  • Amrinder Singh Mann3,
  • Justin Lys3,
  • Becky Skidmore4,
  • Kathryn M. Sibley3, 5,
  • Ahmed Abou-Setta3, 5 and
  • Ryan Zarychanksi3, 5, 6, 7
Implementation Science201712:3

DOI: 10.1186/s13012-016-0538-8

Received: 9 September 2016

Accepted: 13 December 2016

Published: 5 January 2017

The Erratum to this article has been published in Implementation Science 2017 12:38

Abstract

Background

There is a plethora of interventions and policies aimed at changing practice habits of primary healthcare professionals, but it is unclear which are the most appropriate, sustainable, and effective. We aimed to evaluate the evidence on behavior change interventions and policies directed at healthcare professionals working in primary healthcare centers.

Methods

Study design: overview of reviews.

Data source: MEDLINE (Ovid), Embase (Ovid), The Cochrane Library (Wiley), CINAHL (EbscoHost), and grey literature (January 2005 to July 2015).

Study selection: two reviewers independently, and in duplicate, identified systematic reviews, overviews of reviews, scoping reviews, rapid reviews, and relevant health technology reports published in full-text in the English language.

Data extraction and synthesis: two reviewers extracted data pertaining to the types of reviews, study designs, number of studies, demographics of the professionals enrolled, interventions, outcomes, and authors’ conclusions for the included studies. We evaluated the methodological quality of the included studies using the AMSTAR scale. For the comparative evaluation, we classified interventions according to the behavior change wheel (Michie et al.).

Results

Of 2771 citations retrieved, we included 138 reviews representing 3502 individual studies. The majority of systematic reviews (91%) investigated behavior and practice changes among family physicians. Interactive and multifaceted continuous medical education programs, training with audit and feedback, and clinical decision support systems were found to be beneficial in improving knowledge, optimizing screening rate and prescriptions, enhancing patient outcomes, and reducing adverse events. Collaborative team-based policies involving primarily family physicians, nurses, and pharmacists were found to be most effective. Available evidence on environmental restructuring and modeling was found to be effective in improving collaboration and adherence to treatment guidelines. Limited evidence on nurse-led care approaches were found to be as effective as general practitioners in patient satisfaction in settings like asthma, cardiovascular, and diabetes clinics, although this needs further evaluation. Evidence does not support the use of financial incentives to family physicians, especially for long-term behavior change.

Conclusions

Behavior change interventions including education, training, and enablement in the context of collaborative team-based approaches are effective to change practice of primary healthcare professionals. Environmental restructuring approaches including nurse-led care and modeling need further evaluation. Financial incentives to family physicians do not influence long-term practice change.

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).
Fig. 1

Flow diagram of the selection of citations

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.

Notes

Declarations

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.

Authors’ Affiliations

(1)
College of Pharmacy, University of Manitoba
(2)
Children’s Hospital Research Institute of Manitoba
(3)
George & Fay Yee Centre for Healthcare Innovation
(4)
Information Specialist Consultant
(5)
Community Health Sciences, University of Manitoba
(6)
Department of Haematology and Medical Oncology, CancerCare Manitoba
(7)
Department of Internal Medicine, University of Manitoba

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