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Table 5 Using the TDF to synthesise evidence; the example of barriers to diabetes management in primary care

From: A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems

Study title
 Identifying barriers to primary care type 2 diabetes management: qualitative systematic review
Rationale for changing behaviour
 There is broad consensus and a strong evidence base to guide the care of diabetes. Despite encouraging trends in the delivery and outcomes of care for people with diabetes, there remains significant scope for improvement. Most clinical management of diabetes now occurs in primary care. Interventions to enhance the implementation of evidence-based guidelines to improve the care of people with diabetes have shown small to modest effects. To ensure that interventions address barriers to behaviour change and build on known facilitators, it is important to understand primary care clinicians’ beliefs around their day-to-day management of such patients.
Study design and materials
 Systematic review of qualitative studies, including searches of following databases from 1980 to 2013: MEDLINE, EMBASE, CINAHL, PsycINFO and ASSIA. Qualitative studies examining diabetes management in primary care were eligible. Following screening of abstracts and full texts, data were coded to TDF domains and other themes if required. This review focused on behaviours to address clinical targets (including control of blood sugar, cholesterol and blood pressure) and processes of care (including foot examination). Findings were synthesised to identify barriers and facilitators common across or unique to clinical management goals, as well as apparent and potentially unexplored gaps in the literature.
Findings and conclusions
 Out of 32 included studies; 17 address general diabetes care, 11 glycaemic control, three blood pressure, and one cholesterol control. Clinicians struggle to meet evolving treatment targets within limited time and resources and are frustrated with resulting compromises. They lack confidence in knowledge of guidelines and skills, notably initiating insulin and facilitating patient behaviour change. Changing professional boundaries have resulted in uncertainty about where clinical responsibility resides. Accounts are often couched in emotional terms, especially frustrations over patient adherence and anxieties about treatment intensification.
Study outputs
 Rushforth et al. [73]