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Abstract Background The effects of tobacco, physical exercise, diet, and alcohol consumption on morbidity and mortality underline the importance of health promotion and prevention (HPP) at the primary health care (PHC) level. Likewise, the deficiencies when putting such policies into practice and assessing their effectiveness are also widely recognised. The objectives of this research were: a) to gain an in-depth understanding of general practitioners' (GPs) and patients' perceptions about HPP in PHC, and b) to define the areas that could be improved in future interventions. Methods Qualitative methodology focussed on the field of health services research. Information was generated on the basis of two GP-based and two patient-based discussion groups, all of which had previously participated in two interventions concerning healthy lifestyle promotion (tobacco and physical exercise). Transcripts and field notes were analysed on the basis of a sociological discourse-analysis model. The results were validated by triangulation between researchers. Results GPs and patients' discourses about HPP in PHC were different in priorities and contents. An overall explanatory framework was designed to gain a better understanding of the meaning of GP-patient interactions related to HPP, and to show the main trends that emerged from their discourses. GPs linked their perceptions of HPP to their working conditions and experience in health services. The dimensions in this case involved the orientation of interventions, the goal of actions, and the evaluation of results. For patients, habits were mainly related to ways of life particularly influenced by close contexts. Health conceptions, their role as individuals, and the orientation of their demands were the most important dimensions in patients' sphere. Conclusions HPP activities in PHC need to be understood and assessed in the context of their interaction with the conditioning trends in health services and patients' social micro-contexts. On the basis of the explanatory framework, three development lines are proposed: the incorporation of new methodological approaches according to the complexity of HPP in PHC; the openness of habit change policies beyond the medical services; and the effective commitments in the medium to long term by the health services themselves at the policy management level.

Abstract Background The adoption of a healthy lifestyle, including physical activity, a balanced diet, a moderate alcohol consumption and abstinence from smoking, are associated with large decreases in the incidence and mortality rates for the most common chronic diseases. That is why primary health care (PHC) services are trying, so far with less success than desirable, to promote healthy lifestyles among patients. The objective of this study is to design and model, under a participative collaboration framework between clinicians and researchers, interventions that are feasible and sustainable for the promotion of healthy lifestyles in PHC. Methods and design Phase I formative research and a quasi-experimental evaluation of the modelling and planning process will be undertaken in eight primary care centres (PCCs) of the Basque Health Service – OSAKIDETZA, of which four centres will be assigned for convenience to the Intervention Group (the others being Controls). Twelve structured study, discussion and consensus sessions supported by reviews of the literature and relevant documents, will be undertaken throughout 12 months. The first four sessions, including a descriptive strategic needs assessment, will lead to the prioritisation of a health promotion aim in each centre. In the remaining eight sessions, collaborative design of intervention strategies, on the basis of a planning process and pilot trials, will be carried out. The impact of the formative process on the practice of healthy lifestyle promotion, attitude towards health promotion and other factors associated with the optimisation of preventive clinical practice will be assessed, through pre- and post-programme evaluations and comparisons of the indicators measured in professionals from the centres assigned to the Intervention or Control Groups. Discussion There are four necessary factors for the outcome to be successful and result in important changes: (1) the commitment of professional and community partners who are involved; (2) their competence for change; (3) the active cooperation and participation of the interdisciplinary partners involved throughout the process of change; and (4) the availability of resources necessary to facilitate the change.

Abstract Background The adoption of a healthy lifestyle, including physical activity, a healthy diet, moderate alcohol consumption and abstinence from smoking, is associated with a major decrease in the incidence of chronic diseases and mortality. Primary health-care (PHC) services therefore attempt, with rather limited success, to promote such lifestyles in their patients. The objective of the present study is to ascertain the perceptions of clinicians and researchers within the Basque Health System of the factors that hinder or facilitate the integration of healthy lifestyle promotion in routine PHC setting. Methods Formative research based on five consensus meetings held by an expert panel of 12 PHC professionals with clinical and research experience in health promotion, supplied with selected bibliographic material. These meetings were recorded, summarized and the provisional findings were returned to participants in order to improve their validity. Results The Health Belief Model, the Theory of Planned Action, the Social Learning Theory, "stages of change" models and integrative models were considered the most useful by the expert panel. Effective intervention strategies, such as the "5 A's" strategy (assess, advise, agree, assist and arrange) are also available. However, none of these can be directly implemented or continuously maintained under current PHC conditions. These strategies should therefore be redesigned by adjusting the intervention objectives and contents to the operation of primary care centres and, in turn, altering the organisation of the centres where they are to be implemented. Conclusion It is recommended to address optimisation of health promotion in PHC from a research perspective in which PHC professionals, researchers and managers of these services cooperate in designing and evaluating innovative programs. Future strategies should adopt a socio-ecological approach in which the health system plays an essential role but which nevertheless complements other individual, cultural and social factors that condition health. These initiatives require an adequate theoretical and methodological framework for designing and evaluating complex interventions.

Background: Evidence-based interventions are more likely to be adopted if practitioners collaborate with researchers to develop an implementation strategy. This paper describes the steps to plan and execute a strategy, including the development of structure and supports needed for implementing proven health promotion interventions in primary and community care. Results: Between 10 and 13 discussion and consensus sessions were performed in four highly-motivated primary health care centers involving 80% of the primary care staff and 21 community-based organizations. All four centers chose to address physical activity, diet, and smoking. They selected the 5 A's evidence-based clinical intervention to be adapted to the context of the health centers. The planned implementation strategy worked at multiple levels: bottom-up primary care organizational change, top-down support from managers, community involvement, and the development of innovative e-health information and communication tools. Shared decision making and practice facilitation were perceived as the most positive aspects of the collaborative modeling process, which took more time than expected, especially the development of the new e-health tools integrated into electronic health records. Conclusions: Collaborative modeling of an implementation strategy for the integration of health promotion in primary and community care was feasible in motivated centers. However, it was difficult, being hindered by the heavy workload in primary care and generating uncertainty inherent to a bottom-up decision making processes. Lessons from this experience could be useful in diverse settings and for other clinical interventions. Two companion papers report the evaluation of its feasibility and assess quantitatively and qualitatively the implementation process. [ABSTRACT FROM AUTHOR]

Background: Process evaluation is recommended to improve the understanding of underlying mechanisms related to clinicians, patients, context and intervention delivery that may impact on trial or program results, feasibility and transferability to practice. The aim of this study was to assess the feasibility of the Prescribe Healthy Life (PVS from the Spanish "Prescribe Vida Saludable") implementation strategy for enhancing the adoption and implementation of an evidence-based health promotion intervention in primary health care. Methods: A descriptive study of 2-year implementation indicators for the PVS clinical intervention was conducted in four primary health care centers. A multifaceted collaborative modeling implementation strategy was developed to enhance the integration of a clinical intervention to promote healthy lifestyles into clinical practice. Process indicators were assessed for intervention reach, adoption, implementation, sustainability and their variability at center, practice, and patient levels. Results: Mean rates of adoption by means of active collaboration among the three main professional categories (family physicians, nurses and administrative personnel) were 75% in all centers. Just over half of the patients that attended (n = 11650; 51.9%) were reached in terms of having their lifestyle habits assessed, while more than a third (33.7%; n = 7433) and almost 10% (n = 2175) received advice or a printed prescription for at least one lifestyle change, respectively. Only 3.7% of the target population received a repeat prescription. These process indicators significantly (p < 0.001) varied by center, lifestyle habit and patient characteristics. Sustainability of intervention components changed thorough the implementation period within centers. Conclusions: The implementation strategy used showed moderate-to-good performance on process indicators related to adoption, reach, and implementation of the evidence-based healthy lifestyle promotion intervention in the context of routine primary care. Sources of heterogeneity and instability in these indicators may improve our understanding of factors required to attain adequate program adoption and implementation through improved implementation strategies. [ABSTRACT FROM AUTHOR]

Background: The impact of lifestyle on health is undeniable and effective healthy lifestyle promotion interventions do exist. However, this is not a fundamental part of routine primary care clinical practice. We describe factors that determine changes in performance of primary health care centers involved in piloting the health promotion innovation 'Prescribe Vida Saludable' (PVS) phase II. Methods: We engaged four primary health care centers of the Basque Healthcare Service in an action research project aimed at changing preventive health practices. Prescribe Healthy Life (PVS from the Spanish "Prescribe Vida Saludable) is focused on designing, planning, implementing and evaluating innovative programs to promote multiple healthy habits, feasible to be performed in routine primary health care conditions. After 2 years of piloting, centers were categorized as having high, medium, or low implementation effectiveness. We completed qualitative inductive and deductive analysis of five focus groups with the staff of the centers. Themes generated through consensual grounded qualitative analysis were compared between centers to identify the dimensions that explain the variation in actual implementation of PVS, and retrospectively organized and assessed against the Consolidated Framework for Implementation Research (CFIR). Results: Of the 36 CFIR constructs, 11 were directly related to the level of implementation performance: intervention source, evidence strength and quality, adaptability, design quality and packaging, tension for change, learning climate, self-efficacy, planning, champions, executing, and reflecting and evaluating, with --organizational tracking added as a new sub-construct. Additionally, another seven constructs emerged in the participants' discourse but were not related to center performance: relative advantage, complexity, patients' needs and resources, external policy and incentives, structural characteristics, available resources, and formally appointed internal implementation leaders. Our findings indicate that the success of the implementation seems to be associated with the following components: the context, the implementation process, and the collaborative modelling. Conclusions: Identifying barriers and enablers is useful for designing implementation strategies for health promotion in primary health care centers that are essential for innovation success. An implementation model is proposed to highlight the relationships between the CFIR constructs in the context of health promotion in primary care. [ABSTRACT FROM AUTHOR]

Background: The adoption of a healthy lifestyle, including physical activity, a healthy diet, moderate alcohol consumption and abstinence from smoking, is associated with a major decrease in the incidence of chronic diseases and mortality. Primary health-care (PHC) services therefore attempt, with rather limited success, to promote such lifestyles in their patients. The objective of the present study is to ascertain the perceptions of clinicians and researchers within the Basque Health System of the factors that hinder or facilitate the integration of healthy lifestyle promotion in routine PHC setting., Methods: Formative research based on five consensus meetings held by an expert panel of 12 PHC professionals with clinical and research experience in health promotion, supplied with selected bibliographic material. These meetings were recorded, summarized and the provisional findings were returned to participants in order to improve their validity., Results: The Health Belief Model, the Theory of Planned Action, the Social Learning Theory, "stages of change" models and integrative models were considered the most useful by the expert panel. Effective intervention strategies, such as the "5 A's" strategy (assess, advise, agree, assist and arrange) are also available. However, none of these can be directly implemented or continuously maintained under current PHC conditions. These strategies should therefore be redesigned by adjusting the intervention objectives and contents to the operation of primary care centres and, in turn, altering the organisation of the centres where they are to be implemented., Conclusion: It is recommended to address optimisation of health promotion in PHC from a research perspective in which PHC professionals, researchers and managers of these services cooperate in designing and evaluating innovative programs. Future strategies should adopt a socio-ecological approach in which the health system plays an essential role but which nevertheless complements other individual, cultural and social factors that condition health. These initiatives require an adequate theoretical and methodological framework for designing and evaluating complex interventions.

Background: It would be helpful for general practitioners to know which smokers are the most or the least likely to achieve long-term cessation, so that efforts in promoting lifestyle changes can be prioritised., Aim: To identify predictors of abstinence and assess effectiveness over a two-year follow-up of a smoking cessation programme in routine general practice., Design of Study: Quasi-experimental non-randomised controlled trial., Setting: Primary healthcare centres of the Basque Health Service, Spain., Method: All smokers attending seven intervention (n = 1203) and three control (n = 565) practices during one year (from September 1995 to October 1996) were included. The associations between attempts to stop smoking, relapses, and sustained biochemically confirmed abstinence between 12 and 24 months' follow-up, with baseline characteristics and patients' preference with regard to three possible therapeutic options, were assessed by means of logistic regression and survival analyses., Results: Sustained abstinence was biochemically confirmed in 7.3% of smokers in the intervention practices (relative probability = 2.8, 95% confidence interval [CI] = 1.6 to 4.7; probability difference = 4.7%, 95% CI = 2.7% to 6.7%); in 5% of smokers who received advice and a handout (adjusted odds ratio [AOR] = 1.9, 95% CI = 1.0 to 3.4), in 16% who received advice, a handout and follow-up (AOR = 6.6, 95% CI = 2.9 to 14.6), and in 22% who received advice, a handout, follow-up and nicotine patches (AOR = 13.1, 95% CI = 6.6 to 25.9). Positive predictors included previous attempts to stop smoking (AOR = 1.8, 95% CI = 1.1 to 2.7), and age (for each 10 years AOR = 1.32, 95% CI = 1.13 to 1.44). The Fagerström nicotine dependence score was negatively associated (for each point AOR = 0.89, 95% CI = 0.82 to 0.97)., Conclusion: The intensity of the programme can be tailored to the probability of long-term cessation estimated by the statistical model including these predictors.