Barriers and facilitators among health professionals in primary care to prevention of cardiometabolic diseases: A systematic review

Barriers and facilitators among health professionals in primary care to prevention of... Abstract The aim of this study is to identify potential facilitators and barriers for health care professionals to undertake selective prevention of cardiometabolic diseases (CMD) in primary health care. We developed a search string for Medline, Embase, Cinahl and PubMed. We also screened reference lists of relevant articles to retain barriers and facilitators for prevention of CMD. We found 19 qualitative studies, 7 quantitative studies and 2 mixed qualitative and quantitative studies. In terms of five overarching categories, the most frequently reported barriers and facilitators were as follows: Structural (barriers: time restraints, ineffective counselling and interventions, insufficient reimbursement and problems with guidelines; facilitators: feasible and effective counselling and interventions, sufficient assistance and support, adequate referral, and identification of obstacles), Organizational (barriers: general organizational problems, role of practice, insufficient IT support, communication problems within health teams and lack of support services, role of staff, lack of suitable appointment times; facilitators: structured practice, IT support, flexibility of counselling, sufficient logistic/practical support and cooperation with allied health staff/community resources, responsibility to offer and importance of prevention), Professional (barriers: insufficient counselling skills, lack of knowledge and of experience; facilitators: sufficient training, effective in motivating patients), Patient-related factors (barriers: low adherence, causes problems for patients; facilitators: strong GP–patient relationship, appreciation from patients), and Attitudinal (barriers: negative attitudes to prevention; facilitators: positive attitudes of importance of prevention). We identified several frequently reported barriers and facilitators for prevention of CMD, which may be used in designing future implementation and intervention studies. Coronary heart disease, diabetes, general practitioner, health check, myocardial infarction, selective prevention, stroke Introduction In spite of the decrease in coronary heart disease seen in many Western countries in recent years, cardiometabolic diseases [CMDs: cardiovascular diseases (CVDs), diabetes mellitus and chronic kidney disease] continue to be a major global health problem (1,2). As well as genetic and sociodemographic factors, CMDs are caused by unhealthy lifestyles, including poor diet, physical inactivity and smoking (3). It is estimated that >90% of instances of type 2 diabetes are preventable (4) by maintaining a healthy diet and body weight, engaging in moderate to vigorous physical activity and abstaining from tobacco smoking. While the evidence on predictors of CMD is relatively clear, applying this knowledge in a preventive primary care capacity represents a challenge for most health care professionals. In light of high prevalence of smokers, and increasing occurrence of obesity and physical inactivity, an increase in the number of patients with CMD is expected in the coming decades. Risk factors for CVD emerge early in life (5), with several studies suggesting that risk factors identified in young adults predict CVD and diabetes later in life (6,7). Giving advice on both physical activity (8) and diet (9) has been found to be effective in reducing CVD risk factors, though the benefits of such interventions are rather small (9,10). Past research indicates that successful interventions against CVD risk behaviour should target all important risk factors, including a poor diet, sedentary lifestyle and smoking (11). Therefore, there is an urgent need to establish strategies for health care professionals to detect seemingly healthy individuals who are at high risk of developing CMD and to develop and implement interventions to prevent or delay the onset of these diseases. This approach has been termed selective prevention—the identification of patients who, in spite of an apparent lack of symptoms and risk factors, are nonetheless at high risk of developing CMD (12). Particular subgroups of the population are at higher risk of CMD, including those of low socioeconomic status (13,14), immigrants migrating from developing countries (15), people with psychiatric disorders (16) and individuals with intellectual disability (17). While the issue of social inequality in health is well known (18), it is difficult to reach these subgroups of the general population with interventions aimed at reducing CMD risk. This may be due to the fact that maintaining a healthy lifestyle becomes less of a priority in the face of other, more immediate stressors and adversity (19). As such, there is an urgent need to establish inclusive strategies to identify individuals at high risk of disease and to develop and implement interventions to prevent or delay the onset of these diseases in the general population as well as in particularly vulnerable subgroups. Obstacles against successful interventions towards a healthy lifestyle may not only be present in the general population, but also among health care professionals in primary care—the natural arena for health promotion in the general population (20). Thus, to implement successful selective CMD prevention programmes in primary care, it is important to identify potential barriers that may exist among primary care health care professionals. Health care professionals in primary care encounter patients with divergent and poor lifestyle habits that may be harmful to cardiometabolic health (21), which make it difficult to implement selective preventive efforts. The primary care setting is a complex system where patients and professionals’ objectives may not always be in harmony, and barriers in distinct disciplines can vary widely. Therefore, we stress the importance of addressing the barriers and facilitators of effective and efficient selective prevention programmes into clinical practice in primary care (20). The aim of this study was to conduct a systematic review of the relevant literature to identify barriers and facilitators of effective selective CMD prevention programmes in a primary health care setting. Methods The results of the present review will be used to develop a feasibility study of selective CMD prevention within the Determinants of Successful Implementation of Selective Prevention of Cardiometabolic Diseases Across Europe (SPIMEU, www.spimeu.org) project. SPIMEU aims to contribute to the reduction of cardiometabolic morbidity and mortality in EU Member States by establishing the feasibility of implementing innovative, evidence-based selective prevention actions in five EU Member States representing various health care systems. The present study is a systematic search and review (22). In the first step, we performed a backward and forward citation search of five key articles with relevant content that were known to us (23–27). The backward citation search identified articles through the reference lists in each article, and the forward citation search identified articles citing the key article using Google Scholar. Through this process we identified 30 papers. On the basis of this literature, we then identified any common search terms and keywords. In the second step, we searched without restrictions in terms of language, year or publication type in the following databases: Medline (Ovid), Embase (embase.com), Cinahl (Ebsco) and PubMed (complementary search of newly published non-indexed articles) to identify relevant articles and references. The searches were conducted by two librarians at the Karolinska Institutet University Library in March 2016. The complete search strategies are available as Supplementary data. The extensive search strategy included both free text and MeSH terms and was initially created in Medline and later adapted to the other databases with corresponding vocabularies. Reference lists of included articles were also searched for relevant papers, and articles citing the already included studies were identified in further Google Scholar searches. All titles and abstracts were screened according to the inclusion criteria by either AKW, MJH or ACC. If there was any uncertainty as to whether particular articles should be included or not, the papers in question were discussed by AKW, MJH and ACC before a final decision was reached. Inclusion criteria Articles were retained for the review if the study focused on the following: Screening/prevention programmes for adult people without established CMD [all studies in patients diagnosed with CVD (or taking medication for hypertension or dyslipidaemia), diabetes mellitus or chronic kidney disease were excluded]. Prevention of CMD (CVD, type 2 diabetes, chronic kidney disease) in a primary care setting. Reporting data on the barriers or facilitators for health care professionals implementing prevention. Articles describing health care professionals. Articles reporting original research (no review articles or opinion papers such as editorials). Exclusion criteria Articles were excluded if they focused on the following: Reported purely on (clinical) outcomes of preventive interventions (e.g. lower cholesterol, morbidity). Focused solely on study protocols, guidelines and their implementation. If the inclusion of any articles was unclear, they were discussed among AKW, MJH and ACC, using the criteria above, before a final decision was made. The texts of the retained articles were read in full by at least two authors (PW, AKW or ACC). All full texts were screened independently by at least two authors, either AKW, ACC or PW. Any uncertainty was discussed by all three authors. PW conducted the data extraction, and all the extracted data were verified by ACC. Where consensus was found, all extracted data from the studies were tabled. Formal quality assessment was performed using Mixed Methods Appraisal Tool (MMAT) (28). The bias discovered by the use of the MMAT tool or by the authors’ assessment of the included studies was recorded (e.g. response rates in quantitative studies below 60%). If no bias was discovered in the quality assessment or by the authors’ assessment, ‘no bias’ was reported. The relevant content in the qualitative and quantitative studies was extracted in a similar fashion from the result sections and tables in the included studies. To systematize the information, we categorized the articles by the type of barrier/facilitator they focused on, as others have previously described (29–31). In short, we organized the barriers and facilitating factors from the retained articles into structural (related to local, regional and national health care systems), organizational (related to local, regional and national health care systems), professional, patient-related context and attitudes of heath care professionals. All barriers and facilitators reported in three or more studies were regarded as frequently reported. Results Figure 1 shows all screened titles/abstracts (6683 articles), with the individual included studies and relevant information on barriers and facilitators for health care professionals included in the present review. In total, 28 articles were included in the present review (23,25,29–54). Figure 1. View largeDownload slide PRISMA 2009 flow diagram. From Moher et al. (63). For more information, visit www.prisma-statement.org. Figure 1. View largeDownload slide PRISMA 2009 flow diagram. From Moher et al. (63). For more information, visit www.prisma-statement.org. We extracted qualitative data from 19 articles, quantitative data from 7 articles and both qualitative and quantitative data from 2 of the included articles, see Figure 1 and Table 1 (55). The included studies were published between 1990 and 2016 and came from UK (9) (25,33,42,45–49,52), Canada (4) (29,32,44,51), The Netherlands (4) (23,30,37,50), Australia (3) (34–36), Denmark (2) (39,43), Germany (2) (53,54) and a few countries (Argentina (40), France (31), New Zealand (38), Singapore (41)) with one included study. Table 1. Information of included studies of barriers and facilitators in health care professionals to do selective primary prevention of cardiovascular, diabetes and chronic kidney disease in patients without established cardiometabolic disease in primary care. (The search was conducted in March 2016.) Author, publication year, country  Type of study  Health care groups  Responders, n  Response rate  Patient ages  Population  Comments  Mann, 1990, Canada  Qualitative  GPs  50        Interviews  Calnan, 1993, UK  Quantitative  GPs  1092  64%      Postal survey  Hulscher, 1997, The Netherlands  Quantitative  GPs  195        Survey  Makrides, 1997, Canada  Qualitative  GPs  16 + 15        Focus groups and interviews  Grant, 1998, Canada  Quantitative  GPs  156  78%      Phone survey  Steptoe, 1999, UK  Quantitative  GPs, PNs  107 + 58  100%      Postal survey  Williams, 2004, UK (Wales)  Qualitative  GPs, PNs  21 + 22        Focus groups  Wright, 2006, UK  Qualitative  PHC staff: GPs, PNs; CMHT staff: psychiatrists, psychiatric nurses, social workers, occupational therapists  8 + 2; 7 + 10 + 7 + 1    18–65 years  Severe mental illness  Interviews  Pelletier-Fleury, 2007, France  Quantitative  GPs  86        Observational  Amoroso, 2009, Australia  Qualitative  GPs, PN  13 + 1    45–49 years    Interviews  Ampt, 2009, Australia  Qualitative  GPs, PN  15 + 1    45–49 years    Interviews  Graffy, 2010, UK  Quantitative  GPs, PNs, HCAs, PMs  4 + 7 + 3 + 4    40–69 years      Wan, 2010, Australia  Qualitative  GPs  22  85%      Focus groups  Voogdt-Pruis, 2011, The Netherlands  Qualitative  GPs, PNs  25 + 6        Interviews  Doolan-Noble, 2012, New Zealand  Qualitative  GPs, PNs, PHO information analyst  14 + 14 + 1        Focus groups  Huy, 2012, Germany  Quantitative  GPs  260  13%      Postal survey  Sondergaard, 2012, Denmark  Qualitative  GPs  16  16%      Focus groups  Ferrante, 2013, Argentina  Qualitative  GPs, PNs, social workers, PMs, area managers  15 + 10 + 20 + 5 + 5    ≥40 years    Interviews  George, 2013, Singapore  Mixed  GPs  302  25%      Survey, free text  Godefrooij, 2014, The Netherlands  Qualitative  GPs, PNs, medical receptionists  5 + 3 + 5        Focus groups  Vos, 2014, The Netherlands  Qualitative  GPs  7 + 1  39%      Witness seminar; interview  Baker, 2015 UK  Mixed  GPs, PNs, HCAs, PMs, administrator  2 + 6 + 2 + 14 + 1    40–74 years    Interviews  Barfoed, 2015, Denmark  Qualitative  GPs  10        Interviews  Diehl, 2015, Germany  Quantitative  GPs  4074  33.9%      Postal survey  Gavarkovs, 2015, Canada  Qualitative  CDPM programme delivery staff  10      Men  Telephone interviews  Ismail, 2015, UK  Qualitative  GPs, PNs, HCAs, PMs, other support staff  58        Interviews  Riley, 2015, UK  Qualitative  GPs, PNs, HCAs, pharmacists  5 + 5 + 3 + 2        Interviews  Krska, 2016, UK  Qualitative  PMs  23        Postal survey, free-text questions  Author, publication year, country  Type of study  Health care groups  Responders, n  Response rate  Patient ages  Population  Comments  Mann, 1990, Canada  Qualitative  GPs  50        Interviews  Calnan, 1993, UK  Quantitative  GPs  1092  64%      Postal survey  Hulscher, 1997, The Netherlands  Quantitative  GPs  195        Survey  Makrides, 1997, Canada  Qualitative  GPs  16 + 15        Focus groups and interviews  Grant, 1998, Canada  Quantitative  GPs  156  78%      Phone survey  Steptoe, 1999, UK  Quantitative  GPs, PNs  107 + 58  100%      Postal survey  Williams, 2004, UK (Wales)  Qualitative  GPs, PNs  21 + 22        Focus groups  Wright, 2006, UK  Qualitative  PHC staff: GPs, PNs; CMHT staff: psychiatrists, psychiatric nurses, social workers, occupational therapists  8 + 2; 7 + 10 + 7 + 1    18–65 years  Severe mental illness  Interviews  Pelletier-Fleury, 2007, France  Quantitative  GPs  86        Observational  Amoroso, 2009, Australia  Qualitative  GPs, PN  13 + 1    45–49 years    Interviews  Ampt, 2009, Australia  Qualitative  GPs, PN  15 + 1    45–49 years    Interviews  Graffy, 2010, UK  Quantitative  GPs, PNs, HCAs, PMs  4 + 7 + 3 + 4    40–69 years      Wan, 2010, Australia  Qualitative  GPs  22  85%      Focus groups  Voogdt-Pruis, 2011, The Netherlands  Qualitative  GPs, PNs  25 + 6        Interviews  Doolan-Noble, 2012, New Zealand  Qualitative  GPs, PNs, PHO information analyst  14 + 14 + 1        Focus groups  Huy, 2012, Germany  Quantitative  GPs  260  13%      Postal survey  Sondergaard, 2012, Denmark  Qualitative  GPs  16  16%      Focus groups  Ferrante, 2013, Argentina  Qualitative  GPs, PNs, social workers, PMs, area managers  15 + 10 + 20 + 5 + 5    ≥40 years    Interviews  George, 2013, Singapore  Mixed  GPs  302  25%      Survey, free text  Godefrooij, 2014, The Netherlands  Qualitative  GPs, PNs, medical receptionists  5 + 3 + 5        Focus groups  Vos, 2014, The Netherlands  Qualitative  GPs  7 + 1  39%      Witness seminar; interview  Baker, 2015 UK  Mixed  GPs, PNs, HCAs, PMs, administrator  2 + 6 + 2 + 14 + 1    40–74 years    Interviews  Barfoed, 2015, Denmark  Qualitative  GPs  10        Interviews  Diehl, 2015, Germany  Quantitative  GPs  4074  33.9%      Postal survey  Gavarkovs, 2015, Canada  Qualitative  CDPM programme delivery staff  10      Men  Telephone interviews  Ismail, 2015, UK  Qualitative  GPs, PNs, HCAs, PMs, other support staff  58        Interviews  Riley, 2015, UK  Qualitative  GPs, PNs, HCAs, pharmacists  5 + 5 + 3 + 2        Interviews  Krska, 2016, UK  Qualitative  PMs  23        Postal survey, free-text questions  Population only indicated when a specific target population other than the general population is relevant. CDPM, community-based chronic disease prevention and management; CMHT, community mental health teams; HCAs, health care assistants; PHCs, primary health care centres; PHO, primary health organization; PMs, practice managers; PNs, practice nurses. View Large Table 1. Information of included studies of barriers and facilitators in health care professionals to do selective primary prevention of cardiovascular, diabetes and chronic kidney disease in patients without established cardiometabolic disease in primary care. (The search was conducted in March 2016.) Author, publication year, country  Type of study  Health care groups  Responders, n  Response rate  Patient ages  Population  Comments  Mann, 1990, Canada  Qualitative  GPs  50        Interviews  Calnan, 1993, UK  Quantitative  GPs  1092  64%      Postal survey  Hulscher, 1997, The Netherlands  Quantitative  GPs  195        Survey  Makrides, 1997, Canada  Qualitative  GPs  16 + 15        Focus groups and interviews  Grant, 1998, Canada  Quantitative  GPs  156  78%      Phone survey  Steptoe, 1999, UK  Quantitative  GPs, PNs  107 + 58  100%      Postal survey  Williams, 2004, UK (Wales)  Qualitative  GPs, PNs  21 + 22        Focus groups  Wright, 2006, UK  Qualitative  PHC staff: GPs, PNs; CMHT staff: psychiatrists, psychiatric nurses, social workers, occupational therapists  8 + 2; 7 + 10 + 7 + 1    18–65 years  Severe mental illness  Interviews  Pelletier-Fleury, 2007, France  Quantitative  GPs  86        Observational  Amoroso, 2009, Australia  Qualitative  GPs, PN  13 + 1    45–49 years    Interviews  Ampt, 2009, Australia  Qualitative  GPs, PN  15 + 1    45–49 years    Interviews  Graffy, 2010, UK  Quantitative  GPs, PNs, HCAs, PMs  4 + 7 + 3 + 4    40–69 years      Wan, 2010, Australia  Qualitative  GPs  22  85%      Focus groups  Voogdt-Pruis, 2011, The Netherlands  Qualitative  GPs, PNs  25 + 6        Interviews  Doolan-Noble, 2012, New Zealand  Qualitative  GPs, PNs, PHO information analyst  14 + 14 + 1        Focus groups  Huy, 2012, Germany  Quantitative  GPs  260  13%      Postal survey  Sondergaard, 2012, Denmark  Qualitative  GPs  16  16%      Focus groups  Ferrante, 2013, Argentina  Qualitative  GPs, PNs, social workers, PMs, area managers  15 + 10 + 20 + 5 + 5    ≥40 years    Interviews  George, 2013, Singapore  Mixed  GPs  302  25%      Survey, free text  Godefrooij, 2014, The Netherlands  Qualitative  GPs, PNs, medical receptionists  5 + 3 + 5        Focus groups  Vos, 2014, The Netherlands  Qualitative  GPs  7 + 1  39%      Witness seminar; interview  Baker, 2015 UK  Mixed  GPs, PNs, HCAs, PMs, administrator  2 + 6 + 2 + 14 + 1    40–74 years    Interviews  Barfoed, 2015, Denmark  Qualitative  GPs  10        Interviews  Diehl, 2015, Germany  Quantitative  GPs  4074  33.9%      Postal survey  Gavarkovs, 2015, Canada  Qualitative  CDPM programme delivery staff  10      Men  Telephone interviews  Ismail, 2015, UK  Qualitative  GPs, PNs, HCAs, PMs, other support staff  58        Interviews  Riley, 2015, UK  Qualitative  GPs, PNs, HCAs, pharmacists  5 + 5 + 3 + 2        Interviews  Krska, 2016, UK  Qualitative  PMs  23        Postal survey, free-text questions  Author, publication year, country  Type of study  Health care groups  Responders, n  Response rate  Patient ages  Population  Comments  Mann, 1990, Canada  Qualitative  GPs  50        Interviews  Calnan, 1993, UK  Quantitative  GPs  1092  64%      Postal survey  Hulscher, 1997, The Netherlands  Quantitative  GPs  195        Survey  Makrides, 1997, Canada  Qualitative  GPs  16 + 15        Focus groups and interviews  Grant, 1998, Canada  Quantitative  GPs  156  78%      Phone survey  Steptoe, 1999, UK  Quantitative  GPs, PNs  107 + 58  100%      Postal survey  Williams, 2004, UK (Wales)  Qualitative  GPs, PNs  21 + 22        Focus groups  Wright, 2006, UK  Qualitative  PHC staff: GPs, PNs; CMHT staff: psychiatrists, psychiatric nurses, social workers, occupational therapists  8 + 2; 7 + 10 + 7 + 1    18–65 years  Severe mental illness  Interviews  Pelletier-Fleury, 2007, France  Quantitative  GPs  86        Observational  Amoroso, 2009, Australia  Qualitative  GPs, PN  13 + 1    45–49 years    Interviews  Ampt, 2009, Australia  Qualitative  GPs, PN  15 + 1    45–49 years    Interviews  Graffy, 2010, UK  Quantitative  GPs, PNs, HCAs, PMs  4 + 7 + 3 + 4    40–69 years      Wan, 2010, Australia  Qualitative  GPs  22  85%      Focus groups  Voogdt-Pruis, 2011, The Netherlands  Qualitative  GPs, PNs  25 + 6        Interviews  Doolan-Noble, 2012, New Zealand  Qualitative  GPs, PNs, PHO information analyst  14 + 14 + 1        Focus groups  Huy, 2012, Germany  Quantitative  GPs  260  13%      Postal survey  Sondergaard, 2012, Denmark  Qualitative  GPs  16  16%      Focus groups  Ferrante, 2013, Argentina  Qualitative  GPs, PNs, social workers, PMs, area managers  15 + 10 + 20 + 5 + 5    ≥40 years    Interviews  George, 2013, Singapore  Mixed  GPs  302  25%      Survey, free text  Godefrooij, 2014, The Netherlands  Qualitative  GPs, PNs, medical receptionists  5 + 3 + 5        Focus groups  Vos, 2014, The Netherlands  Qualitative  GPs  7 + 1  39%      Witness seminar; interview  Baker, 2015 UK  Mixed  GPs, PNs, HCAs, PMs, administrator  2 + 6 + 2 + 14 + 1    40–74 years    Interviews  Barfoed, 2015, Denmark  Qualitative  GPs  10        Interviews  Diehl, 2015, Germany  Quantitative  GPs  4074  33.9%      Postal survey  Gavarkovs, 2015, Canada  Qualitative  CDPM programme delivery staff  10      Men  Telephone interviews  Ismail, 2015, UK  Qualitative  GPs, PNs, HCAs, PMs, other support staff  58        Interviews  Riley, 2015, UK  Qualitative  GPs, PNs, HCAs, pharmacists  5 + 5 + 3 + 2        Interviews  Krska, 2016, UK  Qualitative  PMs  23        Postal survey, free-text questions  Population only indicated when a specific target population other than the general population is relevant. CDPM, community-based chronic disease prevention and management; CMHT, community mental health teams; HCAs, health care assistants; PHCs, primary health care centres; PHO, primary health organization; PMs, practice managers; PNs, practice nurses. View Large The reported barriers and facilitators from all studies included on the topic of selective prevention of CVD and chronic kidney disease are shown in Table 2. Table 2. Studies of barriers and facilitators in health care professionals to perform selective primary prevention of cardiovascular, diabetes and chronic kidney disease in patients without established cardiometabolic disease in primary care. (The search was conducted in March 2016.) Author, publication year, country  Type of study  Barriers  Facilitators  Bias and potential quality short-comings  Mann, 1990, Canada  Qualitative  Knowledge, attitudes and perceptions (lack of counselling skills, lack of belief in the efficacy of the activities) Conditions in which the activities occur (lack of available and accessible referral, lack of time) Reactions of others to the activities (lack of patient compliance) Difficulties in counselling (lack of appropriate, effective patient education materials)  Engaging a nurse to alleviate lack of time for GPs GPs most effective in dealing with high blood pressure Physician counselling effective in helping patients quit smoking  Focused on barriers to prevention  Calnan, 1993, UK  Quantitative  Negative attitudes to preventiona (health education is dull and boring; causes problems for the patients) Inappropriate skillsa  Positive attitudes to preventiona Training in health promotiona Higher number of practice nursesa GP spends more hours on research and traininga Positive attitudes by female GPsa Assistancea (from facilitator, or authorities) IT supporta  No  Hulscher, 1997, The Netherlands  Quantitative  Poor organization of practice to provide preventive services (lack of registration of activity for self-assessment of progress, lack of written protocols of agreement, not familiar with population approach) Acceptability [risk of causing medicalization in patients at risk for CVD (51%)] Feasibility [not enough time and opportunity (44%), lack of necessary data to screen and detect risk groups (50%)]   Organization of practice [availability of a sex–age registera, regular team work meetingsa, more practice assistance (not significant)] Acceptability [detection and treatment of hypertension will not cause anxiety (51%), patients appreciate monitoring of health (59%)] Responsibility [significant to smaller list size and proactive invitation of patientsa; CVD prevention is an important task in primary care (78%)] Self-efficacy [significant to registration of follow-up appointmentsa; GPs and PNs can motivate patients to live more healthy (70% and 72%), GPs and PNs can motivate hypertensive patients to follow advice (79% and 70%), GPs and PNs could be important support to stop smoking (82% and 65%), can contribute to a healthier way of living (45%)]  No  Makrides, 1997, Canada  Qualitative  Structural obstacles (funding, time, patient’s expectations, sparse community resources) Organizational (inadequate space, organization of practice around the traditional treatment-oriented medical model, negative staff attitude toward prevention) Personal (negative attitude toward prevention, lack of motivation, inadequate counselling skills, poor memory)  Identify prevention strategies: Viewing all visits as an opportunity for prevention Targeting risk factors Providing one-on-one counselling Providing group counselling Providing simple educational materials Offering clear and consistent advice Ensuring adequate follow-up Referring to other health professionals and community resources Enlisting the help of family and friends Identifying/addressing patient’s personal obstacles Identifying/addressing socio-environmental obstacles  No  Grant, 1998, Canada  Quantitative  Interventions to improve lifestyle ineffective (stress reduction 72.2%, weight loss 69.2%, smoking 59.1%, increasing physical activity 58.1%, diet 48.1%) Uncertain efficacy of available interventions (51.9%)  Relationship with patients (96.7%) Personal knowledge (77.6%) Compliance of patients (75.0%) Personal commitment (66.7%) Efficacy of available interventions (50.0%) Availability of time (41.0%) Opportunity to refer (28.2%) Organization of practice (25.6%) Good skill in managing risk factors (from 84.5% for council for lifestyle factors to 99.3% in screening)  Focus on knowledge of different risk factors  Steptoe, 1999, UK  Quantitative  Difficult to counsel patients about an alternative lifestyle (GP 24.8%, PN 25.5%; GP 53.5%, PN 60.0% neutral) Doubt that health professionals very influential in persuading people to change lifestyle (GP 62.5%, PN 62.5% neutral) Doubt that lifestyle counselling is very effective (GP 70.5% neutral) Doubt that you can offer patients a great deal in the way of lifestyle counselling (GP 75.0%, PN 50.0% neutral) Doubt that lifestyle counselling is very effective (GP 70.5%, PN 42.9% neutral)  Responsibility to act as a health educator (GP 70.2%, PN 87.5%) Have time for prevention (GP 29.8%, PN 62.5%) Feel properly trained (GP 48.6%, PN 48.2%) Health professionals very influential in persuading people to change lifestyle (GP 24.0%, PN 33.9%) Can offer patients a great deal in the way of lifestyle counselling (GP 17.3%, PN 50.0%) Lifestyle counselling is very effective (GP 20.0%, PN 53.6%) Possible to persuade patients to modify lifestyle: Hypertension (GP 50.0%, PN 62.5%), high cholesterol (GP 44.2%, 58.9%), smoking (GP 34.6%, 23.2%), obesity (GP 25.0%, PN 32.1%), physical activity (GP 24.0%, PN 34.5%) Overall attitude of effectiveness of lifestyle modification (6.57 of scale 0–10, higher score more effective)    Williams, 2004, UK (Wales)  Qualitative  Existing workload, lack of resources Questionable role of primary care as a ‘screening service’, and not responsibility of primary care Prevention: the responsibility of individuals, and agencies other than primary care, especially outside the health sector Conflict and concern about increasing specialization (here diabetes) Perceived low motivation of patients to modify their lifestyle Unnecessary medicalization No evidence that interventions delivered through primary care are effective  Importance of prevention High-risk patients should be seen anyway  Concerns type 2 diabetes only  Wright, 2006, UK  Qualitative  Lack of appropriate resources in existing services, e.g. time, trained staff Lack of funding Lack of familiarity in general practice with severe mental illness, also negative attitudes to work with these patients Lack of knowledge regarding CHD risk factor screening and difficulties in interpreting screening results and implementing appropriate interventions Mental patients harder to engage, prior experience of low attendance, perceived difficulty in making lifestyle changes A screening offer might be viewed as interference in patients' lives, and some patients get anxious Lack of appropriate services to refer patients Staff resistance to more changes in their role  Flexible solutions with clear lines of responsibility for assessing, communicating and managing CHD risks Mental patients are at high risk, with bad lifestyle manners, needing interventions GPs possess medical expertise Less stigmatising to attend primary care for screening Patients have better links, trust and a longer history with their GP  Concerns patients with severe mental illness Views from both primary care and community mental health teams  Pelletier-Fleury, 2007, France  Quantitative  Urban practicea (OR 0.66; 95% CI 0.65–0.68) Density of GPsa (OR 0.76; 95% CI 0.63–0.92)  Daily work loada (OR 1.03, 95% CI 1.01–1.05) Elderly patient list (>65 y)a (OR 1.04; 95% CI 1.02–1.07) High health care consumptiona (OR 4.29; 95% CI 3.62–5.00)  Register study of preventive services  Amoroso, 2009, Australia  Qualitative  Time Low remuneration Attitude that prevention do not have a high priority Attitude of scepticism about the value of a health check Management, in particular motivating patients to change their behaviour, proved to be more difficult  A useful opportunity to assess and manage risk factors A belief that preventive care was part of their role and responsibility Health check feasible   Short follow-up time  Ampt, 2009, Australia  Qualitative  Time Doubt on the effectiveness of general dietary recommendations Motivational interviewing good in theory, but difficult in practice Difficult to motivate patients to change behaviour Difficult in motivating patients to stop smoking Negative attitudes towards assessment of nutrition, alcohol and physical activity Cost of follow-up visit Difficult to access referrals in working hours Lack of knowledge regarding the role of the exercise physiologist Advice offered by a dietician would be no different to that offered by the GP, and thus referrals were of little value  Usefulness of a computer-based template or patient education and assessment resources Training in motivational interviewing Experience and interest in addressing drug and alcohol issues Giving advice and educating the patient were viewed as a professional responsibility Printed material reinforced any message Practice having an appointment system, as follow-ups could more easily be arranged Quitline (a free smoking referral telephone service) has no restriction to working hours Support services could actually help to motivate patients Potential greater success may be achieved by addressing whichever factor the patient was more ready to change first Primary care teams can play a major role in affecting patients’ ideas  Selection bias towards higher participation among health care professional with an interest for prevention  Graffy, 2010, UK  Quantitative  Workload  Importance of administrative support Efficient systems to identify, invite and follow up patients Flexible appointments for people in work Tagging notes to invite non-attenders when they consult Team meetings contribute to a sense of ownership Training, both at the outset and for new staff Seeing patients benefiting of screening affirms the sense of the value of screening  Selection bias with participation of practices with screening experiences Concerns screening of type 2 diabetes, positive experiences  Wan, 2010, Australia  Qualitative  Low awareness among patients Time pressure Risk of ‘touting for business’ when booking another visit for risk discussion with a new patient  A strong GP–patient relationship, common ground on priorities between GPs and their patients, Patient’s self-motivation a key issue Opportunistic screening easier with regular patients   Selection bias with including GPs with interest in prevention Study included both patients and health care staff  Voogdt-Pruis, 2011, The Netherlands  Qualitative  Workload Lack of physical space Lack of motivation for patients Lack of GP knowledge about the guidelines Different attitudes towards treatment targets Lack of communication, between nurses and GPs and between GPs and second care Insufficient coaching by doctors Content of lifestyle advice Concern of losing nursing tasks for nurses Lack of ability of stop-smoking treatment Organizational issues (insufficient patient recording and computer systems) Considerable effort to get patients to attend, difficult to motivate patients who rarely visited the practice Poor record keeping (smoking behaviour, diagnoses and treatment by specialist)  Nurses could play an important role in preventive care Extending clinic opening hours Desirable to implement a chain of care and an integrated electronic patient record system  Experiences of implementing nurse-delivered prevention  Doolan-Noble, 2012, New Zealand  Qualitative  Time and workload Insufficient funding Lack of strong leadership and consistent messages Difficulty in handling asymptomatic high CV risk patients, and to communicate and motivating behaviour change (e.g. low SES patients, fatalistic views of patients) Attitude of low benefits of behaviour change Design of flip charts unsatisfactory  Ensure infrastructure, including training and to consider how the programme would be implemented Co-location of allied health staff in an integrated centre The need for ongoing tobacco legislation and positive food legislation Clarity around the roles and responsibilities of GPs and practice nurses Primary health care’s longitudinal relationship with patients Attitude of high benefits of behaviour change Useful electronic tools Incentives for patients for motivation and support lifestyle changes  No  Huy, 2012, Germany  Quantitativeb  Lack of time (91%) Insufficient renumeration (92%) Many different guidelines (73%) Unclear recommendations (60%) Lack of training (70%) Lack of material for patients (77%) Lack of adherence among patients (98%)   I can offer my patients a wide range of lifestyle advice (49.1%)a (OR 3.55; 95% CI 1.82–6.93) Risk factor questionnaires in the waiting room (61.5%)a (OR 2.26; 95% CI 1.06–4.85) Female gender of GPa (OR 1.98; 95% CI 1.04–3.76) Knowledge about positive lifestyle effect (54%) Prevention is a GP responsibility (40.9%) Not difficult to give advice on lifestyle changes (47.0%) Well educated for advice on healthy lifestyle (44.2%) Can successfully motivate patients to live healthier (45.6%)  Response rate 13%  Sondergaard, 2012, Denmark  Qualitative  Reservations if the health checks were a core mission of primary care Uncertainty about the best approach Reservations about inducing negative psychological reactions and decreased well-being among patients  Preventive health checks beneficial for the patients  No  Ferrante, 2013, Argentina  Qualitative  Lack of awareness of guidelines Lack of knowledge about preventing cardiovascular disease Communication problems within health teams Lack of motivation Organizational problems Low quality of recording  Intervention tailored to target identified barriers  Focused on barriers for designing an intervention  George, 2013, Singapore  Mixed  Lack of direct access/co-management with renal physician Lack of interest Nature of my practice Lack of confidence and faith Lack of sufficient support and experience Lack of time to keep up-to-date. Lack of medicine for CKD Lack of IT support. Too much paperwork Lack of patient education Poor patient compliance Lack of family/ social support management Lack of time to explain to the patient cQuantitative results: Lack of access to patient’s information (from hospital) (4.7) Lack of access to evidence-based guidelines (4.3) Inability to bill (4.5) Lack of patient’s trust in GP (3.9) Inability for patient to pay (3.7) Lack of time for consultation (3.6) Lack of support services (staff, technical) (2.3)  Access to/co-operation with renal specialist Adequate remuneration Technological assistance, IT Patient education, also to trust the GPs cQuantitative results: Less cost for patient (2.5) Access to patient’s information (2.8) Access to updates and guidelines (3.0) More support services (3.2) Less time consumed (3.3)   Concerns screening for chronic kidney disease Response rate of quantitative survey 25%  Godefrooij, 2014, The Netherlands  Qualitative  Lack of experience in the design and implementation of a structured, large-scale prevention programme, suboptimal instruction of involved staff No clear policy about how to follow up patients with ‘medium risk’, not exceeding the risk to be referred to their GP  Importance of primary prevention (high yield of health check, helped GPs to identify their high-risk population in a structured manner) Collaboration, i.e. ‘delegation of care’, health checks were delivered by medical receptionists and practice nurses, and GPs involved for high-risk patients  Study included both patients and health care staff  Vos, 2014, The Netherlands  Qualitative  Organizational context: insufficient reimbursement Professional context: lack of evidence and guidelines Social context: no focus on prevention  Organizational context: sufficient logistic and practical support and finances Responsibility to offer prevention, equity Professional context: evidence and guidelines Social context: prevention focused on  No  Baker, 2015 UK  Mixed  Extra workload Insufficient knowledge Lack of information collected by the practice prior to the appointment Programme tools developed to aid the assessment process and reduce staff time were not necessarily being used to their full effect Difficulty in engaging patients who were potentially able to receive the most benefit Less confident in second appointments (CVD risk assessment, mean = 3.52, SD = 1.3), risk communication (mean = 2.68, SD = 0.1.8) and changing behaviours (mean = 2.44, SD = 1.6) Mixed opinions concerning the quality of lifestyle services referred to: Weight management (mean = 3.76, SD = 0.90) and alcohol services (mean = 3.76, SD = 0.90) were the lowest rated Some participants were not aware of what health trainers were Caution concerning the programme’s overall effectiveness  Opportunistic approaches Practices periodically reviewed the non-responder list and reissued invites Practices were most confident in first appointments (pre-assessment blood tests, mean = 4.12, SD = 0.60), invitations (mean = 4.04, SD = 0.79) and laboratory tests (mean = 4.04, SD = 0.79) Mixed opinions concerning the quality of lifestyle services referred to: smoking cessation was rated most highly (mean = 4.43, SD = 0.59), health trainers were rated highly (mean = 4.13, SD = 0.83) HCs were useful in early detection and giving the time to discuss patient health and lifestyles (72%) Delivery of HCs in a wider range of settings, e.g. work places More than two-thirds (70.8%) of practice staff indicated that they had training in CVD prevention and 44% (n = 11) indicated that they required further training A need to promote the programme more effectively Conclusions: Adopting continuous approaches to knowledge development and transfer; improve confidence in HCs to deliver meaningful results  Small sample size, no response rate given  Barfoed, 2015, Denmark  Qualitative  Guidelines inhibit the ability to practice independently as a GP Risk communication tools are insufficient Resigned approach to manage patient compliance  Guidelines good and applicable Use of different communication tools depending on the patient context Confrontational approach to manage low patient compliance  No  Diehl, 2015, Germany  Quantitative  Insufficient reimbursement (90.2%) Difficult to give advice on unhealthy habits (73.5%) Cultural differences (59.1%) Insufficient connection with other preventive service providers (56.7%) Lack of time (54.5%) Attitude that patients cannot change lifestyle (49.1%) Difficult to follow guidelines (too many (43.1%), insufficient evidence (28.5%), unclear recommendations (24.9%) Lack of education/training (24.8%)  Responsibility to take a role as a health advisor (96.2%) Feeling well prepared for and successful of prevention (80.9%) Successful in motivating patients to a healthy lifestyle (72.6%) Networking with cooperation partners (70.7%) Being one of the most important influence factors on patients lifestyle (69.3%)  Response rate 34%  Gavarkovs, 2015, Canada  Qualitative  Time and travel constraints Unawareness of spouses of disease prevention programmes Lack of suitable male programme leaders Interfering with high work season of patients  Hiring qualified male instructors Engaging spouses  Concerns recruiting male participants in a rural district  Ismail, 2015, UK  Qualitative  Lack of staff time/hours, increased workload Lack of space in the building Insufficient software Lack of leaflets and posters Lack of awareness of health checks Lack of resources to motivate and support patients in lifestyle changes Problems in reaching important groups with unhealthy behaviours and low motivation for changes Lack of adherence to advices Interference with working time of possible attendants Doubt on impact of the programme Lack of referral services  Evolution of the programme over time in response to local needs to suit the particular characteristics of the patient population Individual staff characteristics such as being proactive, enthusiastic and having specific responsibility A supportive team Clear information to patients what the screening entails, including possible benefits and potential harm Messages in media to raise awareness of health checks Importance of the existing relationships between GPs and patients Attitude that health checks are beneficial and to identify high-risk patients Attendants are motivated and open to advice  No  Riley, 2015, UK  Qualitative  Concerns about the skill set of some staff to competently communicate risk and lifestyle information  Sufficient training to equip health care staff with appropriate skills and knowledge to deliver the service effectively  Study included both patients and staff  Krska, 2016, UK  Qualitative  Time constraints/pressure of work Increased nurse workload impacted on other services Insufficient payments Problems with software Attitude that health checks are a waste of time  IT support Effective software Health checks beneficial for patients  Focus on implementation of health checks  Author, publication year, country  Type of study  Barriers  Facilitators  Bias and potential quality short-comings  Mann, 1990, Canada  Qualitative  Knowledge, attitudes and perceptions (lack of counselling skills, lack of belief in the efficacy of the activities) Conditions in which the activities occur (lack of available and accessible referral, lack of time) Reactions of others to the activities (lack of patient compliance) Difficulties in counselling (lack of appropriate, effective patient education materials)  Engaging a nurse to alleviate lack of time for GPs GPs most effective in dealing with high blood pressure Physician counselling effective in helping patients quit smoking  Focused on barriers to prevention  Calnan, 1993, UK  Quantitative  Negative attitudes to preventiona (health education is dull and boring; causes problems for the patients) Inappropriate skillsa  Positive attitudes to preventiona Training in health promotiona Higher number of practice nursesa GP spends more hours on research and traininga Positive attitudes by female GPsa Assistancea (from facilitator, or authorities) IT supporta  No  Hulscher, 1997, The Netherlands  Quantitative  Poor organization of practice to provide preventive services (lack of registration of activity for self-assessment of progress, lack of written protocols of agreement, not familiar with population approach) Acceptability [risk of causing medicalization in patients at risk for CVD (51%)] Feasibility [not enough time and opportunity (44%), lack of necessary data to screen and detect risk groups (50%)]   Organization of practice [availability of a sex–age registera, regular team work meetingsa, more practice assistance (not significant)] Acceptability [detection and treatment of hypertension will not cause anxiety (51%), patients appreciate monitoring of health (59%)] Responsibility [significant to smaller list size and proactive invitation of patientsa; CVD prevention is an important task in primary care (78%)] Self-efficacy [significant to registration of follow-up appointmentsa; GPs and PNs can motivate patients to live more healthy (70% and 72%), GPs and PNs can motivate hypertensive patients to follow advice (79% and 70%), GPs and PNs could be important support to stop smoking (82% and 65%), can contribute to a healthier way of living (45%)]  No  Makrides, 1997, Canada  Qualitative  Structural obstacles (funding, time, patient’s expectations, sparse community resources) Organizational (inadequate space, organization of practice around the traditional treatment-oriented medical model, negative staff attitude toward prevention) Personal (negative attitude toward prevention, lack of motivation, inadequate counselling skills, poor memory)  Identify prevention strategies: Viewing all visits as an opportunity for prevention Targeting risk factors Providing one-on-one counselling Providing group counselling Providing simple educational materials Offering clear and consistent advice Ensuring adequate follow-up Referring to other health professionals and community resources Enlisting the help of family and friends Identifying/addressing patient’s personal obstacles Identifying/addressing socio-environmental obstacles  No  Grant, 1998, Canada  Quantitative  Interventions to improve lifestyle ineffective (stress reduction 72.2%, weight loss 69.2%, smoking 59.1%, increasing physical activity 58.1%, diet 48.1%) Uncertain efficacy of available interventions (51.9%)  Relationship with patients (96.7%) Personal knowledge (77.6%) Compliance of patients (75.0%) Personal commitment (66.7%) Efficacy of available interventions (50.0%) Availability of time (41.0%) Opportunity to refer (28.2%) Organization of practice (25.6%) Good skill in managing risk factors (from 84.5% for council for lifestyle factors to 99.3% in screening)  Focus on knowledge of different risk factors  Steptoe, 1999, UK  Quantitative  Difficult to counsel patients about an alternative lifestyle (GP 24.8%, PN 25.5%; GP 53.5%, PN 60.0% neutral) Doubt that health professionals very influential in persuading people to change lifestyle (GP 62.5%, PN 62.5% neutral) Doubt that lifestyle counselling is very effective (GP 70.5% neutral) Doubt that you can offer patients a great deal in the way of lifestyle counselling (GP 75.0%, PN 50.0% neutral) Doubt that lifestyle counselling is very effective (GP 70.5%, PN 42.9% neutral)  Responsibility to act as a health educator (GP 70.2%, PN 87.5%) Have time for prevention (GP 29.8%, PN 62.5%) Feel properly trained (GP 48.6%, PN 48.2%) Health professionals very influential in persuading people to change lifestyle (GP 24.0%, PN 33.9%) Can offer patients a great deal in the way of lifestyle counselling (GP 17.3%, PN 50.0%) Lifestyle counselling is very effective (GP 20.0%, PN 53.6%) Possible to persuade patients to modify lifestyle: Hypertension (GP 50.0%, PN 62.5%), high cholesterol (GP 44.2%, 58.9%), smoking (GP 34.6%, 23.2%), obesity (GP 25.0%, PN 32.1%), physical activity (GP 24.0%, PN 34.5%) Overall attitude of effectiveness of lifestyle modification (6.57 of scale 0–10, higher score more effective)    Williams, 2004, UK (Wales)  Qualitative  Existing workload, lack of resources Questionable role of primary care as a ‘screening service’, and not responsibility of primary care Prevention: the responsibility of individuals, and agencies other than primary care, especially outside the health sector Conflict and concern about increasing specialization (here diabetes) Perceived low motivation of patients to modify their lifestyle Unnecessary medicalization No evidence that interventions delivered through primary care are effective  Importance of prevention High-risk patients should be seen anyway  Concerns type 2 diabetes only  Wright, 2006, UK  Qualitative  Lack of appropriate resources in existing services, e.g. time, trained staff Lack of funding Lack of familiarity in general practice with severe mental illness, also negative attitudes to work with these patients Lack of knowledge regarding CHD risk factor screening and difficulties in interpreting screening results and implementing appropriate interventions Mental patients harder to engage, prior experience of low attendance, perceived difficulty in making lifestyle changes A screening offer might be viewed as interference in patients' lives, and some patients get anxious Lack of appropriate services to refer patients Staff resistance to more changes in their role  Flexible solutions with clear lines of responsibility for assessing, communicating and managing CHD risks Mental patients are at high risk, with bad lifestyle manners, needing interventions GPs possess medical expertise Less stigmatising to attend primary care for screening Patients have better links, trust and a longer history with their GP  Concerns patients with severe mental illness Views from both primary care and community mental health teams  Pelletier-Fleury, 2007, France  Quantitative  Urban practicea (OR 0.66; 95% CI 0.65–0.68) Density of GPsa (OR 0.76; 95% CI 0.63–0.92)  Daily work loada (OR 1.03, 95% CI 1.01–1.05) Elderly patient list (>65 y)a (OR 1.04; 95% CI 1.02–1.07) High health care consumptiona (OR 4.29; 95% CI 3.62–5.00)  Register study of preventive services  Amoroso, 2009, Australia  Qualitative  Time Low remuneration Attitude that prevention do not have a high priority Attitude of scepticism about the value of a health check Management, in particular motivating patients to change their behaviour, proved to be more difficult  A useful opportunity to assess and manage risk factors A belief that preventive care was part of their role and responsibility Health check feasible   Short follow-up time  Ampt, 2009, Australia  Qualitative  Time Doubt on the effectiveness of general dietary recommendations Motivational interviewing good in theory, but difficult in practice Difficult to motivate patients to change behaviour Difficult in motivating patients to stop smoking Negative attitudes towards assessment of nutrition, alcohol and physical activity Cost of follow-up visit Difficult to access referrals in working hours Lack of knowledge regarding the role of the exercise physiologist Advice offered by a dietician would be no different to that offered by the GP, and thus referrals were of little value  Usefulness of a computer-based template or patient education and assessment resources Training in motivational interviewing Experience and interest in addressing drug and alcohol issues Giving advice and educating the patient were viewed as a professional responsibility Printed material reinforced any message Practice having an appointment system, as follow-ups could more easily be arranged Quitline (a free smoking referral telephone service) has no restriction to working hours Support services could actually help to motivate patients Potential greater success may be achieved by addressing whichever factor the patient was more ready to change first Primary care teams can play a major role in affecting patients’ ideas  Selection bias towards higher participation among health care professional with an interest for prevention  Graffy, 2010, UK  Quantitative  Workload  Importance of administrative support Efficient systems to identify, invite and follow up patients Flexible appointments for people in work Tagging notes to invite non-attenders when they consult Team meetings contribute to a sense of ownership Training, both at the outset and for new staff Seeing patients benefiting of screening affirms the sense of the value of screening  Selection bias with participation of practices with screening experiences Concerns screening of type 2 diabetes, positive experiences  Wan, 2010, Australia  Qualitative  Low awareness among patients Time pressure Risk of ‘touting for business’ when booking another visit for risk discussion with a new patient  A strong GP–patient relationship, common ground on priorities between GPs and their patients, Patient’s self-motivation a key issue Opportunistic screening easier with regular patients   Selection bias with including GPs with interest in prevention Study included both patients and health care staff  Voogdt-Pruis, 2011, The Netherlands  Qualitative  Workload Lack of physical space Lack of motivation for patients Lack of GP knowledge about the guidelines Different attitudes towards treatment targets Lack of communication, between nurses and GPs and between GPs and second care Insufficient coaching by doctors Content of lifestyle advice Concern of losing nursing tasks for nurses Lack of ability of stop-smoking treatment Organizational issues (insufficient patient recording and computer systems) Considerable effort to get patients to attend, difficult to motivate patients who rarely visited the practice Poor record keeping (smoking behaviour, diagnoses and treatment by specialist)  Nurses could play an important role in preventive care Extending clinic opening hours Desirable to implement a chain of care and an integrated electronic patient record system  Experiences of implementing nurse-delivered prevention  Doolan-Noble, 2012, New Zealand  Qualitative  Time and workload Insufficient funding Lack of strong leadership and consistent messages Difficulty in handling asymptomatic high CV risk patients, and to communicate and motivating behaviour change (e.g. low SES patients, fatalistic views of patients) Attitude of low benefits of behaviour change Design of flip charts unsatisfactory  Ensure infrastructure, including training and to consider how the programme would be implemented Co-location of allied health staff in an integrated centre The need for ongoing tobacco legislation and positive food legislation Clarity around the roles and responsibilities of GPs and practice nurses Primary health care’s longitudinal relationship with patients Attitude of high benefits of behaviour change Useful electronic tools Incentives for patients for motivation and support lifestyle changes  No  Huy, 2012, Germany  Quantitativeb  Lack of time (91%) Insufficient renumeration (92%) Many different guidelines (73%) Unclear recommendations (60%) Lack of training (70%) Lack of material for patients (77%) Lack of adherence among patients (98%)   I can offer my patients a wide range of lifestyle advice (49.1%)a (OR 3.55; 95% CI 1.82–6.93) Risk factor questionnaires in the waiting room (61.5%)a (OR 2.26; 95% CI 1.06–4.85) Female gender of GPa (OR 1.98; 95% CI 1.04–3.76) Knowledge about positive lifestyle effect (54%) Prevention is a GP responsibility (40.9%) Not difficult to give advice on lifestyle changes (47.0%) Well educated for advice on healthy lifestyle (44.2%) Can successfully motivate patients to live healthier (45.6%)  Response rate 13%  Sondergaard, 2012, Denmark  Qualitative  Reservations if the health checks were a core mission of primary care Uncertainty about the best approach Reservations about inducing negative psychological reactions and decreased well-being among patients  Preventive health checks beneficial for the patients  No  Ferrante, 2013, Argentina  Qualitative  Lack of awareness of guidelines Lack of knowledge about preventing cardiovascular disease Communication problems within health teams Lack of motivation Organizational problems Low quality of recording  Intervention tailored to target identified barriers  Focused on barriers for designing an intervention  George, 2013, Singapore  Mixed  Lack of direct access/co-management with renal physician Lack of interest Nature of my practice Lack of confidence and faith Lack of sufficient support and experience Lack of time to keep up-to-date. Lack of medicine for CKD Lack of IT support. Too much paperwork Lack of patient education Poor patient compliance Lack of family/ social support management Lack of time to explain to the patient cQuantitative results: Lack of access to patient’s information (from hospital) (4.7) Lack of access to evidence-based guidelines (4.3) Inability to bill (4.5) Lack of patient’s trust in GP (3.9) Inability for patient to pay (3.7) Lack of time for consultation (3.6) Lack of support services (staff, technical) (2.3)  Access to/co-operation with renal specialist Adequate remuneration Technological assistance, IT Patient education, also to trust the GPs cQuantitative results: Less cost for patient (2.5) Access to patient’s information (2.8) Access to updates and guidelines (3.0) More support services (3.2) Less time consumed (3.3)   Concerns screening for chronic kidney disease Response rate of quantitative survey 25%  Godefrooij, 2014, The Netherlands  Qualitative  Lack of experience in the design and implementation of a structured, large-scale prevention programme, suboptimal instruction of involved staff No clear policy about how to follow up patients with ‘medium risk’, not exceeding the risk to be referred to their GP  Importance of primary prevention (high yield of health check, helped GPs to identify their high-risk population in a structured manner) Collaboration, i.e. ‘delegation of care’, health checks were delivered by medical receptionists and practice nurses, and GPs involved for high-risk patients  Study included both patients and health care staff  Vos, 2014, The Netherlands  Qualitative  Organizational context: insufficient reimbursement Professional context: lack of evidence and guidelines Social context: no focus on prevention  Organizational context: sufficient logistic and practical support and finances Responsibility to offer prevention, equity Professional context: evidence and guidelines Social context: prevention focused on  No  Baker, 2015 UK  Mixed  Extra workload Insufficient knowledge Lack of information collected by the practice prior to the appointment Programme tools developed to aid the assessment process and reduce staff time were not necessarily being used to their full effect Difficulty in engaging patients who were potentially able to receive the most benefit Less confident in second appointments (CVD risk assessment, mean = 3.52, SD = 1.3), risk communication (mean = 2.68, SD = 0.1.8) and changing behaviours (mean = 2.44, SD = 1.6) Mixed opinions concerning the quality of lifestyle services referred to: Weight management (mean = 3.76, SD = 0.90) and alcohol services (mean = 3.76, SD = 0.90) were the lowest rated Some participants were not aware of what health trainers were Caution concerning the programme’s overall effectiveness  Opportunistic approaches Practices periodically reviewed the non-responder list and reissued invites Practices were most confident in first appointments (pre-assessment blood tests, mean = 4.12, SD = 0.60), invitations (mean = 4.04, SD = 0.79) and laboratory tests (mean = 4.04, SD = 0.79) Mixed opinions concerning the quality of lifestyle services referred to: smoking cessation was rated most highly (mean = 4.43, SD = 0.59), health trainers were rated highly (mean = 4.13, SD = 0.83) HCs were useful in early detection and giving the time to discuss patient health and lifestyles (72%) Delivery of HCs in a wider range of settings, e.g. work places More than two-thirds (70.8%) of practice staff indicated that they had training in CVD prevention and 44% (n = 11) indicated that they required further training A need to promote the programme more effectively Conclusions: Adopting continuous approaches to knowledge development and transfer; improve confidence in HCs to deliver meaningful results  Small sample size, no response rate given  Barfoed, 2015, Denmark  Qualitative  Guidelines inhibit the ability to practice independently as a GP Risk communication tools are insufficient Resigned approach to manage patient compliance  Guidelines good and applicable Use of different communication tools depending on the patient context Confrontational approach to manage low patient compliance  No  Diehl, 2015, Germany  Quantitative  Insufficient reimbursement (90.2%) Difficult to give advice on unhealthy habits (73.5%) Cultural differences (59.1%) Insufficient connection with other preventive service providers (56.7%) Lack of time (54.5%) Attitude that patients cannot change lifestyle (49.1%) Difficult to follow guidelines (too many (43.1%), insufficient evidence (28.5%), unclear recommendations (24.9%) Lack of education/training (24.8%)  Responsibility to take a role as a health advisor (96.2%) Feeling well prepared for and successful of prevention (80.9%) Successful in motivating patients to a healthy lifestyle (72.6%) Networking with cooperation partners (70.7%) Being one of the most important influence factors on patients lifestyle (69.3%)  Response rate 34%  Gavarkovs, 2015, Canada  Qualitative  Time and travel constraints Unawareness of spouses of disease prevention programmes Lack of suitable male programme leaders Interfering with high work season of patients  Hiring qualified male instructors Engaging spouses  Concerns recruiting male participants in a rural district  Ismail, 2015, UK  Qualitative  Lack of staff time/hours, increased workload Lack of space in the building Insufficient software Lack of leaflets and posters Lack of awareness of health checks Lack of resources to motivate and support patients in lifestyle changes Problems in reaching important groups with unhealthy behaviours and low motivation for changes Lack of adherence to advices Interference with working time of possible attendants Doubt on impact of the programme Lack of referral services  Evolution of the programme over time in response to local needs to suit the particular characteristics of the patient population Individual staff characteristics such as being proactive, enthusiastic and having specific responsibility A supportive team Clear information to patients what the screening entails, including possible benefits and potential harm Messages in media to raise awareness of health checks Importance of the existing relationships between GPs and patients Attitude that health checks are beneficial and to identify high-risk patients Attendants are motivated and open to advice  No  Riley, 2015, UK  Qualitative  Concerns about the skill set of some staff to competently communicate risk and lifestyle information  Sufficient training to equip health care staff with appropriate skills and knowledge to deliver the service effectively  Study included both patients and staff  Krska, 2016, UK  Qualitative  Time constraints/pressure of work Increased nurse workload impacted on other services Insufficient payments Problems with software Attitude that health checks are a waste of time  IT support Effective software Health checks beneficial for patients  Focus on implementation of health checks  Baker: 1–5 scale. Percentages denote rate of participants giving this statement. CDPM, community-based chronic disease prevention and management; CHD, coronary heart disease; CKD, chronic kidney disease; CMHT, community mental health teams; CVD, cardiovascular diseases; HC, health care; PHCs, primary health care centres; PMs, practice managers; PNs, practice nurses; SES, socioeconomic status. aSignificant factors when statistical analyses were performed [with odds ratio (OR) and 95% confidence interval (95% CI) when shown in the article]. bObstacles include great, medium or small barriers. cObstacles mean rank of severity (1–7, 1 denotes easiest obstacle, 7 most difficult); motivational factors mean rank of motivation (1–5, 1 the most motivating factor, 5 the least motivating factor). View Large Table 2. Studies of barriers and facilitators in health care professionals to perform selective primary prevention of cardiovascular, diabetes and chronic kidney disease in patients without established cardiometabolic disease in primary care. (The search was conducted in March 2016.) Author, publication year, country  Type of study  Barriers  Facilitators  Bias and potential quality short-comings  Mann, 1990, Canada  Qualitative  Knowledge, attitudes and perceptions (lack of counselling skills, lack of belief in the efficacy of the activities) Conditions in which the activities occur (lack of available and accessible referral, lack of time) Reactions of others to the activities (lack of patient compliance) Difficulties in counselling (lack of appropriate, effective patient education materials)  Engaging a nurse to alleviate lack of time for GPs GPs most effective in dealing with high blood pressure Physician counselling effective in helping patients quit smoking  Focused on barriers to prevention  Calnan, 1993, UK  Quantitative  Negative attitudes to preventiona (health education is dull and boring; causes problems for the patients) Inappropriate skillsa  Positive attitudes to preventiona Training in health promotiona Higher number of practice nursesa GP spends more hours on research and traininga Positive attitudes by female GPsa Assistancea (from facilitator, or authorities) IT supporta  No  Hulscher, 1997, The Netherlands  Quantitative  Poor organization of practice to provide preventive services (lack of registration of activity for self-assessment of progress, lack of written protocols of agreement, not familiar with population approach) Acceptability [risk of causing medicalization in patients at risk for CVD (51%)] Feasibility [not enough time and opportunity (44%), lack of necessary data to screen and detect risk groups (50%)]   Organization of practice [availability of a sex–age registera, regular team work meetingsa, more practice assistance (not significant)] Acceptability [detection and treatment of hypertension will not cause anxiety (51%), patients appreciate monitoring of health (59%)] Responsibility [significant to smaller list size and proactive invitation of patientsa; CVD prevention is an important task in primary care (78%)] Self-efficacy [significant to registration of follow-up appointmentsa; GPs and PNs can motivate patients to live more healthy (70% and 72%), GPs and PNs can motivate hypertensive patients to follow advice (79% and 70%), GPs and PNs could be important support to stop smoking (82% and 65%), can contribute to a healthier way of living (45%)]  No  Makrides, 1997, Canada  Qualitative  Structural obstacles (funding, time, patient’s expectations, sparse community resources) Organizational (inadequate space, organization of practice around the traditional treatment-oriented medical model, negative staff attitude toward prevention) Personal (negative attitude toward prevention, lack of motivation, inadequate counselling skills, poor memory)  Identify prevention strategies: Viewing all visits as an opportunity for prevention Targeting risk factors Providing one-on-one counselling Providing group counselling Providing simple educational materials Offering clear and consistent advice Ensuring adequate follow-up Referring to other health professionals and community resources Enlisting the help of family and friends Identifying/addressing patient’s personal obstacles Identifying/addressing socio-environmental obstacles  No  Grant, 1998, Canada  Quantitative  Interventions to improve lifestyle ineffective (stress reduction 72.2%, weight loss 69.2%, smoking 59.1%, increasing physical activity 58.1%, diet 48.1%) Uncertain efficacy of available interventions (51.9%)  Relationship with patients (96.7%) Personal knowledge (77.6%) Compliance of patients (75.0%) Personal commitment (66.7%) Efficacy of available interventions (50.0%) Availability of time (41.0%) Opportunity to refer (28.2%) Organization of practice (25.6%) Good skill in managing risk factors (from 84.5% for council for lifestyle factors to 99.3% in screening)  Focus on knowledge of different risk factors  Steptoe, 1999, UK  Quantitative  Difficult to counsel patients about an alternative lifestyle (GP 24.8%, PN 25.5%; GP 53.5%, PN 60.0% neutral) Doubt that health professionals very influential in persuading people to change lifestyle (GP 62.5%, PN 62.5% neutral) Doubt that lifestyle counselling is very effective (GP 70.5% neutral) Doubt that you can offer patients a great deal in the way of lifestyle counselling (GP 75.0%, PN 50.0% neutral) Doubt that lifestyle counselling is very effective (GP 70.5%, PN 42.9% neutral)  Responsibility to act as a health educator (GP 70.2%, PN 87.5%) Have time for prevention (GP 29.8%, PN 62.5%) Feel properly trained (GP 48.6%, PN 48.2%) Health professionals very influential in persuading people to change lifestyle (GP 24.0%, PN 33.9%) Can offer patients a great deal in the way of lifestyle counselling (GP 17.3%, PN 50.0%) Lifestyle counselling is very effective (GP 20.0%, PN 53.6%) Possible to persuade patients to modify lifestyle: Hypertension (GP 50.0%, PN 62.5%), high cholesterol (GP 44.2%, 58.9%), smoking (GP 34.6%, 23.2%), obesity (GP 25.0%, PN 32.1%), physical activity (GP 24.0%, PN 34.5%) Overall attitude of effectiveness of lifestyle modification (6.57 of scale 0–10, higher score more effective)    Williams, 2004, UK (Wales)  Qualitative  Existing workload, lack of resources Questionable role of primary care as a ‘screening service’, and not responsibility of primary care Prevention: the responsibility of individuals, and agencies other than primary care, especially outside the health sector Conflict and concern about increasing specialization (here diabetes) Perceived low motivation of patients to modify their lifestyle Unnecessary medicalization No evidence that interventions delivered through primary care are effective  Importance of prevention High-risk patients should be seen anyway  Concerns type 2 diabetes only  Wright, 2006, UK  Qualitative  Lack of appropriate resources in existing services, e.g. time, trained staff Lack of funding Lack of familiarity in general practice with severe mental illness, also negative attitudes to work with these patients Lack of knowledge regarding CHD risk factor screening and difficulties in interpreting screening results and implementing appropriate interventions Mental patients harder to engage, prior experience of low attendance, perceived difficulty in making lifestyle changes A screening offer might be viewed as interference in patients' lives, and some patients get anxious Lack of appropriate services to refer patients Staff resistance to more changes in their role  Flexible solutions with clear lines of responsibility for assessing, communicating and managing CHD risks Mental patients are at high risk, with bad lifestyle manners, needing interventions GPs possess medical expertise Less stigmatising to attend primary care for screening Patients have better links, trust and a longer history with their GP  Concerns patients with severe mental illness Views from both primary care and community mental health teams  Pelletier-Fleury, 2007, France  Quantitative  Urban practicea (OR 0.66; 95% CI 0.65–0.68) Density of GPsa (OR 0.76; 95% CI 0.63–0.92)  Daily work loada (OR 1.03, 95% CI 1.01–1.05) Elderly patient list (>65 y)a (OR 1.04; 95% CI 1.02–1.07) High health care consumptiona (OR 4.29; 95% CI 3.62–5.00)  Register study of preventive services  Amoroso, 2009, Australia  Qualitative  Time Low remuneration Attitude that prevention do not have a high priority Attitude of scepticism about the value of a health check Management, in particular motivating patients to change their behaviour, proved to be more difficult  A useful opportunity to assess and manage risk factors A belief that preventive care was part of their role and responsibility Health check feasible   Short follow-up time  Ampt, 2009, Australia  Qualitative  Time Doubt on the effectiveness of general dietary recommendations Motivational interviewing good in theory, but difficult in practice Difficult to motivate patients to change behaviour Difficult in motivating patients to stop smoking Negative attitudes towards assessment of nutrition, alcohol and physical activity Cost of follow-up visit Difficult to access referrals in working hours Lack of knowledge regarding the role of the exercise physiologist Advice offered by a dietician would be no different to that offered by the GP, and thus referrals were of little value  Usefulness of a computer-based template or patient education and assessment resources Training in motivational interviewing Experience and interest in addressing drug and alcohol issues Giving advice and educating the patient were viewed as a professional responsibility Printed material reinforced any message Practice having an appointment system, as follow-ups could more easily be arranged Quitline (a free smoking referral telephone service) has no restriction to working hours Support services could actually help to motivate patients Potential greater success may be achieved by addressing whichever factor the patient was more ready to change first Primary care teams can play a major role in affecting patients’ ideas  Selection bias towards higher participation among health care professional with an interest for prevention  Graffy, 2010, UK  Quantitative  Workload  Importance of administrative support Efficient systems to identify, invite and follow up patients Flexible appointments for people in work Tagging notes to invite non-attenders when they consult Team meetings contribute to a sense of ownership Training, both at the outset and for new staff Seeing patients benefiting of screening affirms the sense of the value of screening  Selection bias with participation of practices with screening experiences Concerns screening of type 2 diabetes, positive experiences  Wan, 2010, Australia  Qualitative  Low awareness among patients Time pressure Risk of ‘touting for business’ when booking another visit for risk discussion with a new patient  A strong GP–patient relationship, common ground on priorities between GPs and their patients, Patient’s self-motivation a key issue Opportunistic screening easier with regular patients   Selection bias with including GPs with interest in prevention Study included both patients and health care staff  Voogdt-Pruis, 2011, The Netherlands  Qualitative  Workload Lack of physical space Lack of motivation for patients Lack of GP knowledge about the guidelines Different attitudes towards treatment targets Lack of communication, between nurses and GPs and between GPs and second care Insufficient coaching by doctors Content of lifestyle advice Concern of losing nursing tasks for nurses Lack of ability of stop-smoking treatment Organizational issues (insufficient patient recording and computer systems) Considerable effort to get patients to attend, difficult to motivate patients who rarely visited the practice Poor record keeping (smoking behaviour, diagnoses and treatment by specialist)  Nurses could play an important role in preventive care Extending clinic opening hours Desirable to implement a chain of care and an integrated electronic patient record system  Experiences of implementing nurse-delivered prevention  Doolan-Noble, 2012, New Zealand  Qualitative  Time and workload Insufficient funding Lack of strong leadership and consistent messages Difficulty in handling asymptomatic high CV risk patients, and to communicate and motivating behaviour change (e.g. low SES patients, fatalistic views of patients) Attitude of low benefits of behaviour change Design of flip charts unsatisfactory  Ensure infrastructure, including training and to consider how the programme would be implemented Co-location of allied health staff in an integrated centre The need for ongoing tobacco legislation and positive food legislation Clarity around the roles and responsibilities of GPs and practice nurses Primary health care’s longitudinal relationship with patients Attitude of high benefits of behaviour change Useful electronic tools Incentives for patients for motivation and support lifestyle changes  No  Huy, 2012, Germany  Quantitativeb  Lack of time (91%) Insufficient renumeration (92%) Many different guidelines (73%) Unclear recommendations (60%) Lack of training (70%) Lack of material for patients (77%) Lack of adherence among patients (98%)   I can offer my patients a wide range of lifestyle advice (49.1%)a (OR 3.55; 95% CI 1.82–6.93) Risk factor questionnaires in the waiting room (61.5%)a (OR 2.26; 95% CI 1.06–4.85) Female gender of GPa (OR 1.98; 95% CI 1.04–3.76) Knowledge about positive lifestyle effect (54%) Prevention is a GP responsibility (40.9%) Not difficult to give advice on lifestyle changes (47.0%) Well educated for advice on healthy lifestyle (44.2%) Can successfully motivate patients to live healthier (45.6%)  Response rate 13%  Sondergaard, 2012, Denmark  Qualitative  Reservations if the health checks were a core mission of primary care Uncertainty about the best approach Reservations about inducing negative psychological reactions and decreased well-being among patients  Preventive health checks beneficial for the patients  No  Ferrante, 2013, Argentina  Qualitative  Lack of awareness of guidelines Lack of knowledge about preventing cardiovascular disease Communication problems within health teams Lack of motivation Organizational problems Low quality of recording  Intervention tailored to target identified barriers  Focused on barriers for designing an intervention  George, 2013, Singapore  Mixed  Lack of direct access/co-management with renal physician Lack of interest Nature of my practice Lack of confidence and faith Lack of sufficient support and experience Lack of time to keep up-to-date. Lack of medicine for CKD Lack of IT support. Too much paperwork Lack of patient education Poor patient compliance Lack of family/ social support management Lack of time to explain to the patient cQuantitative results: Lack of access to patient’s information (from hospital) (4.7) Lack of access to evidence-based guidelines (4.3) Inability to bill (4.5) Lack of patient’s trust in GP (3.9) Inability for patient to pay (3.7) Lack of time for consultation (3.6) Lack of support services (staff, technical) (2.3)  Access to/co-operation with renal specialist Adequate remuneration Technological assistance, IT Patient education, also to trust the GPs cQuantitative results: Less cost for patient (2.5) Access to patient’s information (2.8) Access to updates and guidelines (3.0) More support services (3.2) Less time consumed (3.3)   Concerns screening for chronic kidney disease Response rate of quantitative survey 25%  Godefrooij, 2014, The Netherlands  Qualitative  Lack of experience in the design and implementation of a structured, large-scale prevention programme, suboptimal instruction of involved staff No clear policy about how to follow up patients with ‘medium risk’, not exceeding the risk to be referred to their GP  Importance of primary prevention (high yield of health check, helped GPs to identify their high-risk population in a structured manner) Collaboration, i.e. ‘delegation of care’, health checks were delivered by medical receptionists and practice nurses, and GPs involved for high-risk patients  Study included both patients and health care staff  Vos, 2014, The Netherlands  Qualitative  Organizational context: insufficient reimbursement Professional context: lack of evidence and guidelines Social context: no focus on prevention  Organizational context: sufficient logistic and practical support and finances Responsibility to offer prevention, equity Professional context: evidence and guidelines Social context: prevention focused on  No  Baker, 2015 UK  Mixed  Extra workload Insufficient knowledge Lack of information collected by the practice prior to the appointment Programme tools developed to aid the assessment process and reduce staff time were not necessarily being used to their full effect Difficulty in engaging patients who were potentially able to receive the most benefit Less confident in second appointments (CVD risk assessment, mean = 3.52, SD = 1.3), risk communication (mean = 2.68, SD = 0.1.8) and changing behaviours (mean = 2.44, SD = 1.6) Mixed opinions concerning the quality of lifestyle services referred to: Weight management (mean = 3.76, SD = 0.90) and alcohol services (mean = 3.76, SD = 0.90) were the lowest rated Some participants were not aware of what health trainers were Caution concerning the programme’s overall effectiveness  Opportunistic approaches Practices periodically reviewed the non-responder list and reissued invites Practices were most confident in first appointments (pre-assessment blood tests, mean = 4.12, SD = 0.60), invitations (mean = 4.04, SD = 0.79) and laboratory tests (mean = 4.04, SD = 0.79) Mixed opinions concerning the quality of lifestyle services referred to: smoking cessation was rated most highly (mean = 4.43, SD = 0.59), health trainers were rated highly (mean = 4.13, SD = 0.83) HCs were useful in early detection and giving the time to discuss patient health and lifestyles (72%) Delivery of HCs in a wider range of settings, e.g. work places More than two-thirds (70.8%) of practice staff indicated that they had training in CVD prevention and 44% (n = 11) indicated that they required further training A need to promote the programme more effectively Conclusions: Adopting continuous approaches to knowledge development and transfer; improve confidence in HCs to deliver meaningful results  Small sample size, no response rate given  Barfoed, 2015, Denmark  Qualitative  Guidelines inhibit the ability to practice independently as a GP Risk communication tools are insufficient Resigned approach to manage patient compliance  Guidelines good and applicable Use of different communication tools depending on the patient context Confrontational approach to manage low patient compliance  No  Diehl, 2015, Germany  Quantitative  Insufficient reimbursement (90.2%) Difficult to give advice on unhealthy habits (73.5%) Cultural differences (59.1%) Insufficient connection with other preventive service providers (56.7%) Lack of time (54.5%) Attitude that patients cannot change lifestyle (49.1%) Difficult to follow guidelines (too many (43.1%), insufficient evidence (28.5%), unclear recommendations (24.9%) Lack of education/training (24.8%)  Responsibility to take a role as a health advisor (96.2%) Feeling well prepared for and successful of prevention (80.9%) Successful in motivating patients to a healthy lifestyle (72.6%) Networking with cooperation partners (70.7%) Being one of the most important influence factors on patients lifestyle (69.3%)  Response rate 34%  Gavarkovs, 2015, Canada  Qualitative  Time and travel constraints Unawareness of spouses of disease prevention programmes Lack of suitable male programme leaders Interfering with high work season of patients  Hiring qualified male instructors Engaging spouses  Concerns recruiting male participants in a rural district  Ismail, 2015, UK  Qualitative  Lack of staff time/hours, increased workload Lack of space in the building Insufficient software Lack of leaflets and posters Lack of awareness of health checks Lack of resources to motivate and support patients in lifestyle changes Problems in reaching important groups with unhealthy behaviours and low motivation for changes Lack of adherence to advices Interference with working time of possible attendants Doubt on impact of the programme Lack of referral services  Evolution of the programme over time in response to local needs to suit the particular characteristics of the patient population Individual staff characteristics such as being proactive, enthusiastic and having specific responsibility A supportive team Clear information to patients what the screening entails, including possible benefits and potential harm Messages in media to raise awareness of health checks Importance of the existing relationships between GPs and patients Attitude that health checks are beneficial and to identify high-risk patients Attendants are motivated and open to advice  No  Riley, 2015, UK  Qualitative  Concerns about the skill set of some staff to competently communicate risk and lifestyle information  Sufficient training to equip health care staff with appropriate skills and knowledge to deliver the service effectively  Study included both patients and staff  Krska, 2016, UK  Qualitative  Time constraints/pressure of work Increased nurse workload impacted on other services Insufficient payments Problems with software Attitude that health checks are a waste of time  IT support Effective software Health checks beneficial for patients  Focus on implementation of health checks  Author, publication year, country  Type of study  Barriers  Facilitators  Bias and potential quality short-comings  Mann, 1990, Canada  Qualitative  Knowledge, attitudes and perceptions (lack of counselling skills, lack of belief in the efficacy of the activities) Conditions in which the activities occur (lack of available and accessible referral, lack of time) Reactions of others to the activities (lack of patient compliance) Difficulties in counselling (lack of appropriate, effective patient education materials)  Engaging a nurse to alleviate lack of time for GPs GPs most effective in dealing with high blood pressure Physician counselling effective in helping patients quit smoking  Focused on barriers to prevention  Calnan, 1993, UK  Quantitative  Negative attitudes to preventiona (health education is dull and boring; causes problems for the patients) Inappropriate skillsa  Positive attitudes to preventiona Training in health promotiona Higher number of practice nursesa GP spends more hours on research and traininga Positive attitudes by female GPsa Assistancea (from facilitator, or authorities) IT supporta  No  Hulscher, 1997, The Netherlands  Quantitative  Poor organization of practice to provide preventive services (lack of registration of activity for self-assessment of progress, lack of written protocols of agreement, not familiar with population approach) Acceptability [risk of causing medicalization in patients at risk for CVD (51%)] Feasibility [not enough time and opportunity (44%), lack of necessary data to screen and detect risk groups (50%)]   Organization of practice [availability of a sex–age registera, regular team work meetingsa, more practice assistance (not significant)] Acceptability [detection and treatment of hypertension will not cause anxiety (51%), patients appreciate monitoring of health (59%)] Responsibility [significant to smaller list size and proactive invitation of patientsa; CVD prevention is an important task in primary care (78%)] Self-efficacy [significant to registration of follow-up appointmentsa; GPs and PNs can motivate patients to live more healthy (70% and 72%), GPs and PNs can motivate hypertensive patients to follow advice (79% and 70%), GPs and PNs could be important support to stop smoking (82% and 65%), can contribute to a healthier way of living (45%)]  No  Makrides, 1997, Canada  Qualitative  Structural obstacles (funding, time, patient’s expectations, sparse community resources) Organizational (inadequate space, organization of practice around the traditional treatment-oriented medical model, negative staff attitude toward prevention) Personal (negative attitude toward prevention, lack of motivation, inadequate counselling skills, poor memory)  Identify prevention strategies: Viewing all visits as an opportunity for prevention Targeting risk factors Providing one-on-one counselling Providing group counselling Providing simple educational materials Offering clear and consistent advice Ensuring adequate follow-up Referring to other health professionals and community resources Enlisting the help of family and friends Identifying/addressing patient’s personal obstacles Identifying/addressing socio-environmental obstacles  No  Grant, 1998, Canada  Quantitative  Interventions to improve lifestyle ineffective (stress reduction 72.2%, weight loss 69.2%, smoking 59.1%, increasing physical activity 58.1%, diet 48.1%) Uncertain efficacy of available interventions (51.9%)  Relationship with patients (96.7%) Personal knowledge (77.6%) Compliance of patients (75.0%) Personal commitment (66.7%) Efficacy of available interventions (50.0%) Availability of time (41.0%) Opportunity to refer (28.2%) Organization of practice (25.6%) Good skill in managing risk factors (from 84.5% for council for lifestyle factors to 99.3% in screening)  Focus on knowledge of different risk factors  Steptoe, 1999, UK  Quantitative  Difficult to counsel patients about an alternative lifestyle (GP 24.8%, PN 25.5%; GP 53.5%, PN 60.0% neutral) Doubt that health professionals very influential in persuading people to change lifestyle (GP 62.5%, PN 62.5% neutral) Doubt that lifestyle counselling is very effective (GP 70.5% neutral) Doubt that you can offer patients a great deal in the way of lifestyle counselling (GP 75.0%, PN 50.0% neutral) Doubt that lifestyle counselling is very effective (GP 70.5%, PN 42.9% neutral)  Responsibility to act as a health educator (GP 70.2%, PN 87.5%) Have time for prevention (GP 29.8%, PN 62.5%) Feel properly trained (GP 48.6%, PN 48.2%) Health professionals very influential in persuading people to change lifestyle (GP 24.0%, PN 33.9%) Can offer patients a great deal in the way of lifestyle counselling (GP 17.3%, PN 50.0%) Lifestyle counselling is very effective (GP 20.0%, PN 53.6%) Possible to persuade patients to modify lifestyle: Hypertension (GP 50.0%, PN 62.5%), high cholesterol (GP 44.2%, 58.9%), smoking (GP 34.6%, 23.2%), obesity (GP 25.0%, PN 32.1%), physical activity (GP 24.0%, PN 34.5%) Overall attitude of effectiveness of lifestyle modification (6.57 of scale 0–10, higher score more effective)    Williams, 2004, UK (Wales)  Qualitative  Existing workload, lack of resources Questionable role of primary care as a ‘screening service’, and not responsibility of primary care Prevention: the responsibility of individuals, and agencies other than primary care, especially outside the health sector Conflict and concern about increasing specialization (here diabetes) Perceived low motivation of patients to modify their lifestyle Unnecessary medicalization No evidence that interventions delivered through primary care are effective  Importance of prevention High-risk patients should be seen anyway  Concerns type 2 diabetes only  Wright, 2006, UK  Qualitative  Lack of appropriate resources in existing services, e.g. time, trained staff Lack of funding Lack of familiarity in general practice with severe mental illness, also negative attitudes to work with these patients Lack of knowledge regarding CHD risk factor screening and difficulties in interpreting screening results and implementing appropriate interventions Mental patients harder to engage, prior experience of low attendance, perceived difficulty in making lifestyle changes A screening offer might be viewed as interference in patients' lives, and some patients get anxious Lack of appropriate services to refer patients Staff resistance to more changes in their role  Flexible solutions with clear lines of responsibility for assessing, communicating and managing CHD risks Mental patients are at high risk, with bad lifestyle manners, needing interventions GPs possess medical expertise Less stigmatising to attend primary care for screening Patients have better links, trust and a longer history with their GP  Concerns patients with severe mental illness Views from both primary care and community mental health teams  Pelletier-Fleury, 2007, France  Quantitative  Urban practicea (OR 0.66; 95% CI 0.65–0.68) Density of GPsa (OR 0.76; 95% CI 0.63–0.92)  Daily work loada (OR 1.03, 95% CI 1.01–1.05) Elderly patient list (>65 y)a (OR 1.04; 95% CI 1.02–1.07) High health care consumptiona (OR 4.29; 95% CI 3.62–5.00)  Register study of preventive services  Amoroso, 2009, Australia  Qualitative  Time Low remuneration Attitude that prevention do not have a high priority Attitude of scepticism about the value of a health check Management, in particular motivating patients to change their behaviour, proved to be more difficult  A useful opportunity to assess and manage risk factors A belief that preventive care was part of their role and responsibility Health check feasible   Short follow-up time  Ampt, 2009, Australia  Qualitative  Time Doubt on the effectiveness of general dietary recommendations Motivational interviewing good in theory, but difficult in practice Difficult to motivate patients to change behaviour Difficult in motivating patients to stop smoking Negative attitudes towards assessment of nutrition, alcohol and physical activity Cost of follow-up visit Difficult to access referrals in working hours Lack of knowledge regarding the role of the exercise physiologist Advice offered by a dietician would be no different to that offered by the GP, and thus referrals were of little value  Usefulness of a computer-based template or patient education and assessment resources Training in motivational interviewing Experience and interest in addressing drug and alcohol issues Giving advice and educating the patient were viewed as a professional responsibility Printed material reinforced any message Practice having an appointment system, as follow-ups could more easily be arranged Quitline (a free smoking referral telephone service) has no restriction to working hours Support services could actually help to motivate patients Potential greater success may be achieved by addressing whichever factor the patient was more ready to change first Primary care teams can play a major role in affecting patients’ ideas  Selection bias towards higher participation among health care professional with an interest for prevention  Graffy, 2010, UK  Quantitative  Workload  Importance of administrative support Efficient systems to identify, invite and follow up patients Flexible appointments for people in work Tagging notes to invite non-attenders when they consult Team meetings contribute to a sense of ownership Training, both at the outset and for new staff Seeing patients benefiting of screening affirms the sense of the value of screening  Selection bias with participation of practices with screening experiences Concerns screening of type 2 diabetes, positive experiences  Wan, 2010, Australia  Qualitative  Low awareness among patients Time pressure Risk of ‘touting for business’ when booking another visit for risk discussion with a new patient  A strong GP–patient relationship, common ground on priorities between GPs and their patients, Patient’s self-motivation a key issue Opportunistic screening easier with regular patients   Selection bias with including GPs with interest in prevention Study included both patients and health care staff  Voogdt-Pruis, 2011, The Netherlands  Qualitative  Workload Lack of physical space Lack of motivation for patients Lack of GP knowledge about the guidelines Different attitudes towards treatment targets Lack of communication, between nurses and GPs and between GPs and second care Insufficient coaching by doctors Content of lifestyle advice Concern of losing nursing tasks for nurses Lack of ability of stop-smoking treatment Organizational issues (insufficient patient recording and computer systems) Considerable effort to get patients to attend, difficult to motivate patients who rarely visited the practice Poor record keeping (smoking behaviour, diagnoses and treatment by specialist)  Nurses could play an important role in preventive care Extending clinic opening hours Desirable to implement a chain of care and an integrated electronic patient record system  Experiences of implementing nurse-delivered prevention  Doolan-Noble, 2012, New Zealand  Qualitative  Time and workload Insufficient funding Lack of strong leadership and consistent messages Difficulty in handling asymptomatic high CV risk patients, and to communicate and motivating behaviour change (e.g. low SES patients, fatalistic views of patients) Attitude of low benefits of behaviour change Design of flip charts unsatisfactory  Ensure infrastructure, including training and to consider how the programme would be implemented Co-location of allied health staff in an integrated centre The need for ongoing tobacco legislation and positive food legislation Clarity around the roles and responsibilities of GPs and practice nurses Primary health care’s longitudinal relationship with patients Attitude of high benefits of behaviour change Useful electronic tools Incentives for patients for motivation and support lifestyle changes  No  Huy, 2012, Germany  Quantitativeb  Lack of time (91%) Insufficient renumeration (92%) Many different guidelines (73%) Unclear recommendations (60%) Lack of training (70%) Lack of material for patients (77%) Lack of adherence among patients (98%)   I can offer my patients a wide range of lifestyle advice (49.1%)a (OR 3.55; 95% CI 1.82–6.93) Risk factor questionnaires in the waiting room (61.5%)a (OR 2.26; 95% CI 1.06–4.85) Female gender of GPa (OR 1.98; 95% CI 1.04–3.76) Knowledge about positive lifestyle effect (54%) Prevention is a GP responsibility (40.9%) Not difficult to give advice on lifestyle changes (47.0%) Well educated for advice on healthy lifestyle (44.2%) Can successfully motivate patients to live healthier (45.6%)  Response rate 13%  Sondergaard, 2012, Denmark  Qualitative  Reservations if the health checks were a core mission of primary care Uncertainty about the best approach Reservations about inducing negative psychological reactions and decreased well-being among patients  Preventive health checks beneficial for the patients  No  Ferrante, 2013, Argentina  Qualitative  Lack of awareness of guidelines Lack of knowledge about preventing cardiovascular disease Communication problems within health teams Lack of motivation Organizational problems Low quality of recording  Intervention tailored to target identified barriers  Focused on barriers for designing an intervention  George, 2013, Singapore  Mixed  Lack of direct access/co-management with renal physician Lack of interest Nature of my practice Lack of confidence and faith Lack of sufficient support and experience Lack of time to keep up-to-date. Lack of medicine for CKD Lack of IT support. Too much paperwork Lack of patient education Poor patient compliance Lack of family/ social support management Lack of time to explain to the patient cQuantitative results: Lack of access to patient’s information (from hospital) (4.7) Lack of access to evidence-based guidelines (4.3) Inability to bill (4.5) Lack of patient’s trust in GP (3.9) Inability for patient to pay (3.7) Lack of time for consultation (3.6) Lack of support services (staff, technical) (2.3)  Access to/co-operation with renal specialist Adequate remuneration Technological assistance, IT Patient education, also to trust the GPs cQuantitative results: Less cost for patient (2.5) Access to patient’s information (2.8) Access to updates and guidelines (3.0) More support services (3.2) Less time consumed (3.3)   Concerns screening for chronic kidney disease Response rate of quantitative survey 25%  Godefrooij, 2014, The Netherlands  Qualitative  Lack of experience in the design and implementation of a structured, large-scale prevention programme, suboptimal instruction of involved staff No clear policy about how to follow up patients with ‘medium risk’, not exceeding the risk to be referred to their GP  Importance of primary prevention (high yield of health check, helped GPs to identify their high-risk population in a structured manner) Collaboration, i.e. ‘delegation of care’, health checks were delivered by medical receptionists and practice nurses, and GPs involved for high-risk patients  Study included both patients and health care staff  Vos, 2014, The Netherlands  Qualitative  Organizational context: insufficient reimbursement Professional context: lack of evidence and guidelines Social context: no focus on prevention  Organizational context: sufficient logistic and practical support and finances Responsibility to offer prevention, equity Professional context: evidence and guidelines Social context: prevention focused on  No  Baker, 2015 UK  Mixed  Extra workload Insufficient knowledge Lack of information collected by the practice prior to the appointment Programme tools developed to aid the assessment process and reduce staff time were not necessarily being used to their full effect Difficulty in engaging patients who were potentially able to receive the most benefit Less confident in second appointments (CVD risk assessment, mean = 3.52, SD = 1.3), risk communication (mean = 2.68, SD = 0.1.8) and changing behaviours (mean = 2.44, SD = 1.6) Mixed opinions concerning the quality of lifestyle services referred to: Weight management (mean = 3.76, SD = 0.90) and alcohol services (mean = 3.76, SD = 0.90) were the lowest rated Some participants were not aware of what health trainers were Caution concerning the programme’s overall effectiveness  Opportunistic approaches Practices periodically reviewed the non-responder list and reissued invites Practices were most confident in first appointments (pre-assessment blood tests, mean = 4.12, SD = 0.60), invitations (mean = 4.04, SD = 0.79) and laboratory tests (mean = 4.04, SD = 0.79) Mixed opinions concerning the quality of lifestyle services referred to: smoking cessation was rated most highly (mean = 4.43, SD = 0.59), health trainers were rated highly (mean = 4.13, SD = 0.83) HCs were useful in early detection and giving the time to discuss patient health and lifestyles (72%) Delivery of HCs in a wider range of settings, e.g. work places More than two-thirds (70.8%) of practice staff indicated that they had training in CVD prevention and 44% (n = 11) indicated that they required further training A need to promote the programme more effectively Conclusions: Adopting continuous approaches to knowledge development and transfer; improve confidence in HCs to deliver meaningful results  Small sample size, no response rate given  Barfoed, 2015, Denmark  Qualitative  Guidelines inhibit the ability to practice independently as a GP Risk communication tools are insufficient Resigned approach to manage patient compliance  Guidelines good and applicable Use of different communication tools depending on the patient context Confrontational approach to manage low patient compliance  No  Diehl, 2015, Germany  Quantitative  Insufficient reimbursement (90.2%) Difficult to give advice on unhealthy habits (73.5%) Cultural differences (59.1%) Insufficient connection with other preventive service providers (56.7%) Lack of time (54.5%) Attitude that patients cannot change lifestyle (49.1%) Difficult to follow guidelines (too many (43.1%), insufficient evidence (28.5%), unclear recommendations (24.9%) Lack of education/training (24.8%)  Responsibility to take a role as a health advisor (96.2%) Feeling well prepared for and successful of prevention (80.9%) Successful in motivating patients to a healthy lifestyle (72.6%) Networking with cooperation partners (70.7%) Being one of the most important influence factors on patients lifestyle (69.3%)  Response rate 34%  Gavarkovs, 2015, Canada  Qualitative  Time and travel constraints Unawareness of spouses of disease prevention programmes Lack of suitable male programme leaders Interfering with high work season of patients  Hiring qualified male instructors Engaging spouses  Concerns recruiting male participants in a rural district  Ismail, 2015, UK  Qualitative  Lack of staff time/hours, increased workload Lack of space in the building Insufficient software Lack of leaflets and posters Lack of awareness of health checks Lack of resources to motivate and support patients in lifestyle changes Problems in reaching important groups with unhealthy behaviours and low motivation for changes Lack of adherence to advices Interference with working time of possible attendants Doubt on impact of the programme Lack of referral services  Evolution of the programme over time in response to local needs to suit the particular characteristics of the patient population Individual staff characteristics such as being proactive, enthusiastic and having specific responsibility A supportive team Clear information to patients what the screening entails, including possible benefits and potential harm Messages in media to raise awareness of health checks Importance of the existing relationships between GPs and patients Attitude that health checks are beneficial and to identify high-risk patients Attendants are motivated and open to advice  No  Riley, 2015, UK  Qualitative  Concerns about the skill set of some staff to competently communicate risk and lifestyle information  Sufficient training to equip health care staff with appropriate skills and knowledge to deliver the service effectively  Study included both patients and staff  Krska, 2016, UK  Qualitative  Time constraints/pressure of work Increased nurse workload impacted on other services Insufficient payments Problems with software Attitude that health checks are a waste of time  IT support Effective software Health checks beneficial for patients  Focus on implementation of health checks  Baker: 1–5 scale. Percentages denote rate of participants giving this statement. CDPM, community-based chronic disease prevention and management; CHD, coronary heart disease; CKD, chronic kidney disease; CMHT, community mental health teams; CVD, cardiovascular diseases; HC, health care; PHCs, primary health care centres; PMs, practice managers; PNs, practice nurses; SES, socioeconomic status. aSignificant factors when statistical analyses were performed [with odds ratio (OR) and 95% confidence interval (95% CI) when shown in the article]. bObstacles include great, medium or small barriers. cObstacles mean rank of severity (1–7, 1 denotes easiest obstacle, 7 most difficult); motivational factors mean rank of motivation (1–5, 1 the most motivating factor, 5 the least motivating factor). View Large A complete overview of barriers and facilitators from both qualitative and quantitative studies is shown in Table 3 and organized in five fundamental categories: structural, organizational context, professional context, patient-oriented factors and attitudes. Table 3. Overview of barriers and facilitators in health care professionals to do selective primary prevention of cardiometabolic diseases in patients without established disease in primary care (The search was conducted in March 2016.) Context  Barriers  Facilitators  Structural context  Lack of time, extra workload (18 studies) Lack of space in the building (3 studies) Insufficient reimbursement or community resources (10 studies) Guidelines: lack of awareness of guidelines, lack of evidence and guidelines, too many guidelines in the area, or difficult to follow guidelines) (6 studies) Lack of available and accessible referral (5 studies) Lack of assistance and support from authorities (2 studies) Lack of material for patients (4 studies) Lack of effective and feasible counselling (12 studies) Problems related to follow-up (2 studies)   Availability of time (3 studies)a Sufficient finances (2 studies) Access to good guidelines (2 studies) Ensuring adequate referral (3 studies)a Ensuring adequate follow-up (2 studies)a Assistance and support from authorities (4 studies)a Identifying obstacles for prevention (3 studies) Providing information and educational materials (3 study) Counselling and interventions feasible and effective (10 studies)a Information in media (1 study) Legislation for unhealthy habits (e.g. smoking) (1 study)  Organizational context  Organizational problems in general (3 studies) Lack of strong leadership and consistent messages (1 study) Lack of IT support, software (5 studies) Lack of local support services, communication problems (4 studies) Insufficient connection with other preventive service providers (1 study) Lack of access to information on patients (5 studies) Low quality of recording (2 studies) Lack of suitable appointment times for employed patients (3 studies) Role of practices, no responsibility to offer prevention (6 studies) Roles of primary care staff (4 studies)   Structured organization of practice (4 studies)a IT support (5 studies)a Assistance and support within practice and teams (8 studies)a Important role of practice nurses (4 studies)a Cooperation with allied health staff or community resources (3 studies) Access to patient information or register (2 studies)a Integrated electronic patient record system (1 study) Appointment system (2 studies) Intervention tailored to target identified barriers (2 study) Flexibility in counselling (5 study)a Responsibility to offer and importance of prevention (10 studies) Useful opportunity of health checks and prevention (5 studies)  Professional context  Lack of education/training/skills to competently communicate risk and lifestyle information (lack of counselling skills) (6 studies)a Lack of knowledge (5 studies) Lack of experience (3 studies)  Sufficient training and education (10 studies)a Effective in motivating patients (4 studies) Sufficient knowledge (1 study) Female GPs (2 studies)a  Patient-oriented factors  Low awareness of patients (1 study) Low adherence of patients (9 studies) Lack of trust in GP–patient relation (1 study) Lack of social support from families or friends (1 study) Causes problems, i.e. anxiety and medicalization (5 studies) Cultural differences (1 study)  Motivation of patients (2 studies) A strong/longitudinal GP–patient relationship (5 studies) Enlisting the support from family and friends (2 studies) Appreciated by patients (4 studies)  Attitudes  Negative attitudes in general to prevention (16 studies) Doubt on acceptability (1 study) Doubt on feasibility (1 study)  Positive attitudes to prevention in general (14 studies)a Acceptability (1 study) Feasibility (1 study)  Context  Barriers  Facilitators  Structural context  Lack of time, extra workload (18 studies) Lack of space in the building (3 studies) Insufficient reimbursement or community resources (10 studies) Guidelines: lack of awareness of guidelines, lack of evidence and guidelines, too many guidelines in the area, or difficult to follow guidelines) (6 studies) Lack of available and accessible referral (5 studies) Lack of assistance and support from authorities (2 studies) Lack of material for patients (4 studies) Lack of effective and feasible counselling (12 studies) Problems related to follow-up (2 studies)   Availability of time (3 studies)a Sufficient finances (2 studies) Access to good guidelines (2 studies) Ensuring adequate referral (3 studies)a Ensuring adequate follow-up (2 studies)a Assistance and support from authorities (4 studies)a Identifying obstacles for prevention (3 studies) Providing information and educational materials (3 study) Counselling and interventions feasible and effective (10 studies)a Information in media (1 study) Legislation for unhealthy habits (e.g. smoking) (1 study)  Organizational context  Organizational problems in general (3 studies) Lack of strong leadership and consistent messages (1 study) Lack of IT support, software (5 studies) Lack of local support services, communication problems (4 studies) Insufficient connection with other preventive service providers (1 study) Lack of access to information on patients (5 studies) Low quality of recording (2 studies) Lack of suitable appointment times for employed patients (3 studies) Role of practices, no responsibility to offer prevention (6 studies) Roles of primary care staff (4 studies)   Structured organization of practice (4 studies)a IT support (5 studies)a Assistance and support within practice and teams (8 studies)a Important role of practice nurses (4 studies)a Cooperation with allied health staff or community resources (3 studies) Access to patient information or register (2 studies)a Integrated electronic patient record system (1 study) Appointment system (2 studies) Intervention tailored to target identified barriers (2 study) Flexibility in counselling (5 study)a Responsibility to offer and importance of prevention (10 studies) Useful opportunity of health checks and prevention (5 studies)  Professional context  Lack of education/training/skills to competently communicate risk and lifestyle information (lack of counselling skills) (6 studies)a Lack of knowledge (5 studies) Lack of experience (3 studies)  Sufficient training and education (10 studies)a Effective in motivating patients (4 studies) Sufficient knowledge (1 study) Female GPs (2 studies)a  Patient-oriented factors  Low awareness of patients (1 study) Low adherence of patients (9 studies) Lack of trust in GP–patient relation (1 study) Lack of social support from families or friends (1 study) Causes problems, i.e. anxiety and medicalization (5 studies) Cultural differences (1 study)  Motivation of patients (2 studies) A strong/longitudinal GP–patient relationship (5 studies) Enlisting the support from family and friends (2 studies) Appreciated by patients (4 studies)  Attitudes  Negative attitudes in general to prevention (16 studies) Doubt on acceptability (1 study) Doubt on feasibility (1 study)  Positive attitudes to prevention in general (14 studies)a Acceptability (1 study) Feasibility (1 study)  The numbers of studies reporting a specific factor are given. aSignificant factors when statistical analyses were performed. View Large Table 3. Overview of barriers and facilitators in health care professionals to do selective primary prevention of cardiometabolic diseases in patients without established disease in primary care (The search was conducted in March 2016.) Context  Barriers  Facilitators  Structural context  Lack of time, extra workload (18 studies) Lack of space in the building (3 studies) Insufficient reimbursement or community resources (10 studies) Guidelines: lack of awareness of guidelines, lack of evidence and guidelines, too many guidelines in the area, or difficult to follow guidelines) (6 studies) Lack of available and accessible referral (5 studies) Lack of assistance and support from authorities (2 studies) Lack of material for patients (4 studies) Lack of effective and feasible counselling (12 studies) Problems related to follow-up (2 studies)   Availability of time (3 studies)a Sufficient finances (2 studies) Access to good guidelines (2 studies) Ensuring adequate referral (3 studies)a Ensuring adequate follow-up (2 studies)a Assistance and support from authorities (4 studies)a Identifying obstacles for prevention (3 studies) Providing information and educational materials (3 study) Counselling and interventions feasible and effective (10 studies)a Information in media (1 study) Legislation for unhealthy habits (e.g. smoking) (1 study)  Organizational context  Organizational problems in general (3 studies) Lack of strong leadership and consistent messages (1 study) Lack of IT support, software (5 studies) Lack of local support services, communication problems (4 studies) Insufficient connection with other preventive service providers (1 study) Lack of access to information on patients (5 studies) Low quality of recording (2 studies) Lack of suitable appointment times for employed patients (3 studies) Role of practices, no responsibility to offer prevention (6 studies) Roles of primary care staff (4 studies)   Structured organization of practice (4 studies)a IT support (5 studies)a Assistance and support within practice and teams (8 studies)a Important role of practice nurses (4 studies)a Cooperation with allied health staff or community resources (3 studies) Access to patient information or register (2 studies)a Integrated electronic patient record system (1 study) Appointment system (2 studies) Intervention tailored to target identified barriers (2 study) Flexibility in counselling (5 study)a Responsibility to offer and importance of prevention (10 studies) Useful opportunity of health checks and prevention (5 studies)  Professional context  Lack of education/training/skills to competently communicate risk and lifestyle information (lack of counselling skills) (6 studies)a Lack of knowledge (5 studies) Lack of experience (3 studies)  Sufficient training and education (10 studies)a Effective in motivating patients (4 studies) Sufficient knowledge (1 study) Female GPs (2 studies)a  Patient-oriented factors  Low awareness of patients (1 study) Low adherence of patients (9 studies) Lack of trust in GP–patient relation (1 study) Lack of social support from families or friends (1 study) Causes problems, i.e. anxiety and medicalization (5 studies) Cultural differences (1 study)  Motivation of patients (2 studies) A strong/longitudinal GP–patient relationship (5 studies) Enlisting the support from family and friends (2 studies) Appreciated by patients (4 studies)  Attitudes  Negative attitudes in general to prevention (16 studies) Doubt on acceptability (1 study) Doubt on feasibility (1 study)  Positive attitudes to prevention in general (14 studies)a Acceptability (1 study) Feasibility (1 study)  Context  Barriers  Facilitators  Structural context  Lack of time, extra workload (18 studies) Lack of space in the building (3 studies) Insufficient reimbursement or community resources (10 studies) Guidelines: lack of awareness of guidelines, lack of evidence and guidelines, too many guidelines in the area, or difficult to follow guidelines) (6 studies) Lack of available and accessible referral (5 studies) Lack of assistance and support from authorities (2 studies) Lack of material for patients (4 studies) Lack of effective and feasible counselling (12 studies) Problems related to follow-up (2 studies)   Availability of time (3 studies)a Sufficient finances (2 studies) Access to good guidelines (2 studies) Ensuring adequate referral (3 studies)a Ensuring adequate follow-up (2 studies)a Assistance and support from authorities (4 studies)a Identifying obstacles for prevention (3 studies) Providing information and educational materials (3 study) Counselling and interventions feasible and effective (10 studies)a Information in media (1 study) Legislation for unhealthy habits (e.g. smoking) (1 study)  Organizational context  Organizational problems in general (3 studies) Lack of strong leadership and consistent messages (1 study) Lack of IT support, software (5 studies) Lack of local support services, communication problems (4 studies) Insufficient connection with other preventive service providers (1 study) Lack of access to information on patients (5 studies) Low quality of recording (2 studies) Lack of suitable appointment times for employed patients (3 studies) Role of practices, no responsibility to offer prevention (6 studies) Roles of primary care staff (4 studies)   Structured organization of practice (4 studies)a IT support (5 studies)a Assistance and support within practice and teams (8 studies)a Important role of practice nurses (4 studies)a Cooperation with allied health staff or community resources (3 studies) Access to patient information or register (2 studies)a Integrated electronic patient record system (1 study) Appointment system (2 studies) Intervention tailored to target identified barriers (2 study) Flexibility in counselling (5 study)a Responsibility to offer and importance of prevention (10 studies) Useful opportunity of health checks and prevention (5 studies)  Professional context  Lack of education/training/skills to competently communicate risk and lifestyle information (lack of counselling skills) (6 studies)a Lack of knowledge (5 studies) Lack of experience (3 studies)  Sufficient training and education (10 studies)a Effective in motivating patients (4 studies) Sufficient knowledge (1 study) Female GPs (2 studies)a  Patient-oriented factors  Low awareness of patients (1 study) Low adherence of patients (9 studies) Lack of trust in GP–patient relation (1 study) Lack of social support from families or friends (1 study) Causes problems, i.e. anxiety and medicalization (5 studies) Cultural differences (1 study)  Motivation of patients (2 studies) A strong/longitudinal GP–patient relationship (5 studies) Enlisting the support from family and friends (2 studies) Appreciated by patients (4 studies)  Attitudes  Negative attitudes in general to prevention (16 studies) Doubt on acceptability (1 study) Doubt on feasibility (1 study)  Positive attitudes to prevention in general (14 studies)a Acceptability (1 study) Feasibility (1 study)  The numbers of studies reporting a specific factor are given. aSignificant factors when statistical analyses were performed. View Large The most frequently reported structural barriers were related to lack of time and extra workload (18 studies) (25,29,32–38,41,42,44,46–48,50,53,54), lack of feasible or effective counselling or advice (12 studies) (24,32,35,37,39,42,43,47,51–54), insufficient reimbursement (10 studies) (29,30,33,34,38,41,46,47,53,54), or problems with guidelines (6 studies) (30,37,40,41,43,53,54). Other structural barriers reported were related to lack of available and accessible referral instances (5 studies) (25,32,33,35,41), lack of information material for patients (4 studies) (25,32,38,53), lack of space in the building (3 studies) (25,29,37), lack of support and assistance (2 studies) (29,41) and problems related to follow-up of patients (2 studies) (23,35). Structural barriers regarding guidelines involved a lack of access to or awareness of existing guidelines (37,40,41), lack of evidence and/or guidelines on prevention (30,54), or too many guidelines for a specific purpose (41,54). The most reported structural facilitators were feasible and effective counselling and interventions (10 studies) (29,33,34,42,43,46,50–53), available assistance and support (4 studies), availability of time (3 studies) (22,41,52), adequate referral (3 studies) (29,41,50,51), identifying obstacles for prevention (3 studies) (29,39,40), adequate follow-up (2 studies) (29,50), sufficient finances (2 studies) (30,41,52), adequate patient material (2 studies) (29,35) and adequate guidelines (2 studies) (30,41,43). Other identified facilitators were use of media for health messages (24) and use of legislation for unhealthy habits, e.g. smoking (38). The most frequently reported organizational barriers were role of practices, no responsibility to offer prevention (6 studies) (30,32,41,46,47,53), lack of access to information on patients (5 studies) (37,39,41,42,50), lack of IT support (5 studies) (24,37,41,42,46), role of primary care staff (4 studies) (33,37,43,47), lack of assistance and support services including communication problems (4 studies) (37,39,41,44), organizational problems in general (3 studies) (37,39,50) and lack of suitable appointment times for employed patients (3 studies) (25,35,44). Other organizational barriers were lack of strong leadership (38), low quality of recording (37,40) and insufficient connection with other preventive service providers (54). The most frequently reported organizational facilitators were adequate responsibility to offer and importance of prevention(10 studies) (23,25,30,39,47,48,50,52–54), assistance and support within practice and teams (8 studies) (23,25,35,37,38,41,48,50), IT support (5 studies) (35,37,38,41,46,49), flexibility in counselling (5 studies) (29,33,43,52,53), opportunity of health checks and prevention (5 studies) (34,36,42,47,48), important role of practice nurses (4 studies) (23,32,37,49), structured organization of practice (4 studies) (30,37,50,51) and cooperation with allied health staff or community resources (3 studies) (29,38,54). Other organizational facilitators were functioning appointment system (35,48), interventions tailored to target identified barriers (40), need of an integrated electronic patient record system (37) and access to patient information or register (41,50). The most frequently reported professional barriers were lack of counselling skills and education (6 studies) (29,32,45,49,53,54), lack of knowledge of preventive care (5 studies) (32,33,35,37,40,42) and lack of experience (3 studies) (23,33,41). Lack of counselling skills pertained to insufficient education/training/experience to competently communicate information on risk and lifestyle habits. Yet the most frequently reported facilitating professional factors were sufficient training and education (10 studies) (35,38,42,45,48,49,51–54) and that motivation of patients is effective (4 studies) (25,50,52,53). Other facilitating factors were related to sufficient knowledge (53) and female gender of GP (49,53). The most frequently reported patient-related barriers concerned lack of adherence (9 studies) (32,33,37,38,41–43,47,53) and causing problems to patients (5 studies) (33,39,47,49,50), e.g. medicalization or anxiety. Other noted barriers involved were low awareness among patients (36), lack of support from patients’ families (44), lack of trust in GP–patient contact (41) and cultural differences (54). On the other hand, the most frequently reported patient-related facilitating factors concerned a strong GP–patient relationship (5 studies) (33,36,38,41,51) and that patients do appreciate the preventive measures (4 studies) (33,39,46,50). Other factors were related to the motivation of patients (25,36) and potential of enlisting the help of family and friends (29,44). The most frequently reported attitudinal barriers were negative attitudes to prevention (16 studies) (25,29,33–35,37,38,40,42,43,46,47,49,51,52,54). Other attitudinal barriers were lack of acceptability (50) and of feasibility (50). The most reported attitudinal facilitators were positive attitudes towards the importance of prevention (14 studies) (25,34,35,38,42,46–54). Other facilitators were acceptability (50) and feasibility (34). Discussion We have identified several structural, organizational, professional, social context and attitudinal barriers and facilitators for selective prevention of CMD in primary care. The most frequently reported and important barriers listed were lack of time and reimbursement and lack of counselling skills. The most frequently reported facilitators were positive attitudes towards prevention and awareness of the effectiveness of health checks. In terms of the generalizability of our results, there appears to be reasonable consistency across the reviewed studies, irrespective of continent, world region, or country of origin. Results are also relatively stable across time, with new studies reporting similar barriers and facilitators as older ones. However, the majority of studies were carried out in The Netherlands, or the UK and other English-speaking countries such as Australia, Canada and New Zealand, all of which have similar primary care and health care systems. This begs the question of how representative our sample of studies actually is. Indeed, two noteworthy studies from countries outside of the mainstream reported diverging results. Specifically, a French study indicated high variability between doctors in their willingness to take a preventative approach to CMD (31). Another study from Singapore described how GPs screened their patients for chronic kidney disease with the aim to improve collaborative care (41). It is important to note that the health care system from the countries where all other studies originate in may have influenced the results and could explain the similarities of findings in these studies, allowing the specific organization of primary care or health care in general to be reflected. In regard to earlier reviews in the area (10,20,56), Rubio-Valera concluded that there is a lack of research into the barriers and facilitators of implementation of prevention and health promotion activities in primary health care, and further that multi-risk management is scarce (20). Regarding specific lifestyle factors, an earlier review concluded that ‘research on physical activity interventions has shown clear evidence of small but positive effects of such intervention in primary care settings, but evidence of specific strategies and sample characteristics associated with greater effectiveness is still needed to enhance the implementation of interventions under routine clinical conditions’ (10). It is important to identify barriers and motivate primary health care professionals. In fact, a review of lifestyle interventions showed that dietary and smoking interventions proved more effective in the long term than standard primary care practice (56). One area of contention in preventive health care is related to whether interventions should target only high-risk groups or the general population as well, that is, should preventive measures be taken to prevent CMD in groups at low or moderate risk as well as those at high risk? In regard to diabetes prevention, identifying high-risk individuals in the general population could be difficult (57), thus favouring prevention in the general population over a selected high-risk group (58). The current European guidelines suggest screening all men >40 years and all women >50 years (59). In order to mitigate the difficulties involved in selective CMD prevention programmes, detailed planning to overcome the barriers and to promote facilitators is needed before prevention programmes are initiated. However, owing to divergent results in studies conducted in countries with different health care systems, our recommendation to researchers interested in initiating selective prevention interventions is to not only design the initiative based on the best available evidence, but also tailor the programme as precisely as possible to the specific health care system for which it is intended. This will optimize the chances of success of the programmes. One of the frequently reported barriers was the lack of evidence or the lack of belief in the evidence for prevention. This is partly true, as there is evidence that prevention works to prevent single cardiometabolic events, but a review concluded that ‘it is not possible to make clear recommendations about the economic value of screening programmes for CMD’ (60). There is also limited evidence to suggest that CVD systematic risk assessment may have some favourable effects on cardiovascular risk factors (61). Furthermore, in low- and middle-income countries, no conclusions were to be drawn on the effectiveness of multiple risk factor interventions on combined CVD events and mortality (62). A limitation of the present review relates to the fact that most of the articles included in the review were qualitative making the importance of the results challenging to quantify in any other way than the number of studies reporting each type of barrier and facilitator. Further, in terms of the quantitative articles, it was not meaningful to perform a meta-analysis owing to the different topics in the included articles. As a result, we extracted relevant information from the quantitative studies in a similar fashion as we extracted the relevant information from the qualitative studies, according to relevance and not according to any preset tool. We also acknowledge that individual studies that we include have several types of bias and that the bias of each included study might influence the validity in reported barriers and facilitators. All bias and shortcomings were reported, and none of them were regarded as serious to the point where we considered exclusion. If a barrier of facilitator is frequently reported, the likelihood of it being true is greater, which is why we also report those reported in three or more studies. We did not find any quantitative studies on barriers and facilitators of prevention of diabetes in primary care. This represents a knowledge gap that needs to be bridged. Another limitation pertains to the fact that most of the relevant European studies we identified were conducted in the UK and The Netherlands. Thus, the conclusions drawn may not be representative for other parts of Europe. The main strengths of this review involve the rigorous search strategy, performed by an experienced librarian, in Medline (Ovid), Embase, Cinahl and PubMed. The search was completed with a backward search for articles based on the reference lists of included articles and a forward search on articles citing the included articles through Google Scholar. Besides, the articles found this way were checked by another person than the one who performed the search, and results were discussed when there was any doubt of inclusion or exclusion. We believe that this scrutiny was sufficient and that little relevant information was missed. Furthermore, we screened all included articles using a quality tool, and except for low participation rates in a few studies, all studies had adequate quality. Conclusion Structural, organizational, professional, social context and attitudinal barriers and facilitators of selective CMD prevention efforts in primary care were identified in both qualitative and quantitative studies. The most frequently reported barriers were lack of time, reimbursement and adequate counselling skills. The most frequently reported facilitators were positive attitudes of importance of prevention including a high yield of health check. We found that many factors were similar across various settings and countries, yet a few studies were performed in countries with different primary health care systems, complicating comparison. Ultimately, in addition to studying our review of the relevant evidence, we suggest that before initiating selective prevention studies researchers should study local factors in order to best tailor the intervention to the intended setting. Supplementary material Supplementary material is available at Family Practice online. 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Uthman OA, Hartley L, Rees Ket al.   Multiple risk factor interventions for primary prevention of cardiovascular disease in low- and middle-income countries. Cochrane Database Syst Rev  2015; CD011163. 63. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA Statement. PLoS Med  2009; 6: e1000097. doi:10.1371/journal.pmed1000097. CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Family Practice Oxford University Press

Barriers and facilitators among health professionals in primary care to prevention of cardiometabolic diseases: A systematic review

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
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0263-2136
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Abstract

Abstract The aim of this study is to identify potential facilitators and barriers for health care professionals to undertake selective prevention of cardiometabolic diseases (CMD) in primary health care. We developed a search string for Medline, Embase, Cinahl and PubMed. We also screened reference lists of relevant articles to retain barriers and facilitators for prevention of CMD. We found 19 qualitative studies, 7 quantitative studies and 2 mixed qualitative and quantitative studies. In terms of five overarching categories, the most frequently reported barriers and facilitators were as follows: Structural (barriers: time restraints, ineffective counselling and interventions, insufficient reimbursement and problems with guidelines; facilitators: feasible and effective counselling and interventions, sufficient assistance and support, adequate referral, and identification of obstacles), Organizational (barriers: general organizational problems, role of practice, insufficient IT support, communication problems within health teams and lack of support services, role of staff, lack of suitable appointment times; facilitators: structured practice, IT support, flexibility of counselling, sufficient logistic/practical support and cooperation with allied health staff/community resources, responsibility to offer and importance of prevention), Professional (barriers: insufficient counselling skills, lack of knowledge and of experience; facilitators: sufficient training, effective in motivating patients), Patient-related factors (barriers: low adherence, causes problems for patients; facilitators: strong GP–patient relationship, appreciation from patients), and Attitudinal (barriers: negative attitudes to prevention; facilitators: positive attitudes of importance of prevention). We identified several frequently reported barriers and facilitators for prevention of CMD, which may be used in designing future implementation and intervention studies. Coronary heart disease, diabetes, general practitioner, health check, myocardial infarction, selective prevention, stroke Introduction In spite of the decrease in coronary heart disease seen in many Western countries in recent years, cardiometabolic diseases [CMDs: cardiovascular diseases (CVDs), diabetes mellitus and chronic kidney disease] continue to be a major global health problem (1,2). As well as genetic and sociodemographic factors, CMDs are caused by unhealthy lifestyles, including poor diet, physical inactivity and smoking (3). It is estimated that >90% of instances of type 2 diabetes are preventable (4) by maintaining a healthy diet and body weight, engaging in moderate to vigorous physical activity and abstaining from tobacco smoking. While the evidence on predictors of CMD is relatively clear, applying this knowledge in a preventive primary care capacity represents a challenge for most health care professionals. In light of high prevalence of smokers, and increasing occurrence of obesity and physical inactivity, an increase in the number of patients with CMD is expected in the coming decades. Risk factors for CVD emerge early in life (5), with several studies suggesting that risk factors identified in young adults predict CVD and diabetes later in life (6,7). Giving advice on both physical activity (8) and diet (9) has been found to be effective in reducing CVD risk factors, though the benefits of such interventions are rather small (9,10). Past research indicates that successful interventions against CVD risk behaviour should target all important risk factors, including a poor diet, sedentary lifestyle and smoking (11). Therefore, there is an urgent need to establish strategies for health care professionals to detect seemingly healthy individuals who are at high risk of developing CMD and to develop and implement interventions to prevent or delay the onset of these diseases. This approach has been termed selective prevention—the identification of patients who, in spite of an apparent lack of symptoms and risk factors, are nonetheless at high risk of developing CMD (12). Particular subgroups of the population are at higher risk of CMD, including those of low socioeconomic status (13,14), immigrants migrating from developing countries (15), people with psychiatric disorders (16) and individuals with intellectual disability (17). While the issue of social inequality in health is well known (18), it is difficult to reach these subgroups of the general population with interventions aimed at reducing CMD risk. This may be due to the fact that maintaining a healthy lifestyle becomes less of a priority in the face of other, more immediate stressors and adversity (19). As such, there is an urgent need to establish inclusive strategies to identify individuals at high risk of disease and to develop and implement interventions to prevent or delay the onset of these diseases in the general population as well as in particularly vulnerable subgroups. Obstacles against successful interventions towards a healthy lifestyle may not only be present in the general population, but also among health care professionals in primary care—the natural arena for health promotion in the general population (20). Thus, to implement successful selective CMD prevention programmes in primary care, it is important to identify potential barriers that may exist among primary care health care professionals. Health care professionals in primary care encounter patients with divergent and poor lifestyle habits that may be harmful to cardiometabolic health (21), which make it difficult to implement selective preventive efforts. The primary care setting is a complex system where patients and professionals’ objectives may not always be in harmony, and barriers in distinct disciplines can vary widely. Therefore, we stress the importance of addressing the barriers and facilitators of effective and efficient selective prevention programmes into clinical practice in primary care (20). The aim of this study was to conduct a systematic review of the relevant literature to identify barriers and facilitators of effective selective CMD prevention programmes in a primary health care setting. Methods The results of the present review will be used to develop a feasibility study of selective CMD prevention within the Determinants of Successful Implementation of Selective Prevention of Cardiometabolic Diseases Across Europe (SPIMEU, www.spimeu.org) project. SPIMEU aims to contribute to the reduction of cardiometabolic morbidity and mortality in EU Member States by establishing the feasibility of implementing innovative, evidence-based selective prevention actions in five EU Member States representing various health care systems. The present study is a systematic search and review (22). In the first step, we performed a backward and forward citation search of five key articles with relevant content that were known to us (23–27). The backward citation search identified articles through the reference lists in each article, and the forward citation search identified articles citing the key article using Google Scholar. Through this process we identified 30 papers. On the basis of this literature, we then identified any common search terms and keywords. In the second step, we searched without restrictions in terms of language, year or publication type in the following databases: Medline (Ovid), Embase (embase.com), Cinahl (Ebsco) and PubMed (complementary search of newly published non-indexed articles) to identify relevant articles and references. The searches were conducted by two librarians at the Karolinska Institutet University Library in March 2016. The complete search strategies are available as Supplementary data. The extensive search strategy included both free text and MeSH terms and was initially created in Medline and later adapted to the other databases with corresponding vocabularies. Reference lists of included articles were also searched for relevant papers, and articles citing the already included studies were identified in further Google Scholar searches. All titles and abstracts were screened according to the inclusion criteria by either AKW, MJH or ACC. If there was any uncertainty as to whether particular articles should be included or not, the papers in question were discussed by AKW, MJH and ACC before a final decision was reached. Inclusion criteria Articles were retained for the review if the study focused on the following: Screening/prevention programmes for adult people without established CMD [all studies in patients diagnosed with CVD (or taking medication for hypertension or dyslipidaemia), diabetes mellitus or chronic kidney disease were excluded]. Prevention of CMD (CVD, type 2 diabetes, chronic kidney disease) in a primary care setting. Reporting data on the barriers or facilitators for health care professionals implementing prevention. Articles describing health care professionals. Articles reporting original research (no review articles or opinion papers such as editorials). Exclusion criteria Articles were excluded if they focused on the following: Reported purely on (clinical) outcomes of preventive interventions (e.g. lower cholesterol, morbidity). Focused solely on study protocols, guidelines and their implementation. If the inclusion of any articles was unclear, they were discussed among AKW, MJH and ACC, using the criteria above, before a final decision was made. The texts of the retained articles were read in full by at least two authors (PW, AKW or ACC). All full texts were screened independently by at least two authors, either AKW, ACC or PW. Any uncertainty was discussed by all three authors. PW conducted the data extraction, and all the extracted data were verified by ACC. Where consensus was found, all extracted data from the studies were tabled. Formal quality assessment was performed using Mixed Methods Appraisal Tool (MMAT) (28). The bias discovered by the use of the MMAT tool or by the authors’ assessment of the included studies was recorded (e.g. response rates in quantitative studies below 60%). If no bias was discovered in the quality assessment or by the authors’ assessment, ‘no bias’ was reported. The relevant content in the qualitative and quantitative studies was extracted in a similar fashion from the result sections and tables in the included studies. To systematize the information, we categorized the articles by the type of barrier/facilitator they focused on, as others have previously described (29–31). In short, we organized the barriers and facilitating factors from the retained articles into structural (related to local, regional and national health care systems), organizational (related to local, regional and national health care systems), professional, patient-related context and attitudes of heath care professionals. All barriers and facilitators reported in three or more studies were regarded as frequently reported. Results Figure 1 shows all screened titles/abstracts (6683 articles), with the individual included studies and relevant information on barriers and facilitators for health care professionals included in the present review. In total, 28 articles were included in the present review (23,25,29–54). Figure 1. View largeDownload slide PRISMA 2009 flow diagram. From Moher et al. (63). For more information, visit www.prisma-statement.org. Figure 1. View largeDownload slide PRISMA 2009 flow diagram. From Moher et al. (63). For more information, visit www.prisma-statement.org. We extracted qualitative data from 19 articles, quantitative data from 7 articles and both qualitative and quantitative data from 2 of the included articles, see Figure 1 and Table 1 (55). The included studies were published between 1990 and 2016 and came from UK (9) (25,33,42,45–49,52), Canada (4) (29,32,44,51), The Netherlands (4) (23,30,37,50), Australia (3) (34–36), Denmark (2) (39,43), Germany (2) (53,54) and a few countries (Argentina (40), France (31), New Zealand (38), Singapore (41)) with one included study. Table 1. Information of included studies of barriers and facilitators in health care professionals to do selective primary prevention of cardiovascular, diabetes and chronic kidney disease in patients without established cardiometabolic disease in primary care. (The search was conducted in March 2016.) Author, publication year, country  Type of study  Health care groups  Responders, n  Response rate  Patient ages  Population  Comments  Mann, 1990, Canada  Qualitative  GPs  50        Interviews  Calnan, 1993, UK  Quantitative  GPs  1092  64%      Postal survey  Hulscher, 1997, The Netherlands  Quantitative  GPs  195        Survey  Makrides, 1997, Canada  Qualitative  GPs  16 + 15        Focus groups and interviews  Grant, 1998, Canada  Quantitative  GPs  156  78%      Phone survey  Steptoe, 1999, UK  Quantitative  GPs, PNs  107 + 58  100%      Postal survey  Williams, 2004, UK (Wales)  Qualitative  GPs, PNs  21 + 22        Focus groups  Wright, 2006, UK  Qualitative  PHC staff: GPs, PNs; CMHT staff: psychiatrists, psychiatric nurses, social workers, occupational therapists  8 + 2; 7 + 10 + 7 + 1    18–65 years  Severe mental illness  Interviews  Pelletier-Fleury, 2007, France  Quantitative  GPs  86        Observational  Amoroso, 2009, Australia  Qualitative  GPs, PN  13 + 1    45–49 years    Interviews  Ampt, 2009, Australia  Qualitative  GPs, PN  15 + 1    45–49 years    Interviews  Graffy, 2010, UK  Quantitative  GPs, PNs, HCAs, PMs  4 + 7 + 3 + 4    40–69 years      Wan, 2010, Australia  Qualitative  GPs  22  85%      Focus groups  Voogdt-Pruis, 2011, The Netherlands  Qualitative  GPs, PNs  25 + 6        Interviews  Doolan-Noble, 2012, New Zealand  Qualitative  GPs, PNs, PHO information analyst  14 + 14 + 1        Focus groups  Huy, 2012, Germany  Quantitative  GPs  260  13%      Postal survey  Sondergaard, 2012, Denmark  Qualitative  GPs  16  16%      Focus groups  Ferrante, 2013, Argentina  Qualitative  GPs, PNs, social workers, PMs, area managers  15 + 10 + 20 + 5 + 5    ≥40 years    Interviews  George, 2013, Singapore  Mixed  GPs  302  25%      Survey, free text  Godefrooij, 2014, The Netherlands  Qualitative  GPs, PNs, medical receptionists  5 + 3 + 5        Focus groups  Vos, 2014, The Netherlands  Qualitative  GPs  7 + 1  39%      Witness seminar; interview  Baker, 2015 UK  Mixed  GPs, PNs, HCAs, PMs, administrator  2 + 6 + 2 + 14 + 1    40–74 years    Interviews  Barfoed, 2015, Denmark  Qualitative  GPs  10        Interviews  Diehl, 2015, Germany  Quantitative  GPs  4074  33.9%      Postal survey  Gavarkovs, 2015, Canada  Qualitative  CDPM programme delivery staff  10      Men  Telephone interviews  Ismail, 2015, UK  Qualitative  GPs, PNs, HCAs, PMs, other support staff  58        Interviews  Riley, 2015, UK  Qualitative  GPs, PNs, HCAs, pharmacists  5 + 5 + 3 + 2        Interviews  Krska, 2016, UK  Qualitative  PMs  23        Postal survey, free-text questions  Author, publication year, country  Type of study  Health care groups  Responders, n  Response rate  Patient ages  Population  Comments  Mann, 1990, Canada  Qualitative  GPs  50        Interviews  Calnan, 1993, UK  Quantitative  GPs  1092  64%      Postal survey  Hulscher, 1997, The Netherlands  Quantitative  GPs  195        Survey  Makrides, 1997, Canada  Qualitative  GPs  16 + 15        Focus groups and interviews  Grant, 1998, Canada  Quantitative  GPs  156  78%      Phone survey  Steptoe, 1999, UK  Quantitative  GPs, PNs  107 + 58  100%      Postal survey  Williams, 2004, UK (Wales)  Qualitative  GPs, PNs  21 + 22        Focus groups  Wright, 2006, UK  Qualitative  PHC staff: GPs, PNs; CMHT staff: psychiatrists, psychiatric nurses, social workers, occupational therapists  8 + 2; 7 + 10 + 7 + 1    18–65 years  Severe mental illness  Interviews  Pelletier-Fleury, 2007, France  Quantitative  GPs  86        Observational  Amoroso, 2009, Australia  Qualitative  GPs, PN  13 + 1    45–49 years    Interviews  Ampt, 2009, Australia  Qualitative  GPs, PN  15 + 1    45–49 years    Interviews  Graffy, 2010, UK  Quantitative  GPs, PNs, HCAs, PMs  4 + 7 + 3 + 4    40–69 years      Wan, 2010, Australia  Qualitative  GPs  22  85%      Focus groups  Voogdt-Pruis, 2011, The Netherlands  Qualitative  GPs, PNs  25 + 6        Interviews  Doolan-Noble, 2012, New Zealand  Qualitative  GPs, PNs, PHO information analyst  14 + 14 + 1        Focus groups  Huy, 2012, Germany  Quantitative  GPs  260  13%      Postal survey  Sondergaard, 2012, Denmark  Qualitative  GPs  16  16%      Focus groups  Ferrante, 2013, Argentina  Qualitative  GPs, PNs, social workers, PMs, area managers  15 + 10 + 20 + 5 + 5    ≥40 years    Interviews  George, 2013, Singapore  Mixed  GPs  302  25%      Survey, free text  Godefrooij, 2014, The Netherlands  Qualitative  GPs, PNs, medical receptionists  5 + 3 + 5        Focus groups  Vos, 2014, The Netherlands  Qualitative  GPs  7 + 1  39%      Witness seminar; interview  Baker, 2015 UK  Mixed  GPs, PNs, HCAs, PMs, administrator  2 + 6 + 2 + 14 + 1    40–74 years    Interviews  Barfoed, 2015, Denmark  Qualitative  GPs  10        Interviews  Diehl, 2015, Germany  Quantitative  GPs  4074  33.9%      Postal survey  Gavarkovs, 2015, Canada  Qualitative  CDPM programme delivery staff  10      Men  Telephone interviews  Ismail, 2015, UK  Qualitative  GPs, PNs, HCAs, PMs, other support staff  58        Interviews  Riley, 2015, UK  Qualitative  GPs, PNs, HCAs, pharmacists  5 + 5 + 3 + 2        Interviews  Krska, 2016, UK  Qualitative  PMs  23        Postal survey, free-text questions  Population only indicated when a specific target population other than the general population is relevant. CDPM, community-based chronic disease prevention and management; CMHT, community mental health teams; HCAs, health care assistants; PHCs, primary health care centres; PHO, primary health organization; PMs, practice managers; PNs, practice nurses. View Large Table 1. Information of included studies of barriers and facilitators in health care professionals to do selective primary prevention of cardiovascular, diabetes and chronic kidney disease in patients without established cardiometabolic disease in primary care. (The search was conducted in March 2016.) Author, publication year, country  Type of study  Health care groups  Responders, n  Response rate  Patient ages  Population  Comments  Mann, 1990, Canada  Qualitative  GPs  50        Interviews  Calnan, 1993, UK  Quantitative  GPs  1092  64%      Postal survey  Hulscher, 1997, The Netherlands  Quantitative  GPs  195        Survey  Makrides, 1997, Canada  Qualitative  GPs  16 + 15        Focus groups and interviews  Grant, 1998, Canada  Quantitative  GPs  156  78%      Phone survey  Steptoe, 1999, UK  Quantitative  GPs, PNs  107 + 58  100%      Postal survey  Williams, 2004, UK (Wales)  Qualitative  GPs, PNs  21 + 22        Focus groups  Wright, 2006, UK  Qualitative  PHC staff: GPs, PNs; CMHT staff: psychiatrists, psychiatric nurses, social workers, occupational therapists  8 + 2; 7 + 10 + 7 + 1    18–65 years  Severe mental illness  Interviews  Pelletier-Fleury, 2007, France  Quantitative  GPs  86        Observational  Amoroso, 2009, Australia  Qualitative  GPs, PN  13 + 1    45–49 years    Interviews  Ampt, 2009, Australia  Qualitative  GPs, PN  15 + 1    45–49 years    Interviews  Graffy, 2010, UK  Quantitative  GPs, PNs, HCAs, PMs  4 + 7 + 3 + 4    40–69 years      Wan, 2010, Australia  Qualitative  GPs  22  85%      Focus groups  Voogdt-Pruis, 2011, The Netherlands  Qualitative  GPs, PNs  25 + 6        Interviews  Doolan-Noble, 2012, New Zealand  Qualitative  GPs, PNs, PHO information analyst  14 + 14 + 1        Focus groups  Huy, 2012, Germany  Quantitative  GPs  260  13%      Postal survey  Sondergaard, 2012, Denmark  Qualitative  GPs  16  16%      Focus groups  Ferrante, 2013, Argentina  Qualitative  GPs, PNs, social workers, PMs, area managers  15 + 10 + 20 + 5 + 5    ≥40 years    Interviews  George, 2013, Singapore  Mixed  GPs  302  25%      Survey, free text  Godefrooij, 2014, The Netherlands  Qualitative  GPs, PNs, medical receptionists  5 + 3 + 5        Focus groups  Vos, 2014, The Netherlands  Qualitative  GPs  7 + 1  39%      Witness seminar; interview  Baker, 2015 UK  Mixed  GPs, PNs, HCAs, PMs, administrator  2 + 6 + 2 + 14 + 1    40–74 years    Interviews  Barfoed, 2015, Denmark  Qualitative  GPs  10        Interviews  Diehl, 2015, Germany  Quantitative  GPs  4074  33.9%      Postal survey  Gavarkovs, 2015, Canada  Qualitative  CDPM programme delivery staff  10      Men  Telephone interviews  Ismail, 2015, UK  Qualitative  GPs, PNs, HCAs, PMs, other support staff  58        Interviews  Riley, 2015, UK  Qualitative  GPs, PNs, HCAs, pharmacists  5 + 5 + 3 + 2        Interviews  Krska, 2016, UK  Qualitative  PMs  23        Postal survey, free-text questions  Author, publication year, country  Type of study  Health care groups  Responders, n  Response rate  Patient ages  Population  Comments  Mann, 1990, Canada  Qualitative  GPs  50        Interviews  Calnan, 1993, UK  Quantitative  GPs  1092  64%      Postal survey  Hulscher, 1997, The Netherlands  Quantitative  GPs  195        Survey  Makrides, 1997, Canada  Qualitative  GPs  16 + 15        Focus groups and interviews  Grant, 1998, Canada  Quantitative  GPs  156  78%      Phone survey  Steptoe, 1999, UK  Quantitative  GPs, PNs  107 + 58  100%      Postal survey  Williams, 2004, UK (Wales)  Qualitative  GPs, PNs  21 + 22        Focus groups  Wright, 2006, UK  Qualitative  PHC staff: GPs, PNs; CMHT staff: psychiatrists, psychiatric nurses, social workers, occupational therapists  8 + 2; 7 + 10 + 7 + 1    18–65 years  Severe mental illness  Interviews  Pelletier-Fleury, 2007, France  Quantitative  GPs  86        Observational  Amoroso, 2009, Australia  Qualitative  GPs, PN  13 + 1    45–49 years    Interviews  Ampt, 2009, Australia  Qualitative  GPs, PN  15 + 1    45–49 years    Interviews  Graffy, 2010, UK  Quantitative  GPs, PNs, HCAs, PMs  4 + 7 + 3 + 4    40–69 years      Wan, 2010, Australia  Qualitative  GPs  22  85%      Focus groups  Voogdt-Pruis, 2011, The Netherlands  Qualitative  GPs, PNs  25 + 6        Interviews  Doolan-Noble, 2012, New Zealand  Qualitative  GPs, PNs, PHO information analyst  14 + 14 + 1        Focus groups  Huy, 2012, Germany  Quantitative  GPs  260  13%      Postal survey  Sondergaard, 2012, Denmark  Qualitative  GPs  16  16%      Focus groups  Ferrante, 2013, Argentina  Qualitative  GPs, PNs, social workers, PMs, area managers  15 + 10 + 20 + 5 + 5    ≥40 years    Interviews  George, 2013, Singapore  Mixed  GPs  302  25%      Survey, free text  Godefrooij, 2014, The Netherlands  Qualitative  GPs, PNs, medical receptionists  5 + 3 + 5        Focus groups  Vos, 2014, The Netherlands  Qualitative  GPs  7 + 1  39%      Witness seminar; interview  Baker, 2015 UK  Mixed  GPs, PNs, HCAs, PMs, administrator  2 + 6 + 2 + 14 + 1    40–74 years    Interviews  Barfoed, 2015, Denmark  Qualitative  GPs  10        Interviews  Diehl, 2015, Germany  Quantitative  GPs  4074  33.9%      Postal survey  Gavarkovs, 2015, Canada  Qualitative  CDPM programme delivery staff  10      Men  Telephone interviews  Ismail, 2015, UK  Qualitative  GPs, PNs, HCAs, PMs, other support staff  58        Interviews  Riley, 2015, UK  Qualitative  GPs, PNs, HCAs, pharmacists  5 + 5 + 3 + 2        Interviews  Krska, 2016, UK  Qualitative  PMs  23        Postal survey, free-text questions  Population only indicated when a specific target population other than the general population is relevant. CDPM, community-based chronic disease prevention and management; CMHT, community mental health teams; HCAs, health care assistants; PHCs, primary health care centres; PHO, primary health organization; PMs, practice managers; PNs, practice nurses. View Large The reported barriers and facilitators from all studies included on the topic of selective prevention of CVD and chronic kidney disease are shown in Table 2. Table 2. Studies of barriers and facilitators in health care professionals to perform selective primary prevention of cardiovascular, diabetes and chronic kidney disease in patients without established cardiometabolic disease in primary care. (The search was conducted in March 2016.) Author, publication year, country  Type of study  Barriers  Facilitators  Bias and potential quality short-comings  Mann, 1990, Canada  Qualitative  Knowledge, attitudes and perceptions (lack of counselling skills, lack of belief in the efficacy of the activities) Conditions in which the activities occur (lack of available and accessible referral, lack of time) Reactions of others to the activities (lack of patient compliance) Difficulties in counselling (lack of appropriate, effective patient education materials)  Engaging a nurse to alleviate lack of time for GPs GPs most effective in dealing with high blood pressure Physician counselling effective in helping patients quit smoking  Focused on barriers to prevention  Calnan, 1993, UK  Quantitative  Negative attitudes to preventiona (health education is dull and boring; causes problems for the patients) Inappropriate skillsa  Positive attitudes to preventiona Training in health promotiona Higher number of practice nursesa GP spends more hours on research and traininga Positive attitudes by female GPsa Assistancea (from facilitator, or authorities) IT supporta  No  Hulscher, 1997, The Netherlands  Quantitative  Poor organization of practice to provide preventive services (lack of registration of activity for self-assessment of progress, lack of written protocols of agreement, not familiar with population approach) Acceptability [risk of causing medicalization in patients at risk for CVD (51%)] Feasibility [not enough time and opportunity (44%), lack of necessary data to screen and detect risk groups (50%)]   Organization of practice [availability of a sex–age registera, regular team work meetingsa, more practice assistance (not significant)] Acceptability [detection and treatment of hypertension will not cause anxiety (51%), patients appreciate monitoring of health (59%)] Responsibility [significant to smaller list size and proactive invitation of patientsa; CVD prevention is an important task in primary care (78%)] Self-efficacy [significant to registration of follow-up appointmentsa; GPs and PNs can motivate patients to live more healthy (70% and 72%), GPs and PNs can motivate hypertensive patients to follow advice (79% and 70%), GPs and PNs could be important support to stop smoking (82% and 65%), can contribute to a healthier way of living (45%)]  No  Makrides, 1997, Canada  Qualitative  Structural obstacles (funding, time, patient’s expectations, sparse community resources) Organizational (inadequate space, organization of practice around the traditional treatment-oriented medical model, negative staff attitude toward prevention) Personal (negative attitude toward prevention, lack of motivation, inadequate counselling skills, poor memory)  Identify prevention strategies: Viewing all visits as an opportunity for prevention Targeting risk factors Providing one-on-one counselling Providing group counselling Providing simple educational materials Offering clear and consistent advice Ensuring adequate follow-up Referring to other health professionals and community resources Enlisting the help of family and friends Identifying/addressing patient’s personal obstacles Identifying/addressing socio-environmental obstacles  No  Grant, 1998, Canada  Quantitative  Interventions to improve lifestyle ineffective (stress reduction 72.2%, weight loss 69.2%, smoking 59.1%, increasing physical activity 58.1%, diet 48.1%) Uncertain efficacy of available interventions (51.9%)  Relationship with patients (96.7%) Personal knowledge (77.6%) Compliance of patients (75.0%) Personal commitment (66.7%) Efficacy of available interventions (50.0%) Availability of time (41.0%) Opportunity to refer (28.2%) Organization of practice (25.6%) Good skill in managing risk factors (from 84.5% for council for lifestyle factors to 99.3% in screening)  Focus on knowledge of different risk factors  Steptoe, 1999, UK  Quantitative  Difficult to counsel patients about an alternative lifestyle (GP 24.8%, PN 25.5%; GP 53.5%, PN 60.0% neutral) Doubt that health professionals very influential in persuading people to change lifestyle (GP 62.5%, PN 62.5% neutral) Doubt that lifestyle counselling is very effective (GP 70.5% neutral) Doubt that you can offer patients a great deal in the way of lifestyle counselling (GP 75.0%, PN 50.0% neutral) Doubt that lifestyle counselling is very effective (GP 70.5%, PN 42.9% neutral)  Responsibility to act as a health educator (GP 70.2%, PN 87.5%) Have time for prevention (GP 29.8%, PN 62.5%) Feel properly trained (GP 48.6%, PN 48.2%) Health professionals very influential in persuading people to change lifestyle (GP 24.0%, PN 33.9%) Can offer patients a great deal in the way of lifestyle counselling (GP 17.3%, PN 50.0%) Lifestyle counselling is very effective (GP 20.0%, PN 53.6%) Possible to persuade patients to modify lifestyle: Hypertension (GP 50.0%, PN 62.5%), high cholesterol (GP 44.2%, 58.9%), smoking (GP 34.6%, 23.2%), obesity (GP 25.0%, PN 32.1%), physical activity (GP 24.0%, PN 34.5%) Overall attitude of effectiveness of lifestyle modification (6.57 of scale 0–10, higher score more effective)    Williams, 2004, UK (Wales)  Qualitative  Existing workload, lack of resources Questionable role of primary care as a ‘screening service’, and not responsibility of primary care Prevention: the responsibility of individuals, and agencies other than primary care, especially outside the health sector Conflict and concern about increasing specialization (here diabetes) Perceived low motivation of patients to modify their lifestyle Unnecessary medicalization No evidence that interventions delivered through primary care are effective  Importance of prevention High-risk patients should be seen anyway  Concerns type 2 diabetes only  Wright, 2006, UK  Qualitative  Lack of appropriate resources in existing services, e.g. time, trained staff Lack of funding Lack of familiarity in general practice with severe mental illness, also negative attitudes to work with these patients Lack of knowledge regarding CHD risk factor screening and difficulties in interpreting screening results and implementing appropriate interventions Mental patients harder to engage, prior experience of low attendance, perceived difficulty in making lifestyle changes A screening offer might be viewed as interference in patients' lives, and some patients get anxious Lack of appropriate services to refer patients Staff resistance to more changes in their role  Flexible solutions with clear lines of responsibility for assessing, communicating and managing CHD risks Mental patients are at high risk, with bad lifestyle manners, needing interventions GPs possess medical expertise Less stigmatising to attend primary care for screening Patients have better links, trust and a longer history with their GP  Concerns patients with severe mental illness Views from both primary care and community mental health teams  Pelletier-Fleury, 2007, France  Quantitative  Urban practicea (OR 0.66; 95% CI 0.65–0.68) Density of GPsa (OR 0.76; 95% CI 0.63–0.92)  Daily work loada (OR 1.03, 95% CI 1.01–1.05) Elderly patient list (>65 y)a (OR 1.04; 95% CI 1.02–1.07) High health care consumptiona (OR 4.29; 95% CI 3.62–5.00)  Register study of preventive services  Amoroso, 2009, Australia  Qualitative  Time Low remuneration Attitude that prevention do not have a high priority Attitude of scepticism about the value of a health check Management, in particular motivating patients to change their behaviour, proved to be more difficult  A useful opportunity to assess and manage risk factors A belief that preventive care was part of their role and responsibility Health check feasible   Short follow-up time  Ampt, 2009, Australia  Qualitative  Time Doubt on the effectiveness of general dietary recommendations Motivational interviewing good in theory, but difficult in practice Difficult to motivate patients to change behaviour Difficult in motivating patients to stop smoking Negative attitudes towards assessment of nutrition, alcohol and physical activity Cost of follow-up visit Difficult to access referrals in working hours Lack of knowledge regarding the role of the exercise physiologist Advice offered by a dietician would be no different to that offered by the GP, and thus referrals were of little value  Usefulness of a computer-based template or patient education and assessment resources Training in motivational interviewing Experience and interest in addressing drug and alcohol issues Giving advice and educating the patient were viewed as a professional responsibility Printed material reinforced any message Practice having an appointment system, as follow-ups could more easily be arranged Quitline (a free smoking referral telephone service) has no restriction to working hours Support services could actually help to motivate patients Potential greater success may be achieved by addressing whichever factor the patient was more ready to change first Primary care teams can play a major role in affecting patients’ ideas  Selection bias towards higher participation among health care professional with an interest for prevention  Graffy, 2010, UK  Quantitative  Workload  Importance of administrative support Efficient systems to identify, invite and follow up patients Flexible appointments for people in work Tagging notes to invite non-attenders when they consult Team meetings contribute to a sense of ownership Training, both at the outset and for new staff Seeing patients benefiting of screening affirms the sense of the value of screening  Selection bias with participation of practices with screening experiences Concerns screening of type 2 diabetes, positive experiences  Wan, 2010, Australia  Qualitative  Low awareness among patients Time pressure Risk of ‘touting for business’ when booking another visit for risk discussion with a new patient  A strong GP–patient relationship, common ground on priorities between GPs and their patients, Patient’s self-motivation a key issue Opportunistic screening easier with regular patients   Selection bias with including GPs with interest in prevention Study included both patients and health care staff  Voogdt-Pruis, 2011, The Netherlands  Qualitative  Workload Lack of physical space Lack of motivation for patients Lack of GP knowledge about the guidelines Different attitudes towards treatment targets Lack of communication, between nurses and GPs and between GPs and second care Insufficient coaching by doctors Content of lifestyle advice Concern of losing nursing tasks for nurses Lack of ability of stop-smoking treatment Organizational issues (insufficient patient recording and computer systems) Considerable effort to get patients to attend, difficult to motivate patients who rarely visited the practice Poor record keeping (smoking behaviour, diagnoses and treatment by specialist)  Nurses could play an important role in preventive care Extending clinic opening hours Desirable to implement a chain of care and an integrated electronic patient record system  Experiences of implementing nurse-delivered prevention  Doolan-Noble, 2012, New Zealand  Qualitative  Time and workload Insufficient funding Lack of strong leadership and consistent messages Difficulty in handling asymptomatic high CV risk patients, and to communicate and motivating behaviour change (e.g. low SES patients, fatalistic views of patients) Attitude of low benefits of behaviour change Design of flip charts unsatisfactory  Ensure infrastructure, including training and to consider how the programme would be implemented Co-location of allied health staff in an integrated centre The need for ongoing tobacco legislation and positive food legislation Clarity around the roles and responsibilities of GPs and practice nurses Primary health care’s longitudinal relationship with patients Attitude of high benefits of behaviour change Useful electronic tools Incentives for patients for motivation and support lifestyle changes  No  Huy, 2012, Germany  Quantitativeb  Lack of time (91%) Insufficient renumeration (92%) Many different guidelines (73%) Unclear recommendations (60%) Lack of training (70%) Lack of material for patients (77%) Lack of adherence among patients (98%)   I can offer my patients a wide range of lifestyle advice (49.1%)a (OR 3.55; 95% CI 1.82–6.93) Risk factor questionnaires in the waiting room (61.5%)a (OR 2.26; 95% CI 1.06–4.85) Female gender of GPa (OR 1.98; 95% CI 1.04–3.76) Knowledge about positive lifestyle effect (54%) Prevention is a GP responsibility (40.9%) Not difficult to give advice on lifestyle changes (47.0%) Well educated for advice on healthy lifestyle (44.2%) Can successfully motivate patients to live healthier (45.6%)  Response rate 13%  Sondergaard, 2012, Denmark  Qualitative  Reservations if the health checks were a core mission of primary care Uncertainty about the best approach Reservations about inducing negative psychological reactions and decreased well-being among patients  Preventive health checks beneficial for the patients  No  Ferrante, 2013, Argentina  Qualitative  Lack of awareness of guidelines Lack of knowledge about preventing cardiovascular disease Communication problems within health teams Lack of motivation Organizational problems Low quality of recording  Intervention tailored to target identified barriers  Focused on barriers for designing an intervention  George, 2013, Singapore  Mixed  Lack of direct access/co-management with renal physician Lack of interest Nature of my practice Lack of confidence and faith Lack of sufficient support and experience Lack of time to keep up-to-date. Lack of medicine for CKD Lack of IT support. Too much paperwork Lack of patient education Poor patient compliance Lack of family/ social support management Lack of time to explain to the patient cQuantitative results: Lack of access to patient’s information (from hospital) (4.7) Lack of access to evidence-based guidelines (4.3) Inability to bill (4.5) Lack of patient’s trust in GP (3.9) Inability for patient to pay (3.7) Lack of time for consultation (3.6) Lack of support services (staff, technical) (2.3)  Access to/co-operation with renal specialist Adequate remuneration Technological assistance, IT Patient education, also to trust the GPs cQuantitative results: Less cost for patient (2.5) Access to patient’s information (2.8) Access to updates and guidelines (3.0) More support services (3.2) Less time consumed (3.3)   Concerns screening for chronic kidney disease Response rate of quantitative survey 25%  Godefrooij, 2014, The Netherlands  Qualitative  Lack of experience in the design and implementation of a structured, large-scale prevention programme, suboptimal instruction of involved staff No clear policy about how to follow up patients with ‘medium risk’, not exceeding the risk to be referred to their GP  Importance of primary prevention (high yield of health check, helped GPs to identify their high-risk population in a structured manner) Collaboration, i.e. ‘delegation of care’, health checks were delivered by medical receptionists and practice nurses, and GPs involved for high-risk patients  Study included both patients and health care staff  Vos, 2014, The Netherlands  Qualitative  Organizational context: insufficient reimbursement Professional context: lack of evidence and guidelines Social context: no focus on prevention  Organizational context: sufficient logistic and practical support and finances Responsibility to offer prevention, equity Professional context: evidence and guidelines Social context: prevention focused on  No  Baker, 2015 UK  Mixed  Extra workload Insufficient knowledge Lack of information collected by the practice prior to the appointment Programme tools developed to aid the assessment process and reduce staff time were not necessarily being used to their full effect Difficulty in engaging patients who were potentially able to receive the most benefit Less confident in second appointments (CVD risk assessment, mean = 3.52, SD = 1.3), risk communication (mean = 2.68, SD = 0.1.8) and changing behaviours (mean = 2.44, SD = 1.6) Mixed opinions concerning the quality of lifestyle services referred to: Weight management (mean = 3.76, SD = 0.90) and alcohol services (mean = 3.76, SD = 0.90) were the lowest rated Some participants were not aware of what health trainers were Caution concerning the programme’s overall effectiveness  Opportunistic approaches Practices periodically reviewed the non-responder list and reissued invites Practices were most confident in first appointments (pre-assessment blood tests, mean = 4.12, SD = 0.60), invitations (mean = 4.04, SD = 0.79) and laboratory tests (mean = 4.04, SD = 0.79) Mixed opinions concerning the quality of lifestyle services referred to: smoking cessation was rated most highly (mean = 4.43, SD = 0.59), health trainers were rated highly (mean = 4.13, SD = 0.83) HCs were useful in early detection and giving the time to discuss patient health and lifestyles (72%) Delivery of HCs in a wider range of settings, e.g. work places More than two-thirds (70.8%) of practice staff indicated that they had training in CVD prevention and 44% (n = 11) indicated that they required further training A need to promote the programme more effectively Conclusions: Adopting continuous approaches to knowledge development and transfer; improve confidence in HCs to deliver meaningful results  Small sample size, no response rate given  Barfoed, 2015, Denmark  Qualitative  Guidelines inhibit the ability to practice independently as a GP Risk communication tools are insufficient Resigned approach to manage patient compliance  Guidelines good and applicable Use of different communication tools depending on the patient context Confrontational approach to manage low patient compliance  No  Diehl, 2015, Germany  Quantitative  Insufficient reimbursement (90.2%) Difficult to give advice on unhealthy habits (73.5%) Cultural differences (59.1%) Insufficient connection with other preventive service providers (56.7%) Lack of time (54.5%) Attitude that patients cannot change lifestyle (49.1%) Difficult to follow guidelines (too many (43.1%), insufficient evidence (28.5%), unclear recommendations (24.9%) Lack of education/training (24.8%)  Responsibility to take a role as a health advisor (96.2%) Feeling well prepared for and successful of prevention (80.9%) Successful in motivating patients to a healthy lifestyle (72.6%) Networking with cooperation partners (70.7%) Being one of the most important influence factors on patients lifestyle (69.3%)  Response rate 34%  Gavarkovs, 2015, Canada  Qualitative  Time and travel constraints Unawareness of spouses of disease prevention programmes Lack of suitable male programme leaders Interfering with high work season of patients  Hiring qualified male instructors Engaging spouses  Concerns recruiting male participants in a rural district  Ismail, 2015, UK  Qualitative  Lack of staff time/hours, increased workload Lack of space in the building Insufficient software Lack of leaflets and posters Lack of awareness of health checks Lack of resources to motivate and support patients in lifestyle changes Problems in reaching important groups with unhealthy behaviours and low motivation for changes Lack of adherence to advices Interference with working time of possible attendants Doubt on impact of the programme Lack of referral services  Evolution of the programme over time in response to local needs to suit the particular characteristics of the patient population Individual staff characteristics such as being proactive, enthusiastic and having specific responsibility A supportive team Clear information to patients what the screening entails, including possible benefits and potential harm Messages in media to raise awareness of health checks Importance of the existing relationships between GPs and patients Attitude that health checks are beneficial and to identify high-risk patients Attendants are motivated and open to advice  No  Riley, 2015, UK  Qualitative  Concerns about the skill set of some staff to competently communicate risk and lifestyle information  Sufficient training to equip health care staff with appropriate skills and knowledge to deliver the service effectively  Study included both patients and staff  Krska, 2016, UK  Qualitative  Time constraints/pressure of work Increased nurse workload impacted on other services Insufficient payments Problems with software Attitude that health checks are a waste of time  IT support Effective software Health checks beneficial for patients  Focus on implementation of health checks  Author, publication year, country  Type of study  Barriers  Facilitators  Bias and potential quality short-comings  Mann, 1990, Canada  Qualitative  Knowledge, attitudes and perceptions (lack of counselling skills, lack of belief in the efficacy of the activities) Conditions in which the activities occur (lack of available and accessible referral, lack of time) Reactions of others to the activities (lack of patient compliance) Difficulties in counselling (lack of appropriate, effective patient education materials)  Engaging a nurse to alleviate lack of time for GPs GPs most effective in dealing with high blood pressure Physician counselling effective in helping patients quit smoking  Focused on barriers to prevention  Calnan, 1993, UK  Quantitative  Negative attitudes to preventiona (health education is dull and boring; causes problems for the patients) Inappropriate skillsa  Positive attitudes to preventiona Training in health promotiona Higher number of practice nursesa GP spends more hours on research and traininga Positive attitudes by female GPsa Assistancea (from facilitator, or authorities) IT supporta  No  Hulscher, 1997, The Netherlands  Quantitative  Poor organization of practice to provide preventive services (lack of registration of activity for self-assessment of progress, lack of written protocols of agreement, not familiar with population approach) Acceptability [risk of causing medicalization in patients at risk for CVD (51%)] Feasibility [not enough time and opportunity (44%), lack of necessary data to screen and detect risk groups (50%)]   Organization of practice [availability of a sex–age registera, regular team work meetingsa, more practice assistance (not significant)] Acceptability [detection and treatment of hypertension will not cause anxiety (51%), patients appreciate monitoring of health (59%)] Responsibility [significant to smaller list size and proactive invitation of patientsa; CVD prevention is an important task in primary care (78%)] Self-efficacy [significant to registration of follow-up appointmentsa; GPs and PNs can motivate patients to live more healthy (70% and 72%), GPs and PNs can motivate hypertensive patients to follow advice (79% and 70%), GPs and PNs could be important support to stop smoking (82% and 65%), can contribute to a healthier way of living (45%)]  No  Makrides, 1997, Canada  Qualitative  Structural obstacles (funding, time, patient’s expectations, sparse community resources) Organizational (inadequate space, organization of practice around the traditional treatment-oriented medical model, negative staff attitude toward prevention) Personal (negative attitude toward prevention, lack of motivation, inadequate counselling skills, poor memory)  Identify prevention strategies: Viewing all visits as an opportunity for prevention Targeting risk factors Providing one-on-one counselling Providing group counselling Providing simple educational materials Offering clear and consistent advice Ensuring adequate follow-up Referring to other health professionals and community resources Enlisting the help of family and friends Identifying/addressing patient’s personal obstacles Identifying/addressing socio-environmental obstacles  No  Grant, 1998, Canada  Quantitative  Interventions to improve lifestyle ineffective (stress reduction 72.2%, weight loss 69.2%, smoking 59.1%, increasing physical activity 58.1%, diet 48.1%) Uncertain efficacy of available interventions (51.9%)  Relationship with patients (96.7%) Personal knowledge (77.6%) Compliance of patients (75.0%) Personal commitment (66.7%) Efficacy of available interventions (50.0%) Availability of time (41.0%) Opportunity to refer (28.2%) Organization of practice (25.6%) Good skill in managing risk factors (from 84.5% for council for lifestyle factors to 99.3% in screening)  Focus on knowledge of different risk factors  Steptoe, 1999, UK  Quantitative  Difficult to counsel patients about an alternative lifestyle (GP 24.8%, PN 25.5%; GP 53.5%, PN 60.0% neutral) Doubt that health professionals very influential in persuading people to change lifestyle (GP 62.5%, PN 62.5% neutral) Doubt that lifestyle counselling is very effective (GP 70.5% neutral) Doubt that you can offer patients a great deal in the way of lifestyle counselling (GP 75.0%, PN 50.0% neutral) Doubt that lifestyle counselling is very effective (GP 70.5%, PN 42.9% neutral)  Responsibility to act as a health educator (GP 70.2%, PN 87.5%) Have time for prevention (GP 29.8%, PN 62.5%) Feel properly trained (GP 48.6%, PN 48.2%) Health professionals very influential in persuading people to change lifestyle (GP 24.0%, PN 33.9%) Can offer patients a great deal in the way of lifestyle counselling (GP 17.3%, PN 50.0%) Lifestyle counselling is very effective (GP 20.0%, PN 53.6%) Possible to persuade patients to modify lifestyle: Hypertension (GP 50.0%, PN 62.5%), high cholesterol (GP 44.2%, 58.9%), smoking (GP 34.6%, 23.2%), obesity (GP 25.0%, PN 32.1%), physical activity (GP 24.0%, PN 34.5%) Overall attitude of effectiveness of lifestyle modification (6.57 of scale 0–10, higher score more effective)    Williams, 2004, UK (Wales)  Qualitative  Existing workload, lack of resources Questionable role of primary care as a ‘screening service’, and not responsibility of primary care Prevention: the responsibility of individuals, and agencies other than primary care, especially outside the health sector Conflict and concern about increasing specialization (here diabetes) Perceived low motivation of patients to modify their lifestyle Unnecessary medicalization No evidence that interventions delivered through primary care are effective  Importance of prevention High-risk patients should be seen anyway  Concerns type 2 diabetes only  Wright, 2006, UK  Qualitative  Lack of appropriate resources in existing services, e.g. time, trained staff Lack of funding Lack of familiarity in general practice with severe mental illness, also negative attitudes to work with these patients Lack of knowledge regarding CHD risk factor screening and difficulties in interpreting screening results and implementing appropriate interventions Mental patients harder to engage, prior experience of low attendance, perceived difficulty in making lifestyle changes A screening offer might be viewed as interference in patients' lives, and some patients get anxious Lack of appropriate services to refer patients Staff resistance to more changes in their role  Flexible solutions with clear lines of responsibility for assessing, communicating and managing CHD risks Mental patients are at high risk, with bad lifestyle manners, needing interventions GPs possess medical expertise Less stigmatising to attend primary care for screening Patients have better links, trust and a longer history with their GP  Concerns patients with severe mental illness Views from both primary care and community mental health teams  Pelletier-Fleury, 2007, France  Quantitative  Urban practicea (OR 0.66; 95% CI 0.65–0.68) Density of GPsa (OR 0.76; 95% CI 0.63–0.92)  Daily work loada (OR 1.03, 95% CI 1.01–1.05) Elderly patient list (>65 y)a (OR 1.04; 95% CI 1.02–1.07) High health care consumptiona (OR 4.29; 95% CI 3.62–5.00)  Register study of preventive services  Amoroso, 2009, Australia  Qualitative  Time Low remuneration Attitude that prevention do not have a high priority Attitude of scepticism about the value of a health check Management, in particular motivating patients to change their behaviour, proved to be more difficult  A useful opportunity to assess and manage risk factors A belief that preventive care was part of their role and responsibility Health check feasible   Short follow-up time  Ampt, 2009, Australia  Qualitative  Time Doubt on the effectiveness of general dietary recommendations Motivational interviewing good in theory, but difficult in practice Difficult to motivate patients to change behaviour Difficult in motivating patients to stop smoking Negative attitudes towards assessment of nutrition, alcohol and physical activity Cost of follow-up visit Difficult to access referrals in working hours Lack of knowledge regarding the role of the exercise physiologist Advice offered by a dietician would be no different to that offered by the GP, and thus referrals were of little value  Usefulness of a computer-based template or patient education and assessment resources Training in motivational interviewing Experience and interest in addressing drug and alcohol issues Giving advice and educating the patient were viewed as a professional responsibility Printed material reinforced any message Practice having an appointment system, as follow-ups could more easily be arranged Quitline (a free smoking referral telephone service) has no restriction to working hours Support services could actually help to motivate patients Potential greater success may be achieved by addressing whichever factor the patient was more ready to change first Primary care teams can play a major role in affecting patients’ ideas  Selection bias towards higher participation among health care professional with an interest for prevention  Graffy, 2010, UK  Quantitative  Workload  Importance of administrative support Efficient systems to identify, invite and follow up patients Flexible appointments for people in work Tagging notes to invite non-attenders when they consult Team meetings contribute to a sense of ownership Training, both at the outset and for new staff Seeing patients benefiting of screening affirms the sense of the value of screening  Selection bias with participation of practices with screening experiences Concerns screening of type 2 diabetes, positive experiences  Wan, 2010, Australia  Qualitative  Low awareness among patients Time pressure Risk of ‘touting for business’ when booking another visit for risk discussion with a new patient  A strong GP–patient relationship, common ground on priorities between GPs and their patients, Patient’s self-motivation a key issue Opportunistic screening easier with regular patients   Selection bias with including GPs with interest in prevention Study included both patients and health care staff  Voogdt-Pruis, 2011, The Netherlands  Qualitative  Workload Lack of physical space Lack of motivation for patients Lack of GP knowledge about the guidelines Different attitudes towards treatment targets Lack of communication, between nurses and GPs and between GPs and second care Insufficient coaching by doctors Content of lifestyle advice Concern of losing nursing tasks for nurses Lack of ability of stop-smoking treatment Organizational issues (insufficient patient recording and computer systems) Considerable effort to get patients to attend, difficult to motivate patients who rarely visited the practice Poor record keeping (smoking behaviour, diagnoses and treatment by specialist)  Nurses could play an important role in preventive care Extending clinic opening hours Desirable to implement a chain of care and an integrated electronic patient record system  Experiences of implementing nurse-delivered prevention  Doolan-Noble, 2012, New Zealand  Qualitative  Time and workload Insufficient funding Lack of strong leadership and consistent messages Difficulty in handling asymptomatic high CV risk patients, and to communicate and motivating behaviour change (e.g. low SES patients, fatalistic views of patients) Attitude of low benefits of behaviour change Design of flip charts unsatisfactory  Ensure infrastructure, including training and to consider how the programme would be implemented Co-location of allied health staff in an integrated centre The need for ongoing tobacco legislation and positive food legislation Clarity around the roles and responsibilities of GPs and practice nurses Primary health care’s longitudinal relationship with patients Attitude of high benefits of behaviour change Useful electronic tools Incentives for patients for motivation and support lifestyle changes  No  Huy, 2012, Germany  Quantitativeb  Lack of time (91%) Insufficient renumeration (92%) Many different guidelines (73%) Unclear recommendations (60%) Lack of training (70%) Lack of material for patients (77%) Lack of adherence among patients (98%)   I can offer my patients a wide range of lifestyle advice (49.1%)a (OR 3.55; 95% CI 1.82–6.93) Risk factor questionnaires in the waiting room (61.5%)a (OR 2.26; 95% CI 1.06–4.85) Female gender of GPa (OR 1.98; 95% CI 1.04–3.76) Knowledge about positive lifestyle effect (54%) Prevention is a GP responsibility (40.9%) Not difficult to give advice on lifestyle changes (47.0%) Well educated for advice on healthy lifestyle (44.2%) Can successfully motivate patients to live healthier (45.6%)  Response rate 13%  Sondergaard, 2012, Denmark  Qualitative  Reservations if the health checks were a core mission of primary care Uncertainty about the best approach Reservations about inducing negative psychological reactions and decreased well-being among patients  Preventive health checks beneficial for the patients  No  Ferrante, 2013, Argentina  Qualitative  Lack of awareness of guidelines Lack of knowledge about preventing cardiovascular disease Communication problems within health teams Lack of motivation Organizational problems Low quality of recording  Intervention tailored to target identified barriers  Focused on barriers for designing an intervention  George, 2013, Singapore  Mixed  Lack of direct access/co-management with renal physician Lack of interest Nature of my practice Lack of confidence and faith Lack of sufficient support and experience Lack of time to keep up-to-date. Lack of medicine for CKD Lack of IT support. Too much paperwork Lack of patient education Poor patient compliance Lack of family/ social support management Lack of time to explain to the patient cQuantitative results: Lack of access to patient’s information (from hospital) (4.7) Lack of access to evidence-based guidelines (4.3) Inability to bill (4.5) Lack of patient’s trust in GP (3.9) Inability for patient to pay (3.7) Lack of time for consultation (3.6) Lack of support services (staff, technical) (2.3)  Access to/co-operation with renal specialist Adequate remuneration Technological assistance, IT Patient education, also to trust the GPs cQuantitative results: Less cost for patient (2.5) Access to patient’s information (2.8) Access to updates and guidelines (3.0) More support services (3.2) Less time consumed (3.3)   Concerns screening for chronic kidney disease Response rate of quantitative survey 25%  Godefrooij, 2014, The Netherlands  Qualitative  Lack of experience in the design and implementation of a structured, large-scale prevention programme, suboptimal instruction of involved staff No clear policy about how to follow up patients with ‘medium risk’, not exceeding the risk to be referred to their GP  Importance of primary prevention (high yield of health check, helped GPs to identify their high-risk population in a structured manner) Collaboration, i.e. ‘delegation of care’, health checks were delivered by medical receptionists and practice nurses, and GPs involved for high-risk patients  Study included both patients and health care staff  Vos, 2014, The Netherlands  Qualitative  Organizational context: insufficient reimbursement Professional context: lack of evidence and guidelines Social context: no focus on prevention  Organizational context: sufficient logistic and practical support and finances Responsibility to offer prevention, equity Professional context: evidence and guidelines Social context: prevention focused on  No  Baker, 2015 UK  Mixed  Extra workload Insufficient knowledge Lack of information collected by the practice prior to the appointment Programme tools developed to aid the assessment process and reduce staff time were not necessarily being used to their full effect Difficulty in engaging patients who were potentially able to receive the most benefit Less confident in second appointments (CVD risk assessment, mean = 3.52, SD = 1.3), risk communication (mean = 2.68, SD = 0.1.8) and changing behaviours (mean = 2.44, SD = 1.6) Mixed opinions concerning the quality of lifestyle services referred to: Weight management (mean = 3.76, SD = 0.90) and alcohol services (mean = 3.76, SD = 0.90) were the lowest rated Some participants were not aware of what health trainers were Caution concerning the programme’s overall effectiveness  Opportunistic approaches Practices periodically reviewed the non-responder list and reissued invites Practices were most confident in first appointments (pre-assessment blood tests, mean = 4.12, SD = 0.60), invitations (mean = 4.04, SD = 0.79) and laboratory tests (mean = 4.04, SD = 0.79) Mixed opinions concerning the quality of lifestyle services referred to: smoking cessation was rated most highly (mean = 4.43, SD = 0.59), health trainers were rated highly (mean = 4.13, SD = 0.83) HCs were useful in early detection and giving the time to discuss patient health and lifestyles (72%) Delivery of HCs in a wider range of settings, e.g. work places More than two-thirds (70.8%) of practice staff indicated that they had training in CVD prevention and 44% (n = 11) indicated that they required further training A need to promote the programme more effectively Conclusions: Adopting continuous approaches to knowledge development and transfer; improve confidence in HCs to deliver meaningful results  Small sample size, no response rate given  Barfoed, 2015, Denmark  Qualitative  Guidelines inhibit the ability to practice independently as a GP Risk communication tools are insufficient Resigned approach to manage patient compliance  Guidelines good and applicable Use of different communication tools depending on the patient context Confrontational approach to manage low patient compliance  No  Diehl, 2015, Germany  Quantitative  Insufficient reimbursement (90.2%) Difficult to give advice on unhealthy habits (73.5%) Cultural differences (59.1%) Insufficient connection with other preventive service providers (56.7%) Lack of time (54.5%) Attitude that patients cannot change lifestyle (49.1%) Difficult to follow guidelines (too many (43.1%), insufficient evidence (28.5%), unclear recommendations (24.9%) Lack of education/training (24.8%)  Responsibility to take a role as a health advisor (96.2%) Feeling well prepared for and successful of prevention (80.9%) Successful in motivating patients to a healthy lifestyle (72.6%) Networking with cooperation partners (70.7%) Being one of the most important influence factors on patients lifestyle (69.3%)  Response rate 34%  Gavarkovs, 2015, Canada  Qualitative  Time and travel constraints Unawareness of spouses of disease prevention programmes Lack of suitable male programme leaders Interfering with high work season of patients  Hiring qualified male instructors Engaging spouses  Concerns recruiting male participants in a rural district  Ismail, 2015, UK  Qualitative  Lack of staff time/hours, increased workload Lack of space in the building Insufficient software Lack of leaflets and posters Lack of awareness of health checks Lack of resources to motivate and support patients in lifestyle changes Problems in reaching important groups with unhealthy behaviours and low motivation for changes Lack of adherence to advices Interference with working time of possible attendants Doubt on impact of the programme Lack of referral services  Evolution of the programme over time in response to local needs to suit the particular characteristics of the patient population Individual staff characteristics such as being proactive, enthusiastic and having specific responsibility A supportive team Clear information to patients what the screening entails, including possible benefits and potential harm Messages in media to raise awareness of health checks Importance of the existing relationships between GPs and patients Attitude that health checks are beneficial and to identify high-risk patients Attendants are motivated and open to advice  No  Riley, 2015, UK  Qualitative  Concerns about the skill set of some staff to competently communicate risk and lifestyle information  Sufficient training to equip health care staff with appropriate skills and knowledge to deliver the service effectively  Study included both patients and staff  Krska, 2016, UK  Qualitative  Time constraints/pressure of work Increased nurse workload impacted on other services Insufficient payments Problems with software Attitude that health checks are a waste of time  IT support Effective software Health checks beneficial for patients  Focus on implementation of health checks  Baker: 1–5 scale. Percentages denote rate of participants giving this statement. CDPM, community-based chronic disease prevention and management; CHD, coronary heart disease; CKD, chronic kidney disease; CMHT, community mental health teams; CVD, cardiovascular diseases; HC, health care; PHCs, primary health care centres; PMs, practice managers; PNs, practice nurses; SES, socioeconomic status. aSignificant factors when statistical analyses were performed [with odds ratio (OR) and 95% confidence interval (95% CI) when shown in the article]. bObstacles include great, medium or small barriers. cObstacles mean rank of severity (1–7, 1 denotes easiest obstacle, 7 most difficult); motivational factors mean rank of motivation (1–5, 1 the most motivating factor, 5 the least motivating factor). View Large Table 2. Studies of barriers and facilitators in health care professionals to perform selective primary prevention of cardiovascular, diabetes and chronic kidney disease in patients without established cardiometabolic disease in primary care. (The search was conducted in March 2016.) Author, publication year, country  Type of study  Barriers  Facilitators  Bias and potential quality short-comings  Mann, 1990, Canada  Qualitative  Knowledge, attitudes and perceptions (lack of counselling skills, lack of belief in the efficacy of the activities) Conditions in which the activities occur (lack of available and accessible referral, lack of time) Reactions of others to the activities (lack of patient compliance) Difficulties in counselling (lack of appropriate, effective patient education materials)  Engaging a nurse to alleviate lack of time for GPs GPs most effective in dealing with high blood pressure Physician counselling effective in helping patients quit smoking  Focused on barriers to prevention  Calnan, 1993, UK  Quantitative  Negative attitudes to preventiona (health education is dull and boring; causes problems for the patients) Inappropriate skillsa  Positive attitudes to preventiona Training in health promotiona Higher number of practice nursesa GP spends more hours on research and traininga Positive attitudes by female GPsa Assistancea (from facilitator, or authorities) IT supporta  No  Hulscher, 1997, The Netherlands  Quantitative  Poor organization of practice to provide preventive services (lack of registration of activity for self-assessment of progress, lack of written protocols of agreement, not familiar with population approach) Acceptability [risk of causing medicalization in patients at risk for CVD (51%)] Feasibility [not enough time and opportunity (44%), lack of necessary data to screen and detect risk groups (50%)]   Organization of practice [availability of a sex–age registera, regular team work meetingsa, more practice assistance (not significant)] Acceptability [detection and treatment of hypertension will not cause anxiety (51%), patients appreciate monitoring of health (59%)] Responsibility [significant to smaller list size and proactive invitation of patientsa; CVD prevention is an important task in primary care (78%)] Self-efficacy [significant to registration of follow-up appointmentsa; GPs and PNs can motivate patients to live more healthy (70% and 72%), GPs and PNs can motivate hypertensive patients to follow advice (79% and 70%), GPs and PNs could be important support to stop smoking (82% and 65%), can contribute to a healthier way of living (45%)]  No  Makrides, 1997, Canada  Qualitative  Structural obstacles (funding, time, patient’s expectations, sparse community resources) Organizational (inadequate space, organization of practice around the traditional treatment-oriented medical model, negative staff attitude toward prevention) Personal (negative attitude toward prevention, lack of motivation, inadequate counselling skills, poor memory)  Identify prevention strategies: Viewing all visits as an opportunity for prevention Targeting risk factors Providing one-on-one counselling Providing group counselling Providing simple educational materials Offering clear and consistent advice Ensuring adequate follow-up Referring to other health professionals and community resources Enlisting the help of family and friends Identifying/addressing patient’s personal obstacles Identifying/addressing socio-environmental obstacles  No  Grant, 1998, Canada  Quantitative  Interventions to improve lifestyle ineffective (stress reduction 72.2%, weight loss 69.2%, smoking 59.1%, increasing physical activity 58.1%, diet 48.1%) Uncertain efficacy of available interventions (51.9%)  Relationship with patients (96.7%) Personal knowledge (77.6%) Compliance of patients (75.0%) Personal commitment (66.7%) Efficacy of available interventions (50.0%) Availability of time (41.0%) Opportunity to refer (28.2%) Organization of practice (25.6%) Good skill in managing risk factors (from 84.5% for council for lifestyle factors to 99.3% in screening)  Focus on knowledge of different risk factors  Steptoe, 1999, UK  Quantitative  Difficult to counsel patients about an alternative lifestyle (GP 24.8%, PN 25.5%; GP 53.5%, PN 60.0% neutral) Doubt that health professionals very influential in persuading people to change lifestyle (GP 62.5%, PN 62.5% neutral) Doubt that lifestyle counselling is very effective (GP 70.5% neutral) Doubt that you can offer patients a great deal in the way of lifestyle counselling (GP 75.0%, PN 50.0% neutral) Doubt that lifestyle counselling is very effective (GP 70.5%, PN 42.9% neutral)  Responsibility to act as a health educator (GP 70.2%, PN 87.5%) Have time for prevention (GP 29.8%, PN 62.5%) Feel properly trained (GP 48.6%, PN 48.2%) Health professionals very influential in persuading people to change lifestyle (GP 24.0%, PN 33.9%) Can offer patients a great deal in the way of lifestyle counselling (GP 17.3%, PN 50.0%) Lifestyle counselling is very effective (GP 20.0%, PN 53.6%) Possible to persuade patients to modify lifestyle: Hypertension (GP 50.0%, PN 62.5%), high cholesterol (GP 44.2%, 58.9%), smoking (GP 34.6%, 23.2%), obesity (GP 25.0%, PN 32.1%), physical activity (GP 24.0%, PN 34.5%) Overall attitude of effectiveness of lifestyle modification (6.57 of scale 0–10, higher score more effective)    Williams, 2004, UK (Wales)  Qualitative  Existing workload, lack of resources Questionable role of primary care as a ‘screening service’, and not responsibility of primary care Prevention: the responsibility of individuals, and agencies other than primary care, especially outside the health sector Conflict and concern about increasing specialization (here diabetes) Perceived low motivation of patients to modify their lifestyle Unnecessary medicalization No evidence that interventions delivered through primary care are effective  Importance of prevention High-risk patients should be seen anyway  Concerns type 2 diabetes only  Wright, 2006, UK  Qualitative  Lack of appropriate resources in existing services, e.g. time, trained staff Lack of funding Lack of familiarity in general practice with severe mental illness, also negative attitudes to work with these patients Lack of knowledge regarding CHD risk factor screening and difficulties in interpreting screening results and implementing appropriate interventions Mental patients harder to engage, prior experience of low attendance, perceived difficulty in making lifestyle changes A screening offer might be viewed as interference in patients' lives, and some patients get anxious Lack of appropriate services to refer patients Staff resistance to more changes in their role  Flexible solutions with clear lines of responsibility for assessing, communicating and managing CHD risks Mental patients are at high risk, with bad lifestyle manners, needing interventions GPs possess medical expertise Less stigmatising to attend primary care for screening Patients have better links, trust and a longer history with their GP  Concerns patients with severe mental illness Views from both primary care and community mental health teams  Pelletier-Fleury, 2007, France  Quantitative  Urban practicea (OR 0.66; 95% CI 0.65–0.68) Density of GPsa (OR 0.76; 95% CI 0.63–0.92)  Daily work loada (OR 1.03, 95% CI 1.01–1.05) Elderly patient list (>65 y)a (OR 1.04; 95% CI 1.02–1.07) High health care consumptiona (OR 4.29; 95% CI 3.62–5.00)  Register study of preventive services  Amoroso, 2009, Australia  Qualitative  Time Low remuneration Attitude that prevention do not have a high priority Attitude of scepticism about the value of a health check Management, in particular motivating patients to change their behaviour, proved to be more difficult  A useful opportunity to assess and manage risk factors A belief that preventive care was part of their role and responsibility Health check feasible   Short follow-up time  Ampt, 2009, Australia  Qualitative  Time Doubt on the effectiveness of general dietary recommendations Motivational interviewing good in theory, but difficult in practice Difficult to motivate patients to change behaviour Difficult in motivating patients to stop smoking Negative attitudes towards assessment of nutrition, alcohol and physical activity Cost of follow-up visit Difficult to access referrals in working hours Lack of knowledge regarding the role of the exercise physiologist Advice offered by a dietician would be no different to that offered by the GP, and thus referrals were of little value  Usefulness of a computer-based template or patient education and assessment resources Training in motivational interviewing Experience and interest in addressing drug and alcohol issues Giving advice and educating the patient were viewed as a professional responsibility Printed material reinforced any message Practice having an appointment system, as follow-ups could more easily be arranged Quitline (a free smoking referral telephone service) has no restriction to working hours Support services could actually help to motivate patients Potential greater success may be achieved by addressing whichever factor the patient was more ready to change first Primary care teams can play a major role in affecting patients’ ideas  Selection bias towards higher participation among health care professional with an interest for prevention  Graffy, 2010, UK  Quantitative  Workload  Importance of administrative support Efficient systems to identify, invite and follow up patients Flexible appointments for people in work Tagging notes to invite non-attenders when they consult Team meetings contribute to a sense of ownership Training, both at the outset and for new staff Seeing patients benefiting of screening affirms the sense of the value of screening  Selection bias with participation of practices with screening experiences Concerns screening of type 2 diabetes, positive experiences  Wan, 2010, Australia  Qualitative  Low awareness among patients Time pressure Risk of ‘touting for business’ when booking another visit for risk discussion with a new patient  A strong GP–patient relationship, common ground on priorities between GPs and their patients, Patient’s self-motivation a key issue Opportunistic screening easier with regular patients   Selection bias with including GPs with interest in prevention Study included both patients and health care staff  Voogdt-Pruis, 2011, The Netherlands  Qualitative  Workload Lack of physical space Lack of motivation for patients Lack of GP knowledge about the guidelines Different attitudes towards treatment targets Lack of communication, between nurses and GPs and between GPs and second care Insufficient coaching by doctors Content of lifestyle advice Concern of losing nursing tasks for nurses Lack of ability of stop-smoking treatment Organizational issues (insufficient patient recording and computer systems) Considerable effort to get patients to attend, difficult to motivate patients who rarely visited the practice Poor record keeping (smoking behaviour, diagnoses and treatment by specialist)  Nurses could play an important role in preventive care Extending clinic opening hours Desirable to implement a chain of care and an integrated electronic patient record system  Experiences of implementing nurse-delivered prevention  Doolan-Noble, 2012, New Zealand  Qualitative  Time and workload Insufficient funding Lack of strong leadership and consistent messages Difficulty in handling asymptomatic high CV risk patients, and to communicate and motivating behaviour change (e.g. low SES patients, fatalistic views of patients) Attitude of low benefits of behaviour change Design of flip charts unsatisfactory  Ensure infrastructure, including training and to consider how the programme would be implemented Co-location of allied health staff in an integrated centre The need for ongoing tobacco legislation and positive food legislation Clarity around the roles and responsibilities of GPs and practice nurses Primary health care’s longitudinal relationship with patients Attitude of high benefits of behaviour change Useful electronic tools Incentives for patients for motivation and support lifestyle changes  No  Huy, 2012, Germany  Quantitativeb  Lack of time (91%) Insufficient renumeration (92%) Many different guidelines (73%) Unclear recommendations (60%) Lack of training (70%) Lack of material for patients (77%) Lack of adherence among patients (98%)   I can offer my patients a wide range of lifestyle advice (49.1%)a (OR 3.55; 95% CI 1.82–6.93) Risk factor questionnaires in the waiting room (61.5%)a (OR 2.26; 95% CI 1.06–4.85) Female gender of GPa (OR 1.98; 95% CI 1.04–3.76) Knowledge about positive lifestyle effect (54%) Prevention is a GP responsibility (40.9%) Not difficult to give advice on lifestyle changes (47.0%) Well educated for advice on healthy lifestyle (44.2%) Can successfully motivate patients to live healthier (45.6%)  Response rate 13%  Sondergaard, 2012, Denmark  Qualitative  Reservations if the health checks were a core mission of primary care Uncertainty about the best approach Reservations about inducing negative psychological reactions and decreased well-being among patients  Preventive health checks beneficial for the patients  No  Ferrante, 2013, Argentina  Qualitative  Lack of awareness of guidelines Lack of knowledge about preventing cardiovascular disease Communication problems within health teams Lack of motivation Organizational problems Low quality of recording  Intervention tailored to target identified barriers  Focused on barriers for designing an intervention  George, 2013, Singapore  Mixed  Lack of direct access/co-management with renal physician Lack of interest Nature of my practice Lack of confidence and faith Lack of sufficient support and experience Lack of time to keep up-to-date. Lack of medicine for CKD Lack of IT support. Too much paperwork Lack of patient education Poor patient compliance Lack of family/ social support management Lack of time to explain to the patient cQuantitative results: Lack of access to patient’s information (from hospital) (4.7) Lack of access to evidence-based guidelines (4.3) Inability to bill (4.5) Lack of patient’s trust in GP (3.9) Inability for patient to pay (3.7) Lack of time for consultation (3.6) Lack of support services (staff, technical) (2.3)  Access to/co-operation with renal specialist Adequate remuneration Technological assistance, IT Patient education, also to trust the GPs cQuantitative results: Less cost for patient (2.5) Access to patient’s information (2.8) Access to updates and guidelines (3.0) More support services (3.2) Less time consumed (3.3)   Concerns screening for chronic kidney disease Response rate of quantitative survey 25%  Godefrooij, 2014, The Netherlands  Qualitative  Lack of experience in the design and implementation of a structured, large-scale prevention programme, suboptimal instruction of involved staff No clear policy about how to follow up patients with ‘medium risk’, not exceeding the risk to be referred to their GP  Importance of primary prevention (high yield of health check, helped GPs to identify their high-risk population in a structured manner) Collaboration, i.e. ‘delegation of care’, health checks were delivered by medical receptionists and practice nurses, and GPs involved for high-risk patients  Study included both patients and health care staff  Vos, 2014, The Netherlands  Qualitative  Organizational context: insufficient reimbursement Professional context: lack of evidence and guidelines Social context: no focus on prevention  Organizational context: sufficient logistic and practical support and finances Responsibility to offer prevention, equity Professional context: evidence and guidelines Social context: prevention focused on  No  Baker, 2015 UK  Mixed  Extra workload Insufficient knowledge Lack of information collected by the practice prior to the appointment Programme tools developed to aid the assessment process and reduce staff time were not necessarily being used to their full effect Difficulty in engaging patients who were potentially able to receive the most benefit Less confident in second appointments (CVD risk assessment, mean = 3.52, SD = 1.3), risk communication (mean = 2.68, SD = 0.1.8) and changing behaviours (mean = 2.44, SD = 1.6) Mixed opinions concerning the quality of lifestyle services referred to: Weight management (mean = 3.76, SD = 0.90) and alcohol services (mean = 3.76, SD = 0.90) were the lowest rated Some participants were not aware of what health trainers were Caution concerning the programme’s overall effectiveness  Opportunistic approaches Practices periodically reviewed the non-responder list and reissued invites Practices were most confident in first appointments (pre-assessment blood tests, mean = 4.12, SD = 0.60), invitations (mean = 4.04, SD = 0.79) and laboratory tests (mean = 4.04, SD = 0.79) Mixed opinions concerning the quality of lifestyle services referred to: smoking cessation was rated most highly (mean = 4.43, SD = 0.59), health trainers were rated highly (mean = 4.13, SD = 0.83) HCs were useful in early detection and giving the time to discuss patient health and lifestyles (72%) Delivery of HCs in a wider range of settings, e.g. work places More than two-thirds (70.8%) of practice staff indicated that they had training in CVD prevention and 44% (n = 11) indicated that they required further training A need to promote the programme more effectively Conclusions: Adopting continuous approaches to knowledge development and transfer; improve confidence in HCs to deliver meaningful results  Small sample size, no response rate given  Barfoed, 2015, Denmark  Qualitative  Guidelines inhibit the ability to practice independently as a GP Risk communication tools are insufficient Resigned approach to manage patient compliance  Guidelines good and applicable Use of different communication tools depending on the patient context Confrontational approach to manage low patient compliance  No  Diehl, 2015, Germany  Quantitative  Insufficient reimbursement (90.2%) Difficult to give advice on unhealthy habits (73.5%) Cultural differences (59.1%) Insufficient connection with other preventive service providers (56.7%) Lack of time (54.5%) Attitude that patients cannot change lifestyle (49.1%) Difficult to follow guidelines (too many (43.1%), insufficient evidence (28.5%), unclear recommendations (24.9%) Lack of education/training (24.8%)  Responsibility to take a role as a health advisor (96.2%) Feeling well prepared for and successful of prevention (80.9%) Successful in motivating patients to a healthy lifestyle (72.6%) Networking with cooperation partners (70.7%) Being one of the most important influence factors on patients lifestyle (69.3%)  Response rate 34%  Gavarkovs, 2015, Canada  Qualitative  Time and travel constraints Unawareness of spouses of disease prevention programmes Lack of suitable male programme leaders Interfering with high work season of patients  Hiring qualified male instructors Engaging spouses  Concerns recruiting male participants in a rural district  Ismail, 2015, UK  Qualitative  Lack of staff time/hours, increased workload Lack of space in the building Insufficient software Lack of leaflets and posters Lack of awareness of health checks Lack of resources to motivate and support patients in lifestyle changes Problems in reaching important groups with unhealthy behaviours and low motivation for changes Lack of adherence to advices Interference with working time of possible attendants Doubt on impact of the programme Lack of referral services  Evolution of the programme over time in response to local needs to suit the particular characteristics of the patient population Individual staff characteristics such as being proactive, enthusiastic and having specific responsibility A supportive team Clear information to patients what the screening entails, including possible benefits and potential harm Messages in media to raise awareness of health checks Importance of the existing relationships between GPs and patients Attitude that health checks are beneficial and to identify high-risk patients Attendants are motivated and open to advice  No  Riley, 2015, UK  Qualitative  Concerns about the skill set of some staff to competently communicate risk and lifestyle information  Sufficient training to equip health care staff with appropriate skills and knowledge to deliver the service effectively  Study included both patients and staff  Krska, 2016, UK  Qualitative  Time constraints/pressure of work Increased nurse workload impacted on other services Insufficient payments Problems with software Attitude that health checks are a waste of time  IT support Effective software Health checks beneficial for patients  Focus on implementation of health checks  Author, publication year, country  Type of study  Barriers  Facilitators  Bias and potential quality short-comings  Mann, 1990, Canada  Qualitative  Knowledge, attitudes and perceptions (lack of counselling skills, lack of belief in the efficacy of the activities) Conditions in which the activities occur (lack of available and accessible referral, lack of time) Reactions of others to the activities (lack of patient compliance) Difficulties in counselling (lack of appropriate, effective patient education materials)  Engaging a nurse to alleviate lack of time for GPs GPs most effective in dealing with high blood pressure Physician counselling effective in helping patients quit smoking  Focused on barriers to prevention  Calnan, 1993, UK  Quantitative  Negative attitudes to preventiona (health education is dull and boring; causes problems for the patients) Inappropriate skillsa  Positive attitudes to preventiona Training in health promotiona Higher number of practice nursesa GP spends more hours on research and traininga Positive attitudes by female GPsa Assistancea (from facilitator, or authorities) IT supporta  No  Hulscher, 1997, The Netherlands  Quantitative  Poor organization of practice to provide preventive services (lack of registration of activity for self-assessment of progress, lack of written protocols of agreement, not familiar with population approach) Acceptability [risk of causing medicalization in patients at risk for CVD (51%)] Feasibility [not enough time and opportunity (44%), lack of necessary data to screen and detect risk groups (50%)]   Organization of practice [availability of a sex–age registera, regular team work meetingsa, more practice assistance (not significant)] Acceptability [detection and treatment of hypertension will not cause anxiety (51%), patients appreciate monitoring of health (59%)] Responsibility [significant to smaller list size and proactive invitation of patientsa; CVD prevention is an important task in primary care (78%)] Self-efficacy [significant to registration of follow-up appointmentsa; GPs and PNs can motivate patients to live more healthy (70% and 72%), GPs and PNs can motivate hypertensive patients to follow advice (79% and 70%), GPs and PNs could be important support to stop smoking (82% and 65%), can contribute to a healthier way of living (45%)]  No  Makrides, 1997, Canada  Qualitative  Structural obstacles (funding, time, patient’s expectations, sparse community resources) Organizational (inadequate space, organization of practice around the traditional treatment-oriented medical model, negative staff attitude toward prevention) Personal (negative attitude toward prevention, lack of motivation, inadequate counselling skills, poor memory)  Identify prevention strategies: Viewing all visits as an opportunity for prevention Targeting risk factors Providing one-on-one counselling Providing group counselling Providing simple educational materials Offering clear and consistent advice Ensuring adequate follow-up Referring to other health professionals and community resources Enlisting the help of family and friends Identifying/addressing patient’s personal obstacles Identifying/addressing socio-environmental obstacles  No  Grant, 1998, Canada  Quantitative  Interventions to improve lifestyle ineffective (stress reduction 72.2%, weight loss 69.2%, smoking 59.1%, increasing physical activity 58.1%, diet 48.1%) Uncertain efficacy of available interventions (51.9%)  Relationship with patients (96.7%) Personal knowledge (77.6%) Compliance of patients (75.0%) Personal commitment (66.7%) Efficacy of available interventions (50.0%) Availability of time (41.0%) Opportunity to refer (28.2%) Organization of practice (25.6%) Good skill in managing risk factors (from 84.5% for council for lifestyle factors to 99.3% in screening)  Focus on knowledge of different risk factors  Steptoe, 1999, UK  Quantitative  Difficult to counsel patients about an alternative lifestyle (GP 24.8%, PN 25.5%; GP 53.5%, PN 60.0% neutral) Doubt that health professionals very influential in persuading people to change lifestyle (GP 62.5%, PN 62.5% neutral) Doubt that lifestyle counselling is very effective (GP 70.5% neutral) Doubt that you can offer patients a great deal in the way of lifestyle counselling (GP 75.0%, PN 50.0% neutral) Doubt that lifestyle counselling is very effective (GP 70.5%, PN 42.9% neutral)  Responsibility to act as a health educator (GP 70.2%, PN 87.5%) Have time for prevention (GP 29.8%, PN 62.5%) Feel properly trained (GP 48.6%, PN 48.2%) Health professionals very influential in persuading people to change lifestyle (GP 24.0%, PN 33.9%) Can offer patients a great deal in the way of lifestyle counselling (GP 17.3%, PN 50.0%) Lifestyle counselling is very effective (GP 20.0%, PN 53.6%) Possible to persuade patients to modify lifestyle: Hypertension (GP 50.0%, PN 62.5%), high cholesterol (GP 44.2%, 58.9%), smoking (GP 34.6%, 23.2%), obesity (GP 25.0%, PN 32.1%), physical activity (GP 24.0%, PN 34.5%) Overall attitude of effectiveness of lifestyle modification (6.57 of scale 0–10, higher score more effective)    Williams, 2004, UK (Wales)  Qualitative  Existing workload, lack of resources Questionable role of primary care as a ‘screening service’, and not responsibility of primary care Prevention: the responsibility of individuals, and agencies other than primary care, especially outside the health sector Conflict and concern about increasing specialization (here diabetes) Perceived low motivation of patients to modify their lifestyle Unnecessary medicalization No evidence that interventions delivered through primary care are effective  Importance of prevention High-risk patients should be seen anyway  Concerns type 2 diabetes only  Wright, 2006, UK  Qualitative  Lack of appropriate resources in existing services, e.g. time, trained staff Lack of funding Lack of familiarity in general practice with severe mental illness, also negative attitudes to work with these patients Lack of knowledge regarding CHD risk factor screening and difficulties in interpreting screening results and implementing appropriate interventions Mental patients harder to engage, prior experience of low attendance, perceived difficulty in making lifestyle changes A screening offer might be viewed as interference in patients' lives, and some patients get anxious Lack of appropriate services to refer patients Staff resistance to more changes in their role  Flexible solutions with clear lines of responsibility for assessing, communicating and managing CHD risks Mental patients are at high risk, with bad lifestyle manners, needing interventions GPs possess medical expertise Less stigmatising to attend primary care for screening Patients have better links, trust and a longer history with their GP  Concerns patients with severe mental illness Views from both primary care and community mental health teams  Pelletier-Fleury, 2007, France  Quantitative  Urban practicea (OR 0.66; 95% CI 0.65–0.68) Density of GPsa (OR 0.76; 95% CI 0.63–0.92)  Daily work loada (OR 1.03, 95% CI 1.01–1.05) Elderly patient list (>65 y)a (OR 1.04; 95% CI 1.02–1.07) High health care consumptiona (OR 4.29; 95% CI 3.62–5.00)  Register study of preventive services  Amoroso, 2009, Australia  Qualitative  Time Low remuneration Attitude that prevention do not have a high priority Attitude of scepticism about the value of a health check Management, in particular motivating patients to change their behaviour, proved to be more difficult  A useful opportunity to assess and manage risk factors A belief that preventive care was part of their role and responsibility Health check feasible   Short follow-up time  Ampt, 2009, Australia  Qualitative  Time Doubt on the effectiveness of general dietary recommendations Motivational interviewing good in theory, but difficult in practice Difficult to motivate patients to change behaviour Difficult in motivating patients to stop smoking Negative attitudes towards assessment of nutrition, alcohol and physical activity Cost of follow-up visit Difficult to access referrals in working hours Lack of knowledge regarding the role of the exercise physiologist Advice offered by a dietician would be no different to that offered by the GP, and thus referrals were of little value  Usefulness of a computer-based template or patient education and assessment resources Training in motivational interviewing Experience and interest in addressing drug and alcohol issues Giving advice and educating the patient were viewed as a professional responsibility Printed material reinforced any message Practice having an appointment system, as follow-ups could more easily be arranged Quitline (a free smoking referral telephone service) has no restriction to working hours Support services could actually help to motivate patients Potential greater success may be achieved by addressing whichever factor the patient was more ready to change first Primary care teams can play a major role in affecting patients’ ideas  Selection bias towards higher participation among health care professional with an interest for prevention  Graffy, 2010, UK  Quantitative  Workload  Importance of administrative support Efficient systems to identify, invite and follow up patients Flexible appointments for people in work Tagging notes to invite non-attenders when they consult Team meetings contribute to a sense of ownership Training, both at the outset and for new staff Seeing patients benefiting of screening affirms the sense of the value of screening  Selection bias with participation of practices with screening experiences Concerns screening of type 2 diabetes, positive experiences  Wan, 2010, Australia  Qualitative  Low awareness among patients Time pressure Risk of ‘touting for business’ when booking another visit for risk discussion with a new patient  A strong GP–patient relationship, common ground on priorities between GPs and their patients, Patient’s self-motivation a key issue Opportunistic screening easier with regular patients   Selection bias with including GPs with interest in prevention Study included both patients and health care staff  Voogdt-Pruis, 2011, The Netherlands  Qualitative  Workload Lack of physical space Lack of motivation for patients Lack of GP knowledge about the guidelines Different attitudes towards treatment targets Lack of communication, between nurses and GPs and between GPs and second care Insufficient coaching by doctors Content of lifestyle advice Concern of losing nursing tasks for nurses Lack of ability of stop-smoking treatment Organizational issues (insufficient patient recording and computer systems) Considerable effort to get patients to attend, difficult to motivate patients who rarely visited the practice Poor record keeping (smoking behaviour, diagnoses and treatment by specialist)  Nurses could play an important role in preventive care Extending clinic opening hours Desirable to implement a chain of care and an integrated electronic patient record system  Experiences of implementing nurse-delivered prevention  Doolan-Noble, 2012, New Zealand  Qualitative  Time and workload Insufficient funding Lack of strong leadership and consistent messages Difficulty in handling asymptomatic high CV risk patients, and to communicate and motivating behaviour change (e.g. low SES patients, fatalistic views of patients) Attitude of low benefits of behaviour change Design of flip charts unsatisfactory  Ensure infrastructure, including training and to consider how the programme would be implemented Co-location of allied health staff in an integrated centre The need for ongoing tobacco legislation and positive food legislation Clarity around the roles and responsibilities of GPs and practice nurses Primary health care’s longitudinal relationship with patients Attitude of high benefits of behaviour change Useful electronic tools Incentives for patients for motivation and support lifestyle changes  No  Huy, 2012, Germany  Quantitativeb  Lack of time (91%) Insufficient renumeration (92%) Many different guidelines (73%) Unclear recommendations (60%) Lack of training (70%) Lack of material for patients (77%) Lack of adherence among patients (98%)   I can offer my patients a wide range of lifestyle advice (49.1%)a (OR 3.55; 95% CI 1.82–6.93) Risk factor questionnaires in the waiting room (61.5%)a (OR 2.26; 95% CI 1.06–4.85) Female gender of GPa (OR 1.98; 95% CI 1.04–3.76) Knowledge about positive lifestyle effect (54%) Prevention is a GP responsibility (40.9%) Not difficult to give advice on lifestyle changes (47.0%) Well educated for advice on healthy lifestyle (44.2%) Can successfully motivate patients to live healthier (45.6%)  Response rate 13%  Sondergaard, 2012, Denmark  Qualitative  Reservations if the health checks were a core mission of primary care Uncertainty about the best approach Reservations about inducing negative psychological reactions and decreased well-being among patients  Preventive health checks beneficial for the patients  No  Ferrante, 2013, Argentina  Qualitative  Lack of awareness of guidelines Lack of knowledge about preventing cardiovascular disease Communication problems within health teams Lack of motivation Organizational problems Low quality of recording  Intervention tailored to target identified barriers  Focused on barriers for designing an intervention  George, 2013, Singapore  Mixed  Lack of direct access/co-management with renal physician Lack of interest Nature of my practice Lack of confidence and faith Lack of sufficient support and experience Lack of time to keep up-to-date. Lack of medicine for CKD Lack of IT support. Too much paperwork Lack of patient education Poor patient compliance Lack of family/ social support management Lack of time to explain to the patient cQuantitative results: Lack of access to patient’s information (from hospital) (4.7) Lack of access to evidence-based guidelines (4.3) Inability to bill (4.5) Lack of patient’s trust in GP (3.9) Inability for patient to pay (3.7) Lack of time for consultation (3.6) Lack of support services (staff, technical) (2.3)  Access to/co-operation with renal specialist Adequate remuneration Technological assistance, IT Patient education, also to trust the GPs cQuantitative results: Less cost for patient (2.5) Access to patient’s information (2.8) Access to updates and guidelines (3.0) More support services (3.2) Less time consumed (3.3)   Concerns screening for chronic kidney disease Response rate of quantitative survey 25%  Godefrooij, 2014, The Netherlands  Qualitative  Lack of experience in the design and implementation of a structured, large-scale prevention programme, suboptimal instruction of involved staff No clear policy about how to follow up patients with ‘medium risk’, not exceeding the risk to be referred to their GP  Importance of primary prevention (high yield of health check, helped GPs to identify their high-risk population in a structured manner) Collaboration, i.e. ‘delegation of care’, health checks were delivered by medical receptionists and practice nurses, and GPs involved for high-risk patients  Study included both patients and health care staff  Vos, 2014, The Netherlands  Qualitative  Organizational context: insufficient reimbursement Professional context: lack of evidence and guidelines Social context: no focus on prevention  Organizational context: sufficient logistic and practical support and finances Responsibility to offer prevention, equity Professional context: evidence and guidelines Social context: prevention focused on  No  Baker, 2015 UK  Mixed  Extra workload Insufficient knowledge Lack of information collected by the practice prior to the appointment Programme tools developed to aid the assessment process and reduce staff time were not necessarily being used to their full effect Difficulty in engaging patients who were potentially able to receive the most benefit Less confident in second appointments (CVD risk assessment, mean = 3.52, SD = 1.3), risk communication (mean = 2.68, SD = 0.1.8) and changing behaviours (mean = 2.44, SD = 1.6) Mixed opinions concerning the quality of lifestyle services referred to: Weight management (mean = 3.76, SD = 0.90) and alcohol services (mean = 3.76, SD = 0.90) were the lowest rated Some participants were not aware of what health trainers were Caution concerning the programme’s overall effectiveness  Opportunistic approaches Practices periodically reviewed the non-responder list and reissued invites Practices were most confident in first appointments (pre-assessment blood tests, mean = 4.12, SD = 0.60), invitations (mean = 4.04, SD = 0.79) and laboratory tests (mean = 4.04, SD = 0.79) Mixed opinions concerning the quality of lifestyle services referred to: smoking cessation was rated most highly (mean = 4.43, SD = 0.59), health trainers were rated highly (mean = 4.13, SD = 0.83) HCs were useful in early detection and giving the time to discuss patient health and lifestyles (72%) Delivery of HCs in a wider range of settings, e.g. work places More than two-thirds (70.8%) of practice staff indicated that they had training in CVD prevention and 44% (n = 11) indicated that they required further training A need to promote the programme more effectively Conclusions: Adopting continuous approaches to knowledge development and transfer; improve confidence in HCs to deliver meaningful results  Small sample size, no response rate given  Barfoed, 2015, Denmark  Qualitative  Guidelines inhibit the ability to practice independently as a GP Risk communication tools are insufficient Resigned approach to manage patient compliance  Guidelines good and applicable Use of different communication tools depending on the patient context Confrontational approach to manage low patient compliance  No  Diehl, 2015, Germany  Quantitative  Insufficient reimbursement (90.2%) Difficult to give advice on unhealthy habits (73.5%) Cultural differences (59.1%) Insufficient connection with other preventive service providers (56.7%) Lack of time (54.5%) Attitude that patients cannot change lifestyle (49.1%) Difficult to follow guidelines (too many (43.1%), insufficient evidence (28.5%), unclear recommendations (24.9%) Lack of education/training (24.8%)  Responsibility to take a role as a health advisor (96.2%) Feeling well prepared for and successful of prevention (80.9%) Successful in motivating patients to a healthy lifestyle (72.6%) Networking with cooperation partners (70.7%) Being one of the most important influence factors on patients lifestyle (69.3%)  Response rate 34%  Gavarkovs, 2015, Canada  Qualitative  Time and travel constraints Unawareness of spouses of disease prevention programmes Lack of suitable male programme leaders Interfering with high work season of patients  Hiring qualified male instructors Engaging spouses  Concerns recruiting male participants in a rural district  Ismail, 2015, UK  Qualitative  Lack of staff time/hours, increased workload Lack of space in the building Insufficient software Lack of leaflets and posters Lack of awareness of health checks Lack of resources to motivate and support patients in lifestyle changes Problems in reaching important groups with unhealthy behaviours and low motivation for changes Lack of adherence to advices Interference with working time of possible attendants Doubt on impact of the programme Lack of referral services  Evolution of the programme over time in response to local needs to suit the particular characteristics of the patient population Individual staff characteristics such as being proactive, enthusiastic and having specific responsibility A supportive team Clear information to patients what the screening entails, including possible benefits and potential harm Messages in media to raise awareness of health checks Importance of the existing relationships between GPs and patients Attitude that health checks are beneficial and to identify high-risk patients Attendants are motivated and open to advice  No  Riley, 2015, UK  Qualitative  Concerns about the skill set of some staff to competently communicate risk and lifestyle information  Sufficient training to equip health care staff with appropriate skills and knowledge to deliver the service effectively  Study included both patients and staff  Krska, 2016, UK  Qualitative  Time constraints/pressure of work Increased nurse workload impacted on other services Insufficient payments Problems with software Attitude that health checks are a waste of time  IT support Effective software Health checks beneficial for patients  Focus on implementation of health checks  Baker: 1–5 scale. Percentages denote rate of participants giving this statement. CDPM, community-based chronic disease prevention and management; CHD, coronary heart disease; CKD, chronic kidney disease; CMHT, community mental health teams; CVD, cardiovascular diseases; HC, health care; PHCs, primary health care centres; PMs, practice managers; PNs, practice nurses; SES, socioeconomic status. aSignificant factors when statistical analyses were performed [with odds ratio (OR) and 95% confidence interval (95% CI) when shown in the article]. bObstacles include great, medium or small barriers. cObstacles mean rank of severity (1–7, 1 denotes easiest obstacle, 7 most difficult); motivational factors mean rank of motivation (1–5, 1 the most motivating factor, 5 the least motivating factor). View Large A complete overview of barriers and facilitators from both qualitative and quantitative studies is shown in Table 3 and organized in five fundamental categories: structural, organizational context, professional context, patient-oriented factors and attitudes. Table 3. Overview of barriers and facilitators in health care professionals to do selective primary prevention of cardiometabolic diseases in patients without established disease in primary care (The search was conducted in March 2016.) Context  Barriers  Facilitators  Structural context  Lack of time, extra workload (18 studies) Lack of space in the building (3 studies) Insufficient reimbursement or community resources (10 studies) Guidelines: lack of awareness of guidelines, lack of evidence and guidelines, too many guidelines in the area, or difficult to follow guidelines) (6 studies) Lack of available and accessible referral (5 studies) Lack of assistance and support from authorities (2 studies) Lack of material for patients (4 studies) Lack of effective and feasible counselling (12 studies) Problems related to follow-up (2 studies)   Availability of time (3 studies)a Sufficient finances (2 studies) Access to good guidelines (2 studies) Ensuring adequate referral (3 studies)a Ensuring adequate follow-up (2 studies)a Assistance and support from authorities (4 studies)a Identifying obstacles for prevention (3 studies) Providing information and educational materials (3 study) Counselling and interventions feasible and effective (10 studies)a Information in media (1 study) Legislation for unhealthy habits (e.g. smoking) (1 study)  Organizational context  Organizational problems in general (3 studies) Lack of strong leadership and consistent messages (1 study) Lack of IT support, software (5 studies) Lack of local support services, communication problems (4 studies) Insufficient connection with other preventive service providers (1 study) Lack of access to information on patients (5 studies) Low quality of recording (2 studies) Lack of suitable appointment times for employed patients (3 studies) Role of practices, no responsibility to offer prevention (6 studies) Roles of primary care staff (4 studies)   Structured organization of practice (4 studies)a IT support (5 studies)a Assistance and support within practice and teams (8 studies)a Important role of practice nurses (4 studies)a Cooperation with allied health staff or community resources (3 studies) Access to patient information or register (2 studies)a Integrated electronic patient record system (1 study) Appointment system (2 studies) Intervention tailored to target identified barriers (2 study) Flexibility in counselling (5 study)a Responsibility to offer and importance of prevention (10 studies) Useful opportunity of health checks and prevention (5 studies)  Professional context  Lack of education/training/skills to competently communicate risk and lifestyle information (lack of counselling skills) (6 studies)a Lack of knowledge (5 studies) Lack of experience (3 studies)  Sufficient training and education (10 studies)a Effective in motivating patients (4 studies) Sufficient knowledge (1 study) Female GPs (2 studies)a  Patient-oriented factors  Low awareness of patients (1 study) Low adherence of patients (9 studies) Lack of trust in GP–patient relation (1 study) Lack of social support from families or friends (1 study) Causes problems, i.e. anxiety and medicalization (5 studies) Cultural differences (1 study)  Motivation of patients (2 studies) A strong/longitudinal GP–patient relationship (5 studies) Enlisting the support from family and friends (2 studies) Appreciated by patients (4 studies)  Attitudes  Negative attitudes in general to prevention (16 studies) Doubt on acceptability (1 study) Doubt on feasibility (1 study)  Positive attitudes to prevention in general (14 studies)a Acceptability (1 study) Feasibility (1 study)  Context  Barriers  Facilitators  Structural context  Lack of time, extra workload (18 studies) Lack of space in the building (3 studies) Insufficient reimbursement or community resources (10 studies) Guidelines: lack of awareness of guidelines, lack of evidence and guidelines, too many guidelines in the area, or difficult to follow guidelines) (6 studies) Lack of available and accessible referral (5 studies) Lack of assistance and support from authorities (2 studies) Lack of material for patients (4 studies) Lack of effective and feasible counselling (12 studies) Problems related to follow-up (2 studies)   Availability of time (3 studies)a Sufficient finances (2 studies) Access to good guidelines (2 studies) Ensuring adequate referral (3 studies)a Ensuring adequate follow-up (2 studies)a Assistance and support from authorities (4 studies)a Identifying obstacles for prevention (3 studies) Providing information and educational materials (3 study) Counselling and interventions feasible and effective (10 studies)a Information in media (1 study) Legislation for unhealthy habits (e.g. smoking) (1 study)  Organizational context  Organizational problems in general (3 studies) Lack of strong leadership and consistent messages (1 study) Lack of IT support, software (5 studies) Lack of local support services, communication problems (4 studies) Insufficient connection with other preventive service providers (1 study) Lack of access to information on patients (5 studies) Low quality of recording (2 studies) Lack of suitable appointment times for employed patients (3 studies) Role of practices, no responsibility to offer prevention (6 studies) Roles of primary care staff (4 studies)   Structured organization of practice (4 studies)a IT support (5 studies)a Assistance and support within practice and teams (8 studies)a Important role of practice nurses (4 studies)a Cooperation with allied health staff or community resources (3 studies) Access to patient information or register (2 studies)a Integrated electronic patient record system (1 study) Appointment system (2 studies) Intervention tailored to target identified barriers (2 study) Flexibility in counselling (5 study)a Responsibility to offer and importance of prevention (10 studies) Useful opportunity of health checks and prevention (5 studies)  Professional context  Lack of education/training/skills to competently communicate risk and lifestyle information (lack of counselling skills) (6 studies)a Lack of knowledge (5 studies) Lack of experience (3 studies)  Sufficient training and education (10 studies)a Effective in motivating patients (4 studies) Sufficient knowledge (1 study) Female GPs (2 studies)a  Patient-oriented factors  Low awareness of patients (1 study) Low adherence of patients (9 studies) Lack of trust in GP–patient relation (1 study) Lack of social support from families or friends (1 study) Causes problems, i.e. anxiety and medicalization (5 studies) Cultural differences (1 study)  Motivation of patients (2 studies) A strong/longitudinal GP–patient relationship (5 studies) Enlisting the support from family and friends (2 studies) Appreciated by patients (4 studies)  Attitudes  Negative attitudes in general to prevention (16 studies) Doubt on acceptability (1 study) Doubt on feasibility (1 study)  Positive attitudes to prevention in general (14 studies)a Acceptability (1 study) Feasibility (1 study)  The numbers of studies reporting a specific factor are given. aSignificant factors when statistical analyses were performed. View Large Table 3. Overview of barriers and facilitators in health care professionals to do selective primary prevention of cardiometabolic diseases in patients without established disease in primary care (The search was conducted in March 2016.) Context  Barriers  Facilitators  Structural context  Lack of time, extra workload (18 studies) Lack of space in the building (3 studies) Insufficient reimbursement or community resources (10 studies) Guidelines: lack of awareness of guidelines, lack of evidence and guidelines, too many guidelines in the area, or difficult to follow guidelines) (6 studies) Lack of available and accessible referral (5 studies) Lack of assistance and support from authorities (2 studies) Lack of material for patients (4 studies) Lack of effective and feasible counselling (12 studies) Problems related to follow-up (2 studies)   Availability of time (3 studies)a Sufficient finances (2 studies) Access to good guidelines (2 studies) Ensuring adequate referral (3 studies)a Ensuring adequate follow-up (2 studies)a Assistance and support from authorities (4 studies)a Identifying obstacles for prevention (3 studies) Providing information and educational materials (3 study) Counselling and interventions feasible and effective (10 studies)a Information in media (1 study) Legislation for unhealthy habits (e.g. smoking) (1 study)  Organizational context  Organizational problems in general (3 studies) Lack of strong leadership and consistent messages (1 study) Lack of IT support, software (5 studies) Lack of local support services, communication problems (4 studies) Insufficient connection with other preventive service providers (1 study) Lack of access to information on patients (5 studies) Low quality of recording (2 studies) Lack of suitable appointment times for employed patients (3 studies) Role of practices, no responsibility to offer prevention (6 studies) Roles of primary care staff (4 studies)   Structured organization of practice (4 studies)a IT support (5 studies)a Assistance and support within practice and teams (8 studies)a Important role of practice nurses (4 studies)a Cooperation with allied health staff or community resources (3 studies) Access to patient information or register (2 studies)a Integrated electronic patient record system (1 study) Appointment system (2 studies) Intervention tailored to target identified barriers (2 study) Flexibility in counselling (5 study)a Responsibility to offer and importance of prevention (10 studies) Useful opportunity of health checks and prevention (5 studies)  Professional context  Lack of education/training/skills to competently communicate risk and lifestyle information (lack of counselling skills) (6 studies)a Lack of knowledge (5 studies) Lack of experience (3 studies)  Sufficient training and education (10 studies)a Effective in motivating patients (4 studies) Sufficient knowledge (1 study) Female GPs (2 studies)a  Patient-oriented factors  Low awareness of patients (1 study) Low adherence of patients (9 studies) Lack of trust in GP–patient relation (1 study) Lack of social support from families or friends (1 study) Causes problems, i.e. anxiety and medicalization (5 studies) Cultural differences (1 study)  Motivation of patients (2 studies) A strong/longitudinal GP–patient relationship (5 studies) Enlisting the support from family and friends (2 studies) Appreciated by patients (4 studies)  Attitudes  Negative attitudes in general to prevention (16 studies) Doubt on acceptability (1 study) Doubt on feasibility (1 study)  Positive attitudes to prevention in general (14 studies)a Acceptability (1 study) Feasibility (1 study)  Context  Barriers  Facilitators  Structural context  Lack of time, extra workload (18 studies) Lack of space in the building (3 studies) Insufficient reimbursement or community resources (10 studies) Guidelines: lack of awareness of guidelines, lack of evidence and guidelines, too many guidelines in the area, or difficult to follow guidelines) (6 studies) Lack of available and accessible referral (5 studies) Lack of assistance and support from authorities (2 studies) Lack of material for patients (4 studies) Lack of effective and feasible counselling (12 studies) Problems related to follow-up (2 studies)   Availability of time (3 studies)a Sufficient finances (2 studies) Access to good guidelines (2 studies) Ensuring adequate referral (3 studies)a Ensuring adequate follow-up (2 studies)a Assistance and support from authorities (4 studies)a Identifying obstacles for prevention (3 studies) Providing information and educational materials (3 study) Counselling and interventions feasible and effective (10 studies)a Information in media (1 study) Legislation for unhealthy habits (e.g. smoking) (1 study)  Organizational context  Organizational problems in general (3 studies) Lack of strong leadership and consistent messages (1 study) Lack of IT support, software (5 studies) Lack of local support services, communication problems (4 studies) Insufficient connection with other preventive service providers (1 study) Lack of access to information on patients (5 studies) Low quality of recording (2 studies) Lack of suitable appointment times for employed patients (3 studies) Role of practices, no responsibility to offer prevention (6 studies) Roles of primary care staff (4 studies)   Structured organization of practice (4 studies)a IT support (5 studies)a Assistance and support within practice and teams (8 studies)a Important role of practice nurses (4 studies)a Cooperation with allied health staff or community resources (3 studies) Access to patient information or register (2 studies)a Integrated electronic patient record system (1 study) Appointment system (2 studies) Intervention tailored to target identified barriers (2 study) Flexibility in counselling (5 study)a Responsibility to offer and importance of prevention (10 studies) Useful opportunity of health checks and prevention (5 studies)  Professional context  Lack of education/training/skills to competently communicate risk and lifestyle information (lack of counselling skills) (6 studies)a Lack of knowledge (5 studies) Lack of experience (3 studies)  Sufficient training and education (10 studies)a Effective in motivating patients (4 studies) Sufficient knowledge (1 study) Female GPs (2 studies)a  Patient-oriented factors  Low awareness of patients (1 study) Low adherence of patients (9 studies) Lack of trust in GP–patient relation (1 study) Lack of social support from families or friends (1 study) Causes problems, i.e. anxiety and medicalization (5 studies) Cultural differences (1 study)  Motivation of patients (2 studies) A strong/longitudinal GP–patient relationship (5 studies) Enlisting the support from family and friends (2 studies) Appreciated by patients (4 studies)  Attitudes  Negative attitudes in general to prevention (16 studies) Doubt on acceptability (1 study) Doubt on feasibility (1 study)  Positive attitudes to prevention in general (14 studies)a Acceptability (1 study) Feasibility (1 study)  The numbers of studies reporting a specific factor are given. aSignificant factors when statistical analyses were performed. View Large The most frequently reported structural barriers were related to lack of time and extra workload (18 studies) (25,29,32–38,41,42,44,46–48,50,53,54), lack of feasible or effective counselling or advice (12 studies) (24,32,35,37,39,42,43,47,51–54), insufficient reimbursement (10 studies) (29,30,33,34,38,41,46,47,53,54), or problems with guidelines (6 studies) (30,37,40,41,43,53,54). Other structural barriers reported were related to lack of available and accessible referral instances (5 studies) (25,32,33,35,41), lack of information material for patients (4 studies) (25,32,38,53), lack of space in the building (3 studies) (25,29,37), lack of support and assistance (2 studies) (29,41) and problems related to follow-up of patients (2 studies) (23,35). Structural barriers regarding guidelines involved a lack of access to or awareness of existing guidelines (37,40,41), lack of evidence and/or guidelines on prevention (30,54), or too many guidelines for a specific purpose (41,54). The most reported structural facilitators were feasible and effective counselling and interventions (10 studies) (29,33,34,42,43,46,50–53), available assistance and support (4 studies), availability of time (3 studies) (22,41,52), adequate referral (3 studies) (29,41,50,51), identifying obstacles for prevention (3 studies) (29,39,40), adequate follow-up (2 studies) (29,50), sufficient finances (2 studies) (30,41,52), adequate patient material (2 studies) (29,35) and adequate guidelines (2 studies) (30,41,43). Other identified facilitators were use of media for health messages (24) and use of legislation for unhealthy habits, e.g. smoking (38). The most frequently reported organizational barriers were role of practices, no responsibility to offer prevention (6 studies) (30,32,41,46,47,53), lack of access to information on patients (5 studies) (37,39,41,42,50), lack of IT support (5 studies) (24,37,41,42,46), role of primary care staff (4 studies) (33,37,43,47), lack of assistance and support services including communication problems (4 studies) (37,39,41,44), organizational problems in general (3 studies) (37,39,50) and lack of suitable appointment times for employed patients (3 studies) (25,35,44). Other organizational barriers were lack of strong leadership (38), low quality of recording (37,40) and insufficient connection with other preventive service providers (54). The most frequently reported organizational facilitators were adequate responsibility to offer and importance of prevention(10 studies) (23,25,30,39,47,48,50,52–54), assistance and support within practice and teams (8 studies) (23,25,35,37,38,41,48,50), IT support (5 studies) (35,37,38,41,46,49), flexibility in counselling (5 studies) (29,33,43,52,53), opportunity of health checks and prevention (5 studies) (34,36,42,47,48), important role of practice nurses (4 studies) (23,32,37,49), structured organization of practice (4 studies) (30,37,50,51) and cooperation with allied health staff or community resources (3 studies) (29,38,54). Other organizational facilitators were functioning appointment system (35,48), interventions tailored to target identified barriers (40), need of an integrated electronic patient record system (37) and access to patient information or register (41,50). The most frequently reported professional barriers were lack of counselling skills and education (6 studies) (29,32,45,49,53,54), lack of knowledge of preventive care (5 studies) (32,33,35,37,40,42) and lack of experience (3 studies) (23,33,41). Lack of counselling skills pertained to insufficient education/training/experience to competently communicate information on risk and lifestyle habits. Yet the most frequently reported facilitating professional factors were sufficient training and education (10 studies) (35,38,42,45,48,49,51–54) and that motivation of patients is effective (4 studies) (25,50,52,53). Other facilitating factors were related to sufficient knowledge (53) and female gender of GP (49,53). The most frequently reported patient-related barriers concerned lack of adherence (9 studies) (32,33,37,38,41–43,47,53) and causing problems to patients (5 studies) (33,39,47,49,50), e.g. medicalization or anxiety. Other noted barriers involved were low awareness among patients (36), lack of support from patients’ families (44), lack of trust in GP–patient contact (41) and cultural differences (54). On the other hand, the most frequently reported patient-related facilitating factors concerned a strong GP–patient relationship (5 studies) (33,36,38,41,51) and that patients do appreciate the preventive measures (4 studies) (33,39,46,50). Other factors were related to the motivation of patients (25,36) and potential of enlisting the help of family and friends (29,44). The most frequently reported attitudinal barriers were negative attitudes to prevention (16 studies) (25,29,33–35,37,38,40,42,43,46,47,49,51,52,54). Other attitudinal barriers were lack of acceptability (50) and of feasibility (50). The most reported attitudinal facilitators were positive attitudes towards the importance of prevention (14 studies) (25,34,35,38,42,46–54). Other facilitators were acceptability (50) and feasibility (34). Discussion We have identified several structural, organizational, professional, social context and attitudinal barriers and facilitators for selective prevention of CMD in primary care. The most frequently reported and important barriers listed were lack of time and reimbursement and lack of counselling skills. The most frequently reported facilitators were positive attitudes towards prevention and awareness of the effectiveness of health checks. In terms of the generalizability of our results, there appears to be reasonable consistency across the reviewed studies, irrespective of continent, world region, or country of origin. Results are also relatively stable across time, with new studies reporting similar barriers and facilitators as older ones. However, the majority of studies were carried out in The Netherlands, or the UK and other English-speaking countries such as Australia, Canada and New Zealand, all of which have similar primary care and health care systems. This begs the question of how representative our sample of studies actually is. Indeed, two noteworthy studies from countries outside of the mainstream reported diverging results. Specifically, a French study indicated high variability between doctors in their willingness to take a preventative approach to CMD (31). Another study from Singapore described how GPs screened their patients for chronic kidney disease with the aim to improve collaborative care (41). It is important to note that the health care system from the countries where all other studies originate in may have influenced the results and could explain the similarities of findings in these studies, allowing the specific organization of primary care or health care in general to be reflected. In regard to earlier reviews in the area (10,20,56), Rubio-Valera concluded that there is a lack of research into the barriers and facilitators of implementation of prevention and health promotion activities in primary health care, and further that multi-risk management is scarce (20). Regarding specific lifestyle factors, an earlier review concluded that ‘research on physical activity interventions has shown clear evidence of small but positive effects of such intervention in primary care settings, but evidence of specific strategies and sample characteristics associated with greater effectiveness is still needed to enhance the implementation of interventions under routine clinical conditions’ (10). It is important to identify barriers and motivate primary health care professionals. In fact, a review of lifestyle interventions showed that dietary and smoking interventions proved more effective in the long term than standard primary care practice (56). One area of contention in preventive health care is related to whether interventions should target only high-risk groups or the general population as well, that is, should preventive measures be taken to prevent CMD in groups at low or moderate risk as well as those at high risk? In regard to diabetes prevention, identifying high-risk individuals in the general population could be difficult (57), thus favouring prevention in the general population over a selected high-risk group (58). The current European guidelines suggest screening all men >40 years and all women >50 years (59). In order to mitigate the difficulties involved in selective CMD prevention programmes, detailed planning to overcome the barriers and to promote facilitators is needed before prevention programmes are initiated. However, owing to divergent results in studies conducted in countries with different health care systems, our recommendation to researchers interested in initiating selective prevention interventions is to not only design the initiative based on the best available evidence, but also tailor the programme as precisely as possible to the specific health care system for which it is intended. This will optimize the chances of success of the programmes. One of the frequently reported barriers was the lack of evidence or the lack of belief in the evidence for prevention. This is partly true, as there is evidence that prevention works to prevent single cardiometabolic events, but a review concluded that ‘it is not possible to make clear recommendations about the economic value of screening programmes for CMD’ (60). There is also limited evidence to suggest that CVD systematic risk assessment may have some favourable effects on cardiovascular risk factors (61). Furthermore, in low- and middle-income countries, no conclusions were to be drawn on the effectiveness of multiple risk factor interventions on combined CVD events and mortality (62). A limitation of the present review relates to the fact that most of the articles included in the review were qualitative making the importance of the results challenging to quantify in any other way than the number of studies reporting each type of barrier and facilitator. Further, in terms of the quantitative articles, it was not meaningful to perform a meta-analysis owing to the different topics in the included articles. As a result, we extracted relevant information from the quantitative studies in a similar fashion as we extracted the relevant information from the qualitative studies, according to relevance and not according to any preset tool. We also acknowledge that individual studies that we include have several types of bias and that the bias of each included study might influence the validity in reported barriers and facilitators. All bias and shortcomings were reported, and none of them were regarded as serious to the point where we considered exclusion. If a barrier of facilitator is frequently reported, the likelihood of it being true is greater, which is why we also report those reported in three or more studies. We did not find any quantitative studies on barriers and facilitators of prevention of diabetes in primary care. This represents a knowledge gap that needs to be bridged. Another limitation pertains to the fact that most of the relevant European studies we identified were conducted in the UK and The Netherlands. Thus, the conclusions drawn may not be representative for other parts of Europe. The main strengths of this review involve the rigorous search strategy, performed by an experienced librarian, in Medline (Ovid), Embase, Cinahl and PubMed. The search was completed with a backward search for articles based on the reference lists of included articles and a forward search on articles citing the included articles through Google Scholar. Besides, the articles found this way were checked by another person than the one who performed the search, and results were discussed when there was any doubt of inclusion or exclusion. We believe that this scrutiny was sufficient and that little relevant information was missed. Furthermore, we screened all included articles using a quality tool, and except for low participation rates in a few studies, all studies had adequate quality. Conclusion Structural, organizational, professional, social context and attitudinal barriers and facilitators of selective CMD prevention efforts in primary care were identified in both qualitative and quantitative studies. The most frequently reported barriers were lack of time, reimbursement and adequate counselling skills. The most frequently reported facilitators were positive attitudes of importance of prevention including a high yield of health check. We found that many factors were similar across various settings and countries, yet a few studies were performed in countries with different primary health care systems, complicating comparison. Ultimately, in addition to studying our review of the relevant evidence, we suggest that before initiating selective prevention studies researchers should study local factors in order to best tailor the intervention to the intended setting. Supplementary material Supplementary material is available at Family Practice online. 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Family PracticeOxford University Press

Published: Jan 29, 2018

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