Primary Health Care Practice Research Articles

Knowledge, attitude, and performance of primary healthcare physicians in Aseer Region, Saudi Arabia about attention deficit hyperactivity disorder.

BACKGROUND:Attention-deficit hyperactivity disorder (ADHD) is one of the most common psychiatric disorders. This study aimed to assess the knowledge, attitude, and practice of primary health-care (PHC) physicians on diagnosis and management of ADHD.MATERIALS AND METHODS:This was a cross-sectional study included 340 PHC physicians in Aseer Region, Saudi Arabia. A self-administered questionnaire was used to collect data on personal characteristics, knowledge, attitude, and practice of the diagnosis and management of ADHD.RESULTS:Nearly 47.6% of the PHC physicians were aged <30 years, 60.3% were male, 79.1% were Saudi nationals, and 84.1% had completed MBBS. Only 13.2% had attended continuing medical education courses on ADHD, 63.2% had read about ADHD; Internet was the main source of information (30.7%). Participants' attitude toward ADHD was mainly positive, while 32.1% had poor knowledge and 17.6% had diagnosed ADHD cases in the last year, but 73.3% had referred the diagnosed cases to specialists. Participants' knowledge differed significantly according to their age, gender, and nationality.CONCLUSIONS:PHC physicians' knowledge about ADHD was suboptimal, but they had a positive attitude toward their role with regard to ADHD. PHC physicians should focus on the clinical and diagnostic aspects of ADHD. Awareness and interest of undergraduate medical students and newly graduated physicians in ADHD should be raised. The Ministry of Health should encourage attendance at extracurricular courses and workshops.

Primary Health Care Physicians' Knowledge, Attitude and Practice towards Evidence-Based Medicine in Tabuk City, KSA

Background: Evidence-based medicine (EBM) is an essential component of modern medical practice and crucial for patient safety and high-quality health care services. Objectives: This study was conducted to assess the knowledge, attitude and practice towards evidence-based medicine and the barriers against its application in daily medical practice. Subjects and Methods: This is a cross-sectional survey using a self-administered validated questionnaire among 68 primary health care physicians in Tabuk city, Kingdom of Saudi Arabia during the period from December 2016 to June 2017. Validated questionnaire was used to collect data from the respondents. The Statistical Package for Social Sciences (SPSS) was used for data analysis. P-value of <0.05 was considered as significant. Result: There are 62.2% male participants, the age of the majority were from 30 to 50 years (73.5%) and (72.1%) did not have board qualification, the primary literature review and summaries were the popular methods for EBM. The knowledge and attitude were suboptimal; some did not even access Medline. The unavailability of time and internet access were the most frequent barriers reported. Only a minority received formal EBM training. Conclusion: The knowledge and attitude regarding EBM were suboptimal among the primary health care physicians, the time factors, unavailability of the internet and the lack of letters, access to journals, and guidelines were the principal barriers to EBM incorporation in the clinical practice.

Factors affecting primary health-care physicians' emergency-related practice; Eastern Province, KSA.

Background:Being the first in-line care providers, primary health-care (PHC) physicians may encounter all forms of emergencies, ranging from minor complaints to life-threatening events. This wide variation of cases challenges the physicians to be competent in emergency medicine. Informative literature describing and assessing the factors affecting PHC physicians’ emergency medical services (EMS)-related practice is deficient (nationally and internationally). The aim of this study is to assess PHC physicians’ practice related to EMS, the factors affecting it, as well as their learning needs and preferred methods of continuous training in emergency medicine.Methods:All physicians working in the selected centers were invited to complete a self-administered questionnaire addressing their EMS-related practice. Moreover, physicians were invited to participate in face-to-face semi-structured interviews and focus group discussions.Results:The study revealed that 87.3% of physicians had a good diagnostic knowledge score while only 47.6% had a good management score. Nonetheless, 63.5% of physicians had a neutral attitude toward EMS. The most common reported emergencies encountered are bronchial asthma (86.51%), cut wounds (83.33%), and burns (76.19%). About 62% of participants reported that their greatest needs for further training were in cardiovascular and central nervous system emergency management, preferably by practical training in hospital emergency department (80%).Conclusions:Dammam PHC physicians have a good knowledge, neutral attitude, and fair practice concerning the emergency cases encountered. The majority of physicians reported their need for further hands-on training in emergency medicine.Settings and Design:A cross-sectional, mixed methods study was conducted in 13 out of 26 PHC centers of Dammam, Saudi Arabia.

Implementation of a gerontology nurse specialist role in primary health care: Health professional and older adult perspectives

To explore an innovative primary healthcare gerontology nurse specialist role from the perspectives of older people and health professionals. Primary care is struggling to meet the needs and demands of complex older people. New models which incorporate holistic assessment and care coordination are necessary. A qualitative descriptive general inductive design was used. Older people at risk of health and functional decline were identified and received a comprehensive gerontology assessment and care coordination. Older adults (75years+) enrolled within one of three primary healthcare practices in Auckland, New Zealand were eligible. Healthcare professionals directly involved with the primary healthcare gerontology nurse specialist model were invited for study participation. Face-to-face interviews were held with five older people and six health professionals were interviewed by telephone. A semistructured interview guide was used for all interviews. A general inductive approach was undertaken for analysis to systematically identify codes and themes. Data analysis revealed two central themes from the older people perspective: "holistic expertise" and "communication." Two main themes were identified from the health professional perspective: "competency" and "service delivery." Results showed the gerontology nurse specialist role was highly regarded by both older people and the health professionals. The in-home comprehensive geriatric assessment was identified as greatly beneficial. The competence and care coordination of the gerontology nurse specialist reduced fragmentation and were deemed immensely valuable. Care coordination should be recognised as a key component to meeting the complex needs of at-risk older people in the community. The expert knowledge of the gerontology nurse specialist and in-home comprehensive geriatric assessment were crucial aspects of the new model. Equally important was the assimilation of primary and secondary care infrastructure to upskill and deliver mentorship to the gerontology nurse specialist.

Social work’s scope of practice in the provision of primary mental health care: protocol for a scoping review

IntroductionSocial work is a key member of interprofessional primary healthcare teams and foundational to primary healthcare reforms that aim to improve the provision of mental healthcare. Little is known, however,...

Evaluation of knowledge vouchers as instrument for implementing good practices

Introduction : The Dutch Organisation for Research and Development (ZonMw) has used knowledge vouchers as instrument to implement ‘best practices’ in primary health care. These best practices are local initiatives in primary care, that focused on better collaboration between various disciplines and institutes. With a so called knowledge voucher applicants can temporarily hire an advisor from a best practice for the introduction and implementation of this practice in the applicants’ own organization. ZonMw evaluated the use of these knowledge vouchers for implementing good practices. Are knowledge vouchers a useful instrument for implementing good practices in primary health care (positive and negative experiences)? Do knowledge vouchers indeed lead to dissemination and implementation of good practices in primary health care? Results : There was much interest in the knowledge vouchers all over the Netherlands. In total 51 vouchers, out of 124 requests, were issued. For the evaluation of the knowledge vouchers 48 of the 51 applicants returned the questionaire and 18 of the 20 advisors. Additional Interviews were held with a random selection of 11 applicants and their advisors, allowing for more in depth questioning. The selected good practices were useful for the applicants’ practices. The preparation and presentation of the good practices at the ZonMw website seems helpful. Discussion : It is too early to conclude that knowledge vouchers lead to better implementation, because the consultancy of the experts is still going on. But it definitely helps to disseminate the knowledge of the best practices. Applicants and advisors expect that on the longer term this will lead to better implementation of the good practices. Applicants did not sufficiently realize that they had to invest in conditions (time, catering) for implementing the good practices in their own practice. They expected they could use the knowledge voucher for their own costs as well, but this was only meant for covering the costs of the advisor. Conclusion : This pilot study indicated that the knowledge vouchers as an instrument for implementing good practices is positive. It helps in disseminating good practices. A clear presentation of good practices (e.g. on the website) is an important condition. The use of experts with practice based experience is valuable, but it may make sense to involve national/regional knowledge institutions to assist the advisors as well. Lessons learned : It might be useful to involve knowledge organizations for supporting the advisors, especially when involving other practices learning from each other. The budget of the knowledge voucher for the individual projects seems sufficient. However, in some cases the consultancy is still going on, so maybe not all the costs are known yet. It is clear though, that the demand for the use of knowledge vouchers was much higher than the available budget. Limitations : The interviews were conducted by a trainee with limited knowledge about the best practices studied and had little experience with focused interviews. Suggestions for future research : Further investigation is needed on what information of a good practice is useful to include on the ZonMw website, for example necessary ICT and other conditions. Further research is needed on whether the knowledge vouchers lead to better implementation.

Desempeño de las enfermeras en Atención Primaria de Salud: un Enfoque Fenomenológico

The objective of this study was to identify the performance of Chilean primary health care nurses. This was a qualitative study based on the approach of social phenomenology. Data collection was conducted between January and April 2013 through interviews with 13 nurses. Nurse performance showed that they experience greater professional autonomy and are closer to users; however, they suffered from professional burnout. Their expectations included the desire to be recognized for their work and better service management. Contributions of this study include the possibility of considering new designs for professional management practices in primary health care from the perspective of Chilean nurses. These designs should be based on the reorganization of work processes and by occupying spaces in macropolitics, influencing the professional performance of nurses at this level of health care.

Barriers and enablers for the development and implementation of allied health clinical practice guidelines in South African primary healthcare settings: a qualitative study

BackgroundThe South African allied health (AH) primary healthcare (PHC) workforce is challenged with the complex rehabilitation needs of escalating patient numbers. The application of evidence-based care using clinical practice guidelines (CPGs) is one way to make efficient and effective use of resources. Although CPGs are common for AH in high-income countries, there is limited understanding of how to do this in low- to middle-income countries. This paper describes barriers and enablers for AH CPG uptake in South African PHC.MethodsSemi-structured individual interviews were undertaken with 25 South African AH managers, policymakers, clinicians and academics to explore perspectives on CPGs. Interviews were conducted by researcher dyads, one being familiar with South African AH PHC practice and the other with CPG expertise. Rigour and transparency of data collection was ensured. Interview transcripts were analysed by structuring content into codes, categories and themes. Exemplar quotations were extracted to support themes.ResultsCPGs were generally perceived to be relevant to assist AH providers to address the challenges of consistently providing evidence-based care in South African PHC settings. CPGs were considered to be tools for managing clinical, social and economic complexities of AH PHC practice, particularly if CPG recommendations were contextusalised. CPG uptake was one way to deal with increasing pressures to make efficient use of scarce financial resources, and to demonstrate professional legitimacy. Themes comprised organisational infrastructures and capacities for CPG uptake, interactions between AH actors and interaction with broader political structures, the nature of AH evidence in CPGs, and effectively implementing CPGs into practice.ConclusionCPGs contextualised to local circumstances offer South African PHC AH services with an efficient vehicle for putting evidence into practice. There are challenges to doing this, related to local barriers such as geography, AH training, workforce availability, scarce resources, an escalating number of patients requiring complex rehabilitation, and local knowledge. Concerted attempts to implement locally relevant CPGs for AH primary care in South Africa are required to improve widespread commitment to evidence-based care, as well as to plan efficient and effective service delivery models.

Educational intervention on medication reviews aiming to reduce acute healthcare consumption in elderly patients with potentially inappropriate medicines-A pragmatic open-label cluster-randomized controlled trial in primary care.

Potentially inappropriate medicines (PIMs) may cause 10% of unplanned admissions in elderly people. We performed an educational intervention in primary care to reduce acute health care consumption and PIMs through the promotion of medication reviews (MRs) in elderly patients. This cluster-randomized controlled trial was conducted in the context of an official campaign promoting rational drug use in elderly people. Sixty-nine primary health care practices with 119,910 patients aged older than or equal to 65 were randomized, with 1 dropout in the intervention group. The intervention consisted of educational outreach visits with feedback on prescribing and the development of a working procedure on MRs. Follow-up was 9months. Outcomes were assessed in an administrative health care database. The combined primary outcome was unplanned hospital admission and/or emergency department visit. Secondary outcomes were among other PIMs and rates of MRs. The risk differences in outcomes between intervention and control group were estimated by using regression models. During follow-up, 22.8% of patients in the intervention and 22.0% in the control group were admitted unplanned to hospital and/or experienced at least 1 emergency department (nonsignificant risk difference 0.8%, 95% CI -0.7% to 2.4%). There were no significant differences regarding secondary outcomes such as PIMs or MRs. No changes were seen in acute health care consumption, PIMs, and MRs in elderly patients after an educational intervention in primary care. The reasons for the lack of effect could be a suboptimal intervention, limitations in outcome measures, and the use of administrative data to monitor outcomes.

Stigma towards mental illness and substance use issues in primary health care: Challenges and opportunities for Latin America

ABSTRACTStigma towards mental illness and addictive disorders is a global problem and one of the main obstacles in tackling this issue remains the effective integration of mental health services into primary health care (PHC). In Latin America, information has significantly increased on the existence of stigma; however, little is known about effective interventions to prevent stigma and promote recovery-oriented practices in PHC. The aim of this study is to understand the existing evidence regarding mental health stigma in PHC with a special focus on the Latin American region. A scoping review of the literature related to mental health stigma in PHC was conducted. Two hundred and seventeen articles were evaluated; 74 met inclusion criteria and 14 additional articles were selected from references of search results. Results were subdivided into five different perspectives: users, family members and significant others, health professionals, contextual factors, and potential effective interventions. Only nine studies were based in Latin America, and only one described an intervention to reduce stigma in mental health services, not specifically in PHC. We found an urgent need to develop interventions to understand and reduce stigma in PHC settings, especially in Latin America.

Primary health care social work in Aotearoa New Zealand: An exploratory investigation

INTRODUCTION: The social work profession has a long-standing history of contributing to health care in Aotearoa New Zealand. Traditionally, hospitals have been the stronghold for the profession. However, both international and national evidence demonstrates that social workers have also been integrated in primary health care practices (PHCPs). Primary health care (PHC) provides care in the community and is recognised for its potential to achieve health equity across all population groups. This article reports on a small, qualitative research project which explored the perceptions of key stakeholders about social work integration into PHC and the experiences gained by social workers working within PHCPs regarding their contributions to the achievement of national aspirations for PHC.METHODS: Semi-structured, one-to-one interviews with 18 participants representing three groups (social workers, other PHC professionals and key informants) were undertaken in 2012. The interviews took place in various locations in Aotearoa New Zealand. A general inductive approach was used to identify key themes. FINDINGS: Three key themes were identified from the data: these are issues of context, namely social work professional factors, organisational factors in PHC and lastly, wider factors in the health care system. The integrated social workers enhanced the access of populations to coordinated care, increased engagement with communities, and strengthened the workforce, among other things. These unique contributions towards the PHC vision were well recognised by all groups, with participants calling for the establishment of integrated social work positions on a larger scale. CONCLUSION: The study evidences the successful integration of social workers into PHC practices in Aotearoa New Zealand. This viable model should be of special interest for key stakeholders regarding the design of local, holistic, PHC services which serve populations most affected by health and social inequalities. Importantly, “health for all”, as anticipated by the PHC vision needs long-term and real commitment especially by financial decision-makers.

What does one learn from the implementation of a mandated integrated network for older adults across three different settings in Quebec

Context: In 2004, Quebec mandated its 94 Health and social services centers to lead in the implementation of local integrated health networks. The Health and social services centers, which were created by the fusion of some public establishments (local community health centers, long term care facilities and acute care hospitals in some cases), provide a broad range of health and social services to their populations. To ensure the provision of a comprehensive continuum of care, theses Health and social services centers create partnerships with community organisations, pharmacies and primary healthcare providers of their territories. Objective: To compare the implementation of 3 mandated local integrated health networks for seniors in 3 geographical settings; highly urban, urban and rural. Methods: This research is part of an international research program ICOACH where 3 case studies were carried out in each jurisdiction: Quebec, Ontario and New Zealand. This presentation is based on data collected from 46 semi-structured interviews of healthcare providers and managers in Quebec, as well as the analysis of official documents. Results: The mandated networks for older adults were based on the local implementation of 9 components; 1) a joint governing board, 2) a centralized access point, 3) case management, 4) a common multidisciplinary evaluation tool, 5) an individualized service plan, 6) a common healthcare information system, 7) a geriatric team, 8) the involvement of the family physician in the community and 9) an administrator for the local network. All the main components of the local network were mandated, and several components were implemented with local variations. For instance, each local integrated network for older people had its joint governing board, but the composition and the dynamism of these boards differed considerably. These local integrated networks for older people used the general access point of their Health and social services centers, and in each of these local networks, a common evaluation tool was used to assess the needs of each patient. Services plan would be based on this assessment but a gap can be observed between addressed problems and proposed solutions that are more the services offered by the health and social services centers than by assessed needs. The type of case management varied across networks. For instance, in the highly urban setting, only social workers of the home care team could be case managers while in the urban setting, case managers included different health professionals such as nurses, occupational therapist and social workers. The healthcare information systems were not well implemented. Across the 3 cases studied, few professional teams and healthcare organizations were connected by an information system. Finally, across the 3 cases studied, the primary healthcare practices were not well integrated with public services of the networks. They mostly worked in parallel with respect to the other services of the network. Conclusion: Ten years after the creation of mandated local integrated networks for older people, several implementation challenges are still observed. The implementation of components of the network show local variations and some key components are poorly developed.

Developing capability through peer-assisted learning activities among 4th-year medical students and community health workers in community settings

Background. The Longitudinal Community Attachment programme for Students (L-CAS) is an activity by means of which each student is exposed to primary healthcare learning and practice in communities. Capability has been described as ‘an integration of knowledge, skills, personal qualities and understanding used appropriately and effectively … but in response to new and changing circumstances’. Within this paradigm, peer-assisted learning (PAL) has been used to support the development of student capability during L-CAS activities. Objective. To evaluate the impact of PAL sessions on student and community health worker (CHW) capability development. Methods. Study participants comprised 4th-year medical students and CHWs. Student data were drawn from the rotation reflective reports (RRRs) and CHW data from semi-structured interviews. Results. The main themes that emerged from the RRRs and interviews were the impact on the personal and professional development of participants; the creation of awareness and understanding of the context of the communities; relationship building; and the impact of peer learning activities on the knowledge, skills and attitudes of participants. Conclusion. In the process of addressing the challenge of preparing capable professionals, PAL was found to be a very effective way of positioning peers in relation to each other as resources. PAL activities enhanced the abilities of students and CHWs to learn from experience and to achieve the goals of critical reflection and experiential learning.

Characteristics and respiratory risk profile of children aged less than 5 years presenting to an urban, Aboriginal-friendly, comprehensive primary health practice in Australia.

There are no published data on factors impacting on acute respiratory illness (ARI) among urban Indigenous children. We describe the characteristics and respiratory risk profile of young urban Indigenous children attending an Aboriginal-friendly primary health-care practice. We conducted a cross-sectional analysis of data collected at baseline in a cohort study investigating ARI in urban Indigenous children aged less than 5 years registered with an Aboriginal primary health-care service. Descriptive analyses of epidemiological, clinical, environmental and cultural factors were performed. Logistic regression was undertaken to examine associations between child characteristics and the presence of ARI at baseline. Between February 2013 and October 2015, 180 Indigenous children were enrolled; the median age was 18.4 months (7.7-35), 51% were male. A total of 40 (22%) children presented for a cough-related illness; however, ARI was identified in 33% of all children at the time of enrolment. A total of 72% of children were exposed to environmental tobacco smoke. ARI at baseline was associated with low birthweight (adjusted odds ratio (aOR) 2.54, 95% confidence interval (CI) 1.08-5.94), a history of eczema (aOR 2.67, 95% CI 1.00-7.15) and either having a family member from the Stolen Generation (aOR 3.47, 95% CI 1.33-9.03) or not knowing this family history (aOR 3.35, 95% CI 1.21-9.26). We identified an urban community of children of high socio-economic disadvantage and who have excessive exposure to environmental tobacco smoke. Connection to the Stolen Generation or not knowing the family history may be directly impacting on child health in this community. Further research is needed to understand the relationship between cultural factors and ARI.

The Secondhand Smoke Exposure Scale (SHSES): A hair nicotine validated tool for assessing exposure to secondhand smoke among elderly adults in primary care.

INTRODUCTIONAccurate estimation of exposure to Secondhand Smoke (SHS) is important in both research and clinical practice. We aimed to develop, an easy to implement, biomarker validated scale to provide an estimation of adult exposure to SHS for use within primary health care or epidemiological research.METHODSA pool of 26 baseline questions evaluating exposure to SHS was administered to 178 non-smoking adults (mean age 68.1 years), recruited from both urban and rural primary health care practices in Crete, Greece in November 2011, while concurrent hair samples were collected and nicotine concentrations were measured. To generate scores for each question item, we fitted a backward linear regression using the main predictors of SHS exposure selected from the initial pool of questions, weighted against each individuals biomarker evaluated exposure.RESULTSAmong the pool of participants and weighted according to hair nicotine levels, in descending order, the most important sources of SHS exposure were the home (5 points, β=0.37), the family car (3 points, β=0.20), public places (2 points, β=0.15) and the workplace (1 point, β=0.013), the relative weighting of which led to the development of an 11-point scale to assess exposure to SHS. For every unit increase in the score, there was an associated increase in mean hair nicotine concentrations by 1.35 ng/mg (95%CI: 1.25-1.45, p<0.0001)CONCLUSIONSThe SHS exposure score (SHSES) may be a useful tool in an estimating the level of the exposure to SHS among elderly adults and investigating the relationship between SHS exposure and potential health outcomes.

Complicated measles in an 8-month old infant – a case report

Objective – The aim of the paper is to describe the complexity of pertussis-like syndrome in primary health care practice, and to highlight consequences of vaccine hesitancy. Case reports – We described five cases of pertussis-like syndrome in pediatric practice. Patients were unvaccinated or not fully vaccinated against pertussis due to parental refusal. There was intrafamilial and interfamilial spread of infection. Conclusion – Evaluation and treatment of pertussis-like syndrome remain challenging in primary health care practice. Dealing with vaccine hesitancy requires an adequate understanding and answer. Vaccine refusal increases the individual risk of disease but also increases the risk for outbreaks of vaccine-preventable diseases.

Observations of infection prevention and control practices in primary health care, Kenya

ObjectiveTo assess compliance with infection prevention and control practices in primary health care in Kenya.MethodsWe used an observational, patient-tracking tool to assess compliance with infection prevention and control practices by 1680 health-care workers during outpatient interactions with 14 328 patients at 935 health-care facilities in 2015. Compliance was assessed in five domains: hand hygiene; protective glove use; injections and blood sampling; disinfection of reusable equipment; and waste segregation. We calculated compliance by dividing the number of correct actions performed by the number of indications and evaluated associations between compliance and the health-care worker’s and facility’s characteristics.FindingsAcross 106 464 observed indications for an infection prevention and control practice, the mean compliance was 0.318 (95% confidence interval, CI: 0.315 to 0.321). The compliance ranged from 0.023 (95% CI: 0.021 to 0.024) for hand hygiene to 0.871 (95% CI: 0.866 to 0.876) for injection and blood sampling safety. Compliance was weakly associated with the facility’s characteristics (e.g. public or private, or level of specialization) and the health-care worker’s knowledge of, and training in, infection prevention and control practices.ConclusionThe observational tool was effective for assessing compliance with infection prevention and control practices across multiple domains in primary health care in a low-income country. Compliance varied widely across infection prevention and control domains. The weak associations observed between compliance and the characteristics of health-care workers and facilities, such as knowledge and the availability of supplies, suggest that a broader focus on behavioural change is required.

Protocol for determining primary healthcare practice characteristics, models of practice and patient accessibility using an exploratory census survey with linkage to administrative data in Nova Scotia, Canada

IntroductionThere is little evidence on how primary care providers (PCPs) model their practices in Nova Scotia (NS), Canada, what services they offer or what accessibility is like for the average...

Implementation of cardiovascular disease prevention in primary health care: enhancing understanding using normalisation process theory

BackgroundThe reorientation of primary health care towards prevention is fundamental to addressing the rising burden of chronic disease. However, in Australia, cardiovascular disease prevention practice in primary health care is not generally consistent with existing guidelines. The Model for Prevention study was a whole-of-system cardiovascular disease prevention intervention, with one component being enhanced lifestyle modification support and addition of a health coaching service in the general practice setting. To determine the feasibility of translating intervention outcomes into real world practice, implementation work done by stakeholders was examined using Normalisation Process Theory as a framework.MethodsData was collected through interviews with 40 intervention participants and included general practitioners, practice nurses, practice managers, lifestyle advisors and participants. Data analysis was informed by normalisation process theory constructs.ResultsStakeholders were in agreement that, while prevention is a key function of general practice, it was not their usual work. There were varying levels of engagement with the intervention by practice staff due to staff interest, capacity and turnover, but most staff reconfigured their work for required activities. The Lifestyle Advisors believed staff had varied levels of interest in and understanding of, their service, but most staff felt their role was useful. Patients expanded their existing relationships with their general practice, and most achieved their lifestyle modification goals.While the study highlighted the complex nature of the change required, many of the new or enhanced processes implemented as part of the intervention could be scaled up to improve the systems approach to prevention. Overcoming the barriers to change, such as the perception of CVD prevention as a ‘hard sell’, is going to rely on improving the value proposition for all stakeholders.ConclusionsThe study provided a detailed understanding of the work required to implement a complex cardiovascular disease prevention intervention within general practice. The findings highlighted the need for multiple strategies that engage all stakeholders. Normalisation process theory was a useful framework for guiding change implementation.

94: ONLINE MANAGEMENT OF METABOLIC SYNDROME AND CARDIOVASCULAR RISK FACTORS: A SIMPLE METHOD FOR AWARENESS AND ACTIONS

Background and aims:Metabolic syndrome is a major public health problem in worldwide and Iran. It is argued that metabolic syndrome is the most responsible risk factor for developing the disease...