SY S T E M A T I C REV I E W Open Access
Behavior change interventions and
policies influencing primary healthcare
professionals’ practice—an overview
of reviews
Bhupendrasinh F. Chauhan
1,2,3*
, Maya Jeyaraman
3
, Amrinder Singh Mann
3
, Justin Lys
3
, Becky Skidmore
4
,
Kathryn M. Sibley
3,5
, Ahmed Abou-Setta
3,5
and Ryan Zarychanksi
3,5,6,7
Abstract
Background: There is a plethora of interventions and policies aimed at changing practice habits of primary
healthcare professionals, but it is unclear which are the most appropriate, sustainable, and effective. We aimed
to evaluate the evidence on behavior change interventions and policies directed at healthcare professionals
working in primary healthcare centers.
Methods: Study design: overview of reviews.
Data source: MEDLINE (Ovid), Embase (Ovid), The Cochrane Library (Wiley), CINAHL (EbscoHost), and grey literature
(January 2005 to July 2015).
Study selection: two reviewers independently, and in duplicate, identified systematic reviews, overviews of reviews,
scoping reviews, rapid reviews, and relevant health technology reports published in full-text in the English language.
Data extraction and synthesis: two reviewers extracted data pertaining to the types of reviews, study designs, number
of studies, demographics of the professionals enrolled, interventions, outcomes, and authors’ conclusions for the
included studies. We evaluated the methodological quality of the included studies using the AMSTAR scale. For the
comparative evaluation, we classified interventions according to the behavior change wheel (Michie et al.).
Results: Of 2771 citations retrieved, we included 138 reviews representing 3502 individual studies. The majority of
systematic reviews (91%) investigated behavior and practice changes among family physicians. Interactive and
multifaceted continuous medical education programs, training with audit and feedback, and clinical decision support
systems were found to be beneficial in improving knowledge, optimizing screening rate and prescriptions, enhancing
patient outcomes, and reducing adverse events. Collaborative team-based policies involving primarily family physicians,
nurses, and pharmacists were found to be most effective. Available evidence on environmental restructuring and
modeling was found to be effective in improving collaboration and adherence to treatment guidelines. Limited
evidence on nurse-led care approaches were found to be as effective as general practitioners in patient satisfaction
in settings like asthma, cardiovascular, and diabetes clinics, although this needs further evaluation. Evidence does not
support the use of financial incentives to family physicians, especially for long-term behavior change.
Conclusions: Behavior change interventions including education, training, and enablement in the context of
collaborative team-based approaches are effective to change practice of primary healthcare professionals.
Environmental restructuring approaches including nurse-led care and modeling need further evaluation. Financial
incentives to family physicians do not influence long-term practice change.
* Correspondence: bchauhan28@gmail.com
1
College of Pharmacy, University of Manitoba, Winnipeg, Canada
2
Children’s Hospital Research Institute of Manitoba, Winnipeg, Canada
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Chauhan et al. Implementation Science (2017) 12:3
DOI 10.1186/s13012-016-0538-8
Introduction
Approximately one in six Canadians aged 20 years or
older suffer from chronic diseases such as diabetes,
cardiovascular diseases, chronic respiratory diseases,
arthritis, osteoporosis, mental illness, and cancer [1].
Combining direct medical costs ($38.9 billion) and indir-
ect productivity losses ($54.4 billion), the total economic
burden of chronic illness exceeds Canadian $93 billion a
year [2]. Despite this enormous expenditure, 12 to 15%
of Canadians feel they receive inadequate chronic dis-
ease care [3, 4]. The major unmet needs include long
waiting periods for medical services [5] and unavailabil-
ity of essential services [4]. Compared with people in
other de veloped nations, Canadians today are less satis-
fied with their access to and quality of care [6] and have
worse health outcomes for several medical conditions
[7]. The numbers of patients with chronic diseases and
the existing gap in quality of care present a significant
challenge for public health policy-makers [8, 9].
With the objective of closing gaps in quality of care
and managing patients with chronic diseases, the
implementation of patient-centred treatment has re-
cently gained attention from policy-makers [10–12].
Patient-centered medical centres may become the future
backbone of the Canadian healthcare system [13]. These
teams may include family physicians, physician assistants,
nurses, pharmacists, social workers, mental health coun-
selors/psychologists, dieticians, and midwives among
others. To achieve efficient and effective patient-centered
medical homes, some changes in the way healthcare is de-
livered will be required. To do so, effective behavior
change interventions and supporting policies are required
[14, 15]. However, it is unclear which intervention(s) and
policies are appropriate, sustainable, and sufficiently safe
to support practice change and improve patient-relevant
outcomes in primary healthcare settings. Despite extensive
published literature including randomized controlled trials
[16, 17], observational studies [18, 19], and systematic re-
views [20–22], no recent comprehensive review classifying
or evaluating the feasibility or effectiveness of interven-
tions and policies in terms of patients’ and professionals’
outcomes exists. The objectives of this overview of reviews
were to identify, classify, and critically appraise reviews
evaluating behavior change interventions and policies in-
fluencing primary healthcare professionals working at pri-
mary healthcare centers.
Methods
Data sources and searches
The search strategy was developed and tested through an
iterative process by an experienced medical information
specialist in consultation with the review team. We
searched MEDLINE (Ovid), Embase (Ovid), CINAHL
(EbscoHost), and the Cochrane Library (Wiley). Strategies
utilized a combination of controlled vocabulary (e.g.,
“Physicians", "Primary Care”, “Physician’sPracticePat-
terns”, “Quality Improvement”) and keywords (e.g., family
practitioner, home clinic, policy adherence). Vocabulary
and syntax were adjusted across databases. Results were
restricted to the English language and the dates from
January 2005 to July 2015 (Additional file 1). We used Dis-
tillerSR (Version 2, Evidence Partners Inc. ON, Canada) for
study selection, data extraction, and project management.
Study selection
We included (1) systematic reviews, overview of re views,
scoping reviews, rapid reviews, or health technology as-
sessments that (2) evaluated behavior change interven-
tions or policies on primary healthcare professionals
(including general practitioners/family physicians, phys-
ician assistants, nurses, pharmacists, social workers,
mental health counselors/psychologist s, dieticians, and
midwives) (3) working at primary healthcare settings (4)
reporting any outcomes of primary healthcare profes-
sionals’ practice change, and (5) published in the English
language as full-text articles. Primary healthcare settings
were defined as the provision of integrated, accessible
health care services by clinicians who are accountable
for addressing a large majority of personal health care
needs, developing a sustained partnership with patients,
and practicing in the context of family and community
[23, 24]. Considering the application of outcomes in the
Canadian context, reviews that exclusively included
studies conducted in either underdeveloped or develop-
ing countries were excluded.
The abstracts and titles of relevant citations were inde-
pendently screened by two reviewers to determine eligi-
bility. The same two reviewers independently assessed
the eligibility of full-text reports of relevant citations
using a standardized pre-piloted form outlining the in-
clusion and exclusion criteria. Disagreements were re-
solved by consensus or with the involvement of a third
reviewer, if needed.
Data extraction and quality assessment
Two reviewers independently abstracted data from the
included reviews using standardiz ed piloted forms. The
following data were extracted from each included review:
review type, number and study designs that the review
included, types of professionals evaluated, interventions,
outcomes, therapeutic domains, and authors’ conclusions.
All behavior change interventions and policies were
classified into nine categories of interventions and seven
categories of policies following the behavior change
wheel framework proposed by Michie et al. [15]. This
framework consist s of a behavior system at the hub,
encircled by nine intervention functions and then by
seven policy categories. The nine behavior change
Chauhan et al. Implementation Science (2017) 12:3 Page 2 of 16
interventions include (1) education (increasing know-
ledge or understanding): e.g., continuous medical educa-
tion; (2) persuasion (using communication to induce
positive or negative feelings or stimulate action): e.g.,
reminders; (3) incentivization (c reating expectation of re-
ward): e.g., payment for performance; (4) coercion (creating
expectation of punishment or cost): e.g., punishment or
fines; (5) training (imparting skills): e.g., communication
skills training; (6) restriction (using rules to reduce the op-
portunity to engage in the target behavior): e.g., rules for
prohibiting the use; (7) environmental restructuring (chan-
ging the physical or social context): e.g., shared decision-
making; (8) modeling (providing an example for people to
aspire to or imitate): e.g., local opinion leaders; (9) enable-
ment (increasing means/reducing barriers to increase
capability or opportunity): e.g., clinical decision support sys-
tems. While the seven policies include: (1) communication/
marketing (using print, electronic, telephonic or broadcast
media): e.g., advertising media; (2) guidelines (creating doc-
uments that recommend or mandate practice): e.g., man-
agement guidelines; (3) fiscal (using the tax system to
reduce or increase the financial cost): e.g., financial provi-
sions from policy-makers; (4) regulation (establishing rules
or principles of behavior or practice): e.g., rules and regula-
tions; (5) l egislatio n (makingorchanginglaws):e.g.,law
amendments; (6) environmental/social planning (designing
and/or controlling the physical or social environment): e.g.,
social support; (7) service provision (delivering a ser-
vice): e.g., service or facilitation.
Two reviewers independently, and in duplicate, evalu-
ated the methodological quality of the included reviews
using the assessing the methodological quality of system-
atic reviews (AMSTAR) scoring system [25]. Conflicts
were resolved by consensus or discussion with a third
reviewer, if needed. Reviews with AMSTAR score ≥8, 4
to 7, ≤3 were considered as high, moderate, or low-
methodological quality, respectively.
We summarized the findings that emerged from the
subjective judgment matrix, which was based on the au-
thors’ conclusions, qualitative data, quantitative data
with statistically significant group differences in terms of
patients’ and primary healthcare providers’ outcomes,
and the methodological quality of included reviews [25–
28]. The protocol for this overview of reviews has been
developed prior to conduc t the review and provided to
the Primary Health Care Branch, Manitoba Health,
Seniors and Active Living, Government of Manitoba,
Canada. The Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) guidelines for
reporting the systematic review were followed.
Results
We screened 2771 citations and included 138 reviews
representing 3502 individual studies (Fig. 1). The
characteristics of the included reviews are presented in
Table 1. Of the included studies, three were overviews of
reviews [29–31]. Most reviews (91%) investigated behav-
ior change interventions and policies among family phy-
sicians primarily managing chronic diseases at primary
healthcare centers. We classified the included reviews
into eight of nine categories of behavior change inter-
ventions including education (n = 28, 20%), enablement
(n = 16, 12%), environmental restructuring (n = 18, 13%),
incentivization (n = 7, 5%), modeling (n = 2, 2%), multiple
interventions (n = 42, 30%), persuasion (n = 4, 3%), train-
ing (n = 11, 8%), and three of seven categories of policies
including service provision (n = 5, 4%), communications
(n = 3, 2%), and guidelines (n = 2, 2%). Major chronic
diseases evaluated were mental disorders (n = 12, 9%),
diabetes (n = 10, 7%), respiratory diseases (n = 8, 6%),
cancer (n = 5, 4%), cardiovascular diseases (n = 4, 3%),
arthritis/osteoporosis (n = 3, 2%), and hypertension (n =
2, 2%); some reviews reported more than one chronic
disease. Total of 36 (26%) reviews exclusively included
randomized con trolled trials. The remaining reviews in-
cluded systematic reviews, observational studies, inter-
rupted time series studies, and controlled before-after
studies (Table 1). Of the total included reviews, 68 (49%)
reviews were of high quality, 60 (44%) reviews were of
moderate quality, and 11 (8%) reviews were of low qual-
ity (Additional file 1: Table S1).
Behavior change interventions (Additional file 1: Table S1)
Education (increasing know ledge/understanding)
Twenty-eight reviews [20, 21, 29, 32–56] (n = 509 stud-
ies) evaluated educational interventio ns. Evidence from
moderate- to high-quality reviews demonstrated that
education to improve knowledge and skills [37–42, 48,
49, 51–56], continuing medic al education [20, 21, 29, 34,
43], and academic detailing [32] were found to be effect-
ive in professional development to increase knowledge,
optimize prescriptions, screening rate, and improve
patient outcomes [20, 29, 32–36, 41, 44, 45, 50, 54]. Cer-
tain education interventions were evaluated as compo-
nents of multifaceted education interventions, including
interactive educational methods, reminder systems, audit
and feedback, academic detailing, computer-based learn-
ing, lecture, as well as pamphlet in several reviews [29,
33, 36, 43, 44, 49]; which reported improvement in
implementing guidelines into general practice [29], im-
proved antibiotic prescribing [33], improved detection of
cancer, dementia, and skin lesions [36, 44, 49]. Conflict-
ing evidence exists on patient feedback. One review [50],
based on ten studies, reported some evidence for the ef-
fectivene ss of using feedback from real patients to im-
prove knowledge and primary healthcare professionals’
practice change exists while other reviews [34, 46, 47]
failed to reach the same conclu sion.
Chauhan et al. Implementation Science (2017) 12:3 Page 3 of 16
Enablement (increasing means/reducing barriers to increase
capability or opportunity)
Sixteen reviews [57–72] (n = 377 studies) evaluated the
use of information technologies including interactive
analysis systems [57–59, 69], clinical decision support
systems [60, 62–66], electronic health records and pre-
scriptions [61, 68, 72], and point of care testing [67, 70,
71] to increase capability and facilitate practice change
of primary healthcare professionals. Evidence from mod-
erate- to high-quality reviews demon strated that enable-
ment interventions improved communication between
healthcare professionals and patients [59, 63], aug-
mented knowledge [61], facilitated the appropriate anti-
biotic prescriptions [60], increased quality of service,
reduced potential adverse events (drug interactions, con-
traindications, dose monitoring, and adjustment) [62],
and improved several patient outcomes [64].
Environmental restructuring (changing the physical or
social context)
Nineteen [73–91] (n = 470 studies) evaluated the impact
of environmental restructuring including the use of col-
laborative or shared care practices or the institution of
specialized nurses or other allied healthcare professionals
[73, 74, 77–83, 85–91], or guideline implementation [75,
76] in primary healthcare settings. Evidence from poor- to
high-quality reviews indicate organizational changes to
increase collaboration among pharmacists, nurses, pre-
vention coordinators, and other primary healthcare pro-
fessionals led to increased physicians’ adherence to
guidelines [75]. Nurse-led care was found to be as equally
effective as general practitioners in patient satisfaction,
asthma, cardiovascular, and diabetes management. How-
ever, weak study designs and restricted interventional
scopes mean that further evaluation is required [80–82,
84], especially in the context of other chronic diseases.
Incentivization (creating an expectation of reward)
Seven reviews [30 , 92–97] (n = 198 studies) evaluated
the impact of financial incentives on family phy sicians.
All reviews [30, 92–97] of poor- to high-quality failed to
provide supportive evidence of any significant improvement
in family physicians’ behavior change. One high-quality re-
view [96] observed modest improvements in quality of care
for chronic diseases, albeit, the impact on costs, profes-
sional behavior, and patient experience remained uncertain.
Modeling (providin g an exampl e for pe ople to aspir e or
imitate)
Two reviews [98, 99] (n = 60 studies) evaluated modeling
using local opinion leaders [98], or mental health
workers [99] in primary healthcare settings. Evidence
from moderate- to high-quality reviews demonstrated
that involving local opinion leaders or subject expert s to
promote evidence-informed practices decreased the
rates of consult ations and prescriptions [98, 99].
Persuasion (using communication to induce positive or
negative feelings or stimulat e action)
Four reviews [100–103] (n = 218 studies) reported on in-
terventions categorized as persuasion. Evidence from
moderate- to high-quality reviews indicates that re-
minders [100–103] worked well to reduce unnecessary
imaging for lower back pain [100] while improving the
rate of screening [101] and vaccination [101].
Fig. 1 Flow diagram of the selection of citations
Chauhan et al. Implementation Science (2017) 12:3 Page 4 of 16
Table 1 Key features of included reviews
Study Type of
review
Study design included Number of
included
studies
Professionals evaluated Intervention(s) Type of disease(s) Funding
Behavior change interventions
Education (increasing knowledge or understanding)
Chhina et al. [32] 2013 SR Any study design 15 FPs Academic detailing NR No
Mostofian et al. [29] 2015 Overview Reviews 14 FPs Any interventions NR No
Velden et al. [33] 2012 SR Any study design 58 FPs, others Any interventions RTIs Yes
Thepwongsa et al. [20] 2014 SR RCTs, non-RCTs, ITS 11 FPs CME NR Yes
Thomas et al. [34] 2006 SR Any study design 13 FPs CME NR Yes
Ginige et al. [21] 2007 SR Any study design 4 FPs CME, video, text Chlamydia No
Brody et al. [35] 2013 SR Any study design 16 FPs, nurses, SWs,
pharmacists
Dementia educational/dissemination
intention
Dementia Yes
Schichtel et al. [36] 2013 SR RCTs, cluster RCTs 21 FPs, Nurses, PAs Education Cancer Yes
Hardy et al. [37] 2011 SR Any study design 0 FPs Education Mental illness No
Miller et al. [38] 2010 SR Any study design 16 FPs Education NR No
Lineker et al. [39] 2010 SR Any study design 7 FPs, nurses Education Arthritis No
Alvarez et al. [40] 2006 SR Any study design 18 FPs Education Pallative care No
Howe et al. [41] 2006 SR RCTs 18 FPs Education NR No
Kamarudin et al. [42] 2013 SR Any study design 47 FPs Education NR No
Thepwongsa et al. [43] 2014 SR Any study design 13 FPs Education T2DM Yes
Perry et al. [44] 2011 SR Any study design 5 FPs Educational meetings, audit-feedback,
reminders, mass media, local opinion leaders
Dementia Yes
Vodicka et al. [45] 2013 SR Any study design 17 FPs, nurses Educational or behavior change
interventions
RTIs, otitis media Yes
Guldberg et al. [46] 2009 SR RCTs 10 FPs Feedback T2DM Yes
Cheraghi-Sohi et al. [47] 2008 SR RCTs 9 FPs Feedback or training or both NR No
Ring et al. [48] 2007 SR RCTs 14 FPs Interactive educational seminar, QI learning
collaborative for general practice teams
Asthma Yes
Rourke et al. [49] 2015 MA Any study design 37 FPs Lecture, audit-feedback, computer based
learing, multicomponent intervention
Skin lesions No
Reinders et al. [50] 2011 SR RCTs 10 FPs Patient feedback NR Yes
Gijbels et al. [51] 2010 SR Any study design 61 Nurses, midwives Education NR Yes
Zaher et al, [52] 2012 SR Any study design 13 FPs Practice-based small group learning programs NR No
Curti et al. [53] 2015 SR, MA RCTs, cluster-RCTs, CBA 12 FPs Educational materials, meetings, CME,
audit-feedbacks, reminders
Occupational diseases No
Chauhan et al. Implementation Science (2017) 12:3 Page 5 of 16