title: An exploration of how clinician attitudes and beliefs influence the implementation of lifestyle risk factor management in primary healthcare: a grounded theory study.
abstract: BACKGROUND
  Despite the effectiveness of brief lifestyle intervention delivered in primary healthcare (PHC), implementation in routine practice remains suboptimal. Beliefs and attitudes have been shown to be associated with risk factor management practices, but little is known about the process by which clinicians' perceptions shape implementation. This study aims to describe a theoretical model to understand how clinicians' perceptions shape the implementation of lifestyle risk factor management in routine practice. The implications of the model for enhancing practices will also be discussed.
  
  
  METHODS
  The study analysed data collected as part of a larger feasibility project of risk factor management in three community health teams in New South Wales (NSW), Australia. This included journal notes kept through the implementation of the project, and interviews with 48 participants comprising 23 clinicians (including community nurses, allied health practitioners and an Aboriginal health worker), five managers, and two project officers. Data were analysed using grounded theory principles of open, focused, and theoretical coding and constant comparative techniques to construct a model grounded in the data.
  
  
  RESULTS
  The model suggests that implementation reflects both clinician beliefs about whether they should (commitment) and can (capacity) address lifestyle issues. Commitment represents the priority placed on risk factor management and reflects beliefs about role responsibility congruence, client receptiveness, and the likely impact of intervening. Clinician beliefs about their capacity for risk factor management reflect their views about self-efficacy, role support, and the fit between risk factor management ways of working. The model suggests that clinicians formulate different expectations and intentions about how they will intervene based on these beliefs about commitment and capacity and their philosophical views about appropriate ways to intervene. These expectations then provide a cognitive framework guiding their risk factor management practices. Finally, clinicians' appraisal of the overall benefits versus costs of addressing lifestyle issues acts to positively or negatively reinforce their commitment to implementing these practices.
  
  
  CONCLUSIONS
  The model extends previous research by outlining a process by which clinicians' perceptions shape implementation of lifestyle risk factor management in routine practice. This provides new insights to inform the development of effective strategies to improve such practices.
authors.affiliation: Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, University of New South Wales, Sydney NSW 2052, Australia. r.laws@unsw.edu.au
authors.forename: Rachel A
authors.initials: RA
authors.lastname: Laws
authors.forename: Lynn A
authors.initials: LA
authors.lastname: Kemp
authors.forename: Mark F
authors.initials: MF
authors.lastname: Harris
authors.forename: Gawaine Powell
authors.initials: GP
authors.lastname: Davies
authors.forename: Anna M
authors.initials: AM
authors.lastname: Williams
authors.forename: Rosslyn
authors.initials: R
authors.lastname: Eames-Brown