title: Barriers and facilitators for the implementation of primary prevention and health promotion activities in primary care: a synthesis through meta-ethnography.
abstract: BACKGROUND
  Evidence supports the implementation of primary prevention and health promotion (PP&HP) activities but primary care (PC) professionals show resistance to implementing these activities. The aim was to synthesize the available qualitative research on barriers and facilitators identified by PC physicians and nurses in the implementation of PP&HP in adults.
  
  
  RESULTS
  A systematic search of three databases was conducted and supported by manual searches. The 35 articles included were translated into each other and a new interpretation of the concepts extracted was generated. The factors affecting the implementation of PP&HP activities in PC according to professionals were fitted into a five-level ecological model: intrapersonal factors, interpersonal processes, institutional factors, community factors and public policy. At the intrapersonal level we find professionals' beliefs about PP&HP, experiences, skills and knowledge, and selfconcept. The attitudes and behavior towards PP&HP of patients, specialists, practice managers and colleagues (interpersonal factors) affect the feasibility of implementing PP&HP. Institutional level: PC is perceived as well-placed to implement PP&HP but workload, lack of time and referral resources, and the predominance of the biomedical model (which prioritizes disease treatment) hamper the implementation of PP&HP. The effectiveness of financial incentives and tools such as guidelines and alarms/reminders is conditioned by professionals' attitudes to them. Community factors include patients' social and cultural characteristics (religion, financial resources, etc.), local referral resources, mass-media messages and pharmaceutical industry campaigns, and the importance given to PP&HP in the curriculum in university. Finally, policies affect the distribution of resources, thus affecting the implementation of PP&HP.
  
  
  CONCLUSIONS
  Research on barriers and facilitators in the implementation of PP&HP activities in multirisk management is scarce. The conceptual overview provided by this synthesis resulted in the development of practical recommendations for the design of PP&HP in PC. However, the effectiveness of these recommendations needs to be demonstrated.
authors.affiliation: Research and Development Unit, Fundació Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain ; Spanish Research Network on Preventative Activities and Health Promotion in Primary Care (RedIAPP), Spain.
authors.forename: Maria
authors.initials: M
authors.lastname: Rubio-Valera
authors.affiliation: Spanish Research Network on Preventative Activities and Health Promotion in Primary Care (RedIAPP), Spain ; Research Department, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain ; Departamento de Psicología clínica y de la Salud, Universitat Autònoma de Barcelona, Bellaterra, Spain.
authors.forename: Mariona
authors.initials: M
authors.lastname: Pons-Vigués
authors.affiliation: Spanish Research Network on Preventative Activities and Health Promotion in Primary Care (RedIAPP), Spain ; Social and Health Care Research Center, University of Castilla-La Mancha, Cuenca, Spain.
authors.forename: María
authors.initials: M
authors.lastname: Martínez-Andrés
authors.affiliation: Spanish Research Network on Preventative Activities and Health Promotion in Primary Care (RedIAPP), Spain ; Research Unit, Distrito Sanitario Malaga, Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (IMABIS Foundation), Málaga, Spain.
authors.forename: Patricia
authors.initials: P
authors.lastname: Moreno-Peral
authors.affiliation: Spanish Research Network on Preventative Activities and Health Promotion in Primary Care (RedIAPP), Spain ; Research Department, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain ; Departamento de Psicología clínica y de la Salud, Universitat Autònoma de Barcelona, Bellaterra, Spain.
authors.forename: Anna
authors.initials: A
authors.lastname: Berenguera
authors.affiliation: Research and Development Unit, Fundació Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain ; Spanish Research Network on Preventative Activities and Health Promotion in Primary Care (RedIAPP), Spain ; Centre for Disability Research and Policy, Faculty of Health Sciences, The University of Sydney, Sydney, Australia.
authors.forename: Ana
authors.initials: A
authors.lastname: Fernández
mesh_terms: D000884:Anthropology, Cultural / Q000379:methods*; D006293:Health Promotion; D006801:Humans; D011320:Primary Health Care; D011322:Primary Prevention / Q000379:methods*