title: Implementation of the BETTER 2 program: a qualitative study exploring barriers and facilitators of a novel way to improve chronic disease prevention and screening in primary care.
abstract: BETTER (Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care) is a patient-based intervention to improve chronic disease prevention and screening (CDPS) for cardiovascular disease, diabetes, cancer, and associated lifestyle factors in patients aged 40 to 65. The key component of BETTER is a prevention practitioner (PP), a health care professional with specialized skills in CDPS who meets with patients to develop a personalized prevention prescription, using the BETTER toolkit and Brief Action Planning. The purpose of this qualitative study was to understand facilitators and barriers of the implementation of the BETTER 2 program among clinicians, patients, and stakeholders in three (urban, rural, and remote) primary care settings in Newfoundland and Labrador, Canada.
  
  
  
  We collected and analyzed responses from 20 key informant interviews and 5 focus groups, as well as memos and field notes. Data were organized using Nvivo 10 software and coded using constant comparison methods. We then employed the Consolidated Framework for Implementation Research (CFIR) to focus our analysis on the domains most relevant for program implementation.
  
  
  
  The following key elements, within the five CFIR domains, were identified as impacting the implementation of BETTER 2: (1) intervention characteristics-complexity and cost of the intervention; (2) outer setting-perception of fit including lack of remuneration, lack of resources, and duplication of services, as well as patients' needs as perceived by physicians and patients; (3) characteristics of prevention practitioners-interest in prevention and ability to support and motivate patients; (4) inner setting-the availability of a local champion and working in a team versus working as a team; and (5) process-planning and engaging, collaboration, and teamwork.
  
  
  
  The implementation of a novel CDPS program into new primary care settings is a complex, multi-level process. This study identified key elements that hindered or facilitated the implementation of the BETTER approach in three primary care settings in Newfoundland and Labrador. Employing the CFIR as an overarching typology allows for comparisons with other contexts and settings, and may be useful for practices, researchers, and policy-makers interested in the implementation of CDPS programs.
authors.affiliation: Department of Family Medicine, University of Alberta, 6-10 University Terrace, Edmonton, Alberta, T6G 2T4, Canada. nsopcak@ualberta.ca.
authors.forename: Nicolette
authors.identifier: 0000-0002-0795-2341
authors.initials: N
authors.lastname: Sopcak
authors.affiliation: Department of Family Medicine, University of Alberta, 6-10 University Terrace, Edmonton, Alberta, T6G 2T4, Canada.
authors.forename: Carolina
authors.initials: C
authors.lastname: Aguilar
authors.affiliation: Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, ON, M5G 1V7, Canada.
authors.forename: Mary Ann
authors.initials: MA
authors.lastname: O'Brien
authors.affiliation: School of Public Health, University of Alberta, 3-291 Edmonton Clinic Health Academy, Edmonton, AB, T6G 1C9, Canada.
authors.forename: Candace
authors.initials: C
authors.lastname: Nykiforuk
authors.affiliation: Primary Healthcare Research Unit, Memorial University of Newfoundland, Health Sciences Centre, 300 Prince Phillip Drive, St. John's, Newfoundland, A1B 3V6, Canada.
authors.forename: Kris
authors.initials: K
authors.lastname: Aubrey-Bassler
authors.affiliation: Primary Healthcare Research Unit, Memorial University of Newfoundland, Health Sciences Centre, 300 Prince Phillip Drive, St. John's, Newfoundland, A1B 3V6, Canada.
authors.forename: Richard
authors.initials: R
authors.lastname: Cullen
authors.affiliation: Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, ON, M5G 1V7, Canada.|Ontario Institute for Cancer Research, 661 University Avenue, Suite 510, Toronto, ON, M5G 0A3, Canada.
authors.forename: Eva
authors.initials: E
authors.lastname: Grunfeld
authors.affiliation: Department of Family Medicine, University of Alberta, 6-10 University Terrace, Edmonton, Alberta, T6G 2T4, Canada.|Covenant Health, Grey Nuns Community Hospital, 1100 Youville Drive Northwest, Edmonton, Alberta, T6L 5X8, Canada.
authors.forename: Donna Patricia
authors.initials: DP
authors.lastname: Manca
mesh_terms: D000328:Adult; D000368:Aged; D002170:Canada; D002908:Chronic Disease / Q000517:prevention & control*; D003299:Cooperative Behavior; D005260:Female; D017144:Focus Groups; D006282:Health Personnel; D006297:Health Services Accessibility; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008403:Mass Screening / Q000379:methods*; D008875:Middle Aged; D011320:Primary Health Care / Q000379:methods*; D015397:Program Evaluation / Q000379:methods*; D036301:Qualitative Research; D012424:Rural Population; D014505:Urban Population
keywords: Health plan implementation; Primary care; Primary prevention; Qualitative research; Team-based care