Implementation of evidence-based nutritional management in primary health care settings: a systematic scoping review

Keywords: evidence-based practice, implementation science.

One in five deaths worldwide (estimated at 11 million deaths in 2017) is associated with eating habits (GBD 2017 Diet Collaborators 2019). The relationship between inappropriate eating habits and chronic non-communicable diseases has been extensively investigated (Micha et al. 2017; World Cancer Research Fund 2018), producing evidence that suggests that the high consumption of certain foods, including ultra-processed foods, contributes to diseases such as diabetes, colorectal cancer and ischaemic heart disease.

Despite the significant evidence that relatively small changes in eating habits may significantly improve an individual’s health, primary healthcare (PHC) professionals frequently cite deficiencies in training as to why they do not implement evidence-based nutritional management (Blonstein et al. 2013). Only a minority feel prepared to provide nutritional management advice following clinical protocols (The Counterweight Project Team 2004; Brown and Psarou 2008).

PHC represents the entry point for individuals, families and communities into health services, playing a central role in the quality of health care and the promotion of evidence-based dietary recommendations (World Health Organization (WHO) 2008). Considering this key role, the aim of this scoping review was to better understand how healthcare professionals in PHC settings have implemented evidence-based nutritional management. This review focuses on the barriers and facilitators to effective implementation. Two research questions guided this scoping review: (1) what are the steps in the implementation of evidence-based nutritional management in primary healthcare settings; and (2) what are the facilitators and barriers to effective implementation?

By collecting and organising study results, a scoping review allows existing evidence to be mapped, providing valuable information on the different ways in which evidence-based nutritional management is being implemented in PHC (Tricco et al. 2018).

This study chose the scoping review methodology proposed by the Joanna Briggs Institute (JBI) using an approved and published protocol (Oliveira et al. 2018). The scoping review methodology used by the JBI is based on previous scoping reviews, such as that of Arksey and O’Malley (2005).

To be eligible for inclusion in this study, articles had to be: original scientific articles (using any methodology) or published in the grey literature; written in Spanish, Portuguese or English; about the implementation of evidence-based dietary recommendations and/or nutritional counselling; performed in PHC settings; and implemented by health practitioners, regardless of education level.

Studies that only pointed out dietary recommendations to be followed for the prevention or treatment of a particular pathology and studies that analysed only the preceding steps of nutritional management, such as nutritional assessment, were excluded.

Seven electronic databases (PubMed, CINAHL, EMBASE, LILACS, PsycINFO, ERIC and SCOPUS) and three sources of grey literature (Catálogo de Teses e Dissertações (CAPES), the RedeNutri portal of the Brazilian Government and Open Access Theses and Dissertations (OATD)) were search for articles from the start date of each database up to July 2018. The databases were searched using a combination of indexed terms and/or keywords referring to ‘nutritional management’, ‘evidence-based practice’ and ‘PHC’, with the exception of the RedeNutri portal, where the research was conducted through the ‘Experiences’ tab. The indexed terms and keywords used in the searches of the electronic databases and sources of grey literature are presented in Table 1. The final combination of indexed terms and/or keywords used in searches of an electronic database (PubMed) and a source of grey literature (CAPES) is presented in Table 2.

Table 1.  Search strategy for electronic databases and the grey literature

Table 2.  Combination of indexed terms and/or keywords for the search through using Boolean operators (AND/OR)

First, three reviewers (NLZO, HLFA and KSS) individually applied the inclusion criteria to all titles and abstracts of publications retrieved from the databases. Then, the titles and abstracts of studies classified as ‘included’ or ‘uncertain’ were reviewed by two different reviewers (NLZO and MP), with any disagreements were resolved by consensus. Finally, the reference lists of included studies were manually searched to identify any other publications. During the review process, there was no formal assessment performed of the quality of the included studies because of the purpose of scoping reviews (Tricco et al. 2018).

A data chart form was used to extract standard basic information (article title, authors, year of publication, country of origin, study design) and relevant findings related to the objectives of the review: interventions/programs linked to evidence-based nutritional management, context and stages of the implementation process, health professionals involved and barriers and facilitators for implementation.

A synthesis of the collected data is presented in a narrative summary focused on the objectives of the review, with the addition of tables and numerical descriptions to show the number and distribution of studies included in the review (years of publication and countries of origin).

Because this study was a scoping review based on previously published studies, it did not involve direct participation by humans or animals and, as such, was exempt from approval by a research ethics committee.

The search identified 5843 records from databases and the grey literature, with a further 1034 identified from the references lists. After excluding duplicates and unavailable records, 5809 titles and abstracts were evaluated. Of these, 5570 articles that did not meet the selection criteria were removed; 239 studies were checked by two separate reviewers (NLZO and HLFA), with 41 selected to be read in full. Of those, 15 were discarded (three not available as full text; 12 not eligible for inclusion after reading of the full text), resulting in the final selection of 26 studies (Fig. 1; for a list of the studies included, see Table 3).

Fig. 1.  Adapted Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart.

Table 3.  General characteristics of the studies included, outlines of the implementation process and the health professionals involved
EAAB, Estratégia Amamenta e Alimenta Brasil; EMRs, electronic medical records; RCT, randomised control trial

Of the 26 studies included, 23 were written in English and published between 2004 and 2017, with 11 studies published between 2015 and 2017. Fifty per cent of the studies came from the Americas, with the largest number of publications (10 studies) coming from the US. The PHC services or community services studied were in urban, rural and/or designated Indigenous territories.

The professionals most frequently involved in the implementation of evidence-based nutritional management were GPs or family physicians (60% of studies), followed by nurses. Nutritionists had a key function supervising and supporting the implementation of nutritional management, even though they did not have the same role as direct agents of the interventions and programs.

Studies of the implementation of evidence-based nutritional management included in this review were classified into five themes related to food and nutrition, namely: (1) breastfeeding (Labarere et al. 2005; Bettinelli et al. 2012; Corriveau et al. 2013; Hernández-Aguilar et al. 2014; Fontoura et al. 2015; Mueller 2015; Schwartz et al. 2015; Baerug et al. 2016; Aguiar et al. 2017; Souza et al. 2017a); (2) infant feeding (Ewing et al. 2009; Inglis et al. 2010; Sargent 2011; Shaikh et al. 2014; Cloutier et al. 2015; Gabrielli et al. 2017); (3) weight control in adults – overweight/obesity (The Counterweight Project Team 2004; Huseinovic et al. 2016; Little et al. 2016); (4) control of alcohol consumption (Beich et al. 2007; Clifford and Shakeshaft 2011; Ornstein et al. 2013); and (5) the care of diabetic patients (Glasgow et al. 2004; Vachon et al. 2007; Garza et al. 2017). The scoping review found one study directed towards nutritional risk/malnutrition (Kennelly et al. 2010).

The general characteristics of the studies included in this scoping review, their themes, an outline of the implementation process for the interventions and the health professionals involved are detailed in Table 3.

The implementation processes described in the studies show that evidence-based nutritional management in PHC settings was based on four steps: (1) acknowledging health needs in the catchment area and determining the characteristics of services and health professionals; (2) developing continuing education aimed at practitioners; (3) integrating nutritional management into interprofessional practice; and (4) adapting the interventions using a patient-centred care approach.

Eight of the studies in this review analysed the execution of activities and the dynamics of the work process before beginning implementation (The Counterweight Project Team 2004; Inglis et al. 2010; Kennelly et al. 2010; Shaikh et al. 2014; Baerug et al. 2016; Little et al. 2016; Gabrielli et al. 2017; Garza et al. 2017).

Nine of the studies selected for this review referred to the adoption of pre-intervention training and support materials as strategies to assist in the implementation of evidence-based nutritional management in PHC services (The Counterweight Project Team 2004; Labarere et al. 2005; Beich et al. 2007; Ewing et al. 2009; Corriveau et al. 2013; Hernández-Aguilar et al. 2014; Cloutier et al. 2015; Mueller 2015; Baerug et al. 2016). Another five studies described moments of the providers’ work routine in which they shared their experiences regarding the implementation process in order to improve it (Sargent 2011; Bettinelli et al. 2012; Shaikh et al. 2014; Schwartz et al. 2015; Garza et al. 2017).

Integrating nutritional management into interprofessional practice was addressed through different aspects, including: task division within the implementing organisation (The Counterweight Project Team 2004; Glasgow et al. 2004; Labarere et al. 2005; Beich et al. 2007; Vachon et al. 2007; Ewing et al. 2009; Corriveau et al. 2013; Ornstein et al. 2013; Shaikh et al. 2014; Mueller 2015); training with different groups professional in interaction (Kennelly et al. 2010; Clifford and Shakeshaft 2011; Bettinelli et al. 2012; Ornstein et al. 2013; Hernández-Aguilar et al. 2014; Shaikh et al. 2014; Schwartz et al. 2015; Baerug et al. 2016); meetings to share and discuss experiences (The Counterweight Project Team 2004; Clifford and Shakeshaft 2011; Sargent 2011; Bettinelli et al. 2012; Ornstein et al. 2013; Shaikh et al. 2014; Fontoura et al. 2015; Schwartz et al. 2015; Aguiar et al. 2017; Garza et al. 2017); and supervision and support from researchers and/or specialist professionals (The Counterweight Project Team 2004; Ewing et al. 2009; Inglis et al. 2010; Kennelly et al. 2010; Clifford and Shakeshaft 2011; Bettinelli et al. 2012; Corriveau et al. 2013; Ornstein et al. 2013; Shaikh et al. 2014; Fontoura et al. 2015; Schwartz et al. 2015; Baerug et al. 2016; Gabrielli et al. 2017; Aguiar et al. 2017; Garza et al. 2017; Souza et al. 2017a).

The reviewed studies demonstrated that shared decision making was the main element of patient-centred care, primarily through the setting of goals and/or structuring strategies to overcome possible difficulties in the change process. Meetings and face-to-face consultations with health professionals were considered the most appropriate conditions for health care. However, nine studies provided evidence that the use of digital media in the implementation of interventions (virtual platforms, text messages and emails, sometimes accompanied by telephone contact) guaranteed the sustainability of changes in the follow-up stages (Glasgow et al. 2004; Sargent 2011; Ornstein et al. 2013; Cloutier et al. 2015; Schwartz et al. 2015; Huseinovic et al. 2016; Little et al. 2016; Gabrielli et al. 2017; Garza et al. 2017).

The most frequent barriers to the implementation of evidence-based nutritional management in primary care included time constraints, a lack of resources, incompatibility of the proposed interventions with patients’ living conditions and health needs and resistance to change in working dynamics.

Among the potential factors facilitating implementation, the main factors identified were pre-intervention training, the provision of support materials for health professionals, interprofessional actions with support from specialists, easy to apply interventions adapted to patients’ needs and the situation of the services.

The barriers to and facilitators of implementation processes mentioned by at least three studies included in this review found to be linked to the four steps described above are presented in Table 4.

Table 4.  Barriers to and facilitators of the implementation process

A review by Brownson et al. (2018) discussed different approaches to the process of translating scientific evidence into practice in public health services, stressing that there is a disconnect between the ‘evidence generators’ and the ‘evidence users’, thus reinforcing the premise that the implementation process is as crucial as the scientific evidence in the effectiveness of nutritional management.

This scoping review showed that the initial step in the implementation process of evidence-based nutritional management in PHC settings is based on the understanding of the needs of users and families and the availability of resources in the community (e.g. access points to healthy foods), acknowledging current practices and incorporating the current characteristics of health professionals (knowledge, skills, attitudes, trust and interest) regarding nutritional counselling.

According to Cabana and Flores (2002) and Souza et al. (2017b), an analysis of the demographic and epidemiological aspects of the region, such as life expectancy and disease burden, as well as the current practices and situation of each health unit, organisational issues (staff, pressure for productivity) and/or structural factors (access to computers, meeting rooms, availability of educational materials), is key to forecasting possible barriers to the implementation of practices and suggesting strategies to overcome them.

The second step in the implementation process is related to the training of healthcare practitioners. Danek et al. (2017) and Kahan and Manson (2017) identified weaknesses associated with adopting nutritional management in clinical practice in PHC. Those weaknesses are linked to gaps in the training of health professionals at both the undergraduate and graduate levels, as well as to limitations of in-service training. This review also found continuing and participative educational activities for practitioners (pre-intervention training, the preparation and provision of study materials and support for implementation, moments of sharing new knowledge and skills acquired during the process) were guiding steps for the implementation process. The educational experiences based on real-world settings, applying interactive and practical activities, emerged as enablers to the enrichment of theoretical knowledge, creating conditions for the development of previously dormant or non-existent skills (Andolsek et al. 2013).

The third step in the implementation process highlighted by this review is the integration of nutritional management into interprofessional practice. Driving forces behind the implementation of evidence-based nutritional management in PHC settings include: structuring of the implementation plan; dividing tasks between professionals from different areas, as well as members of the community; sharing practice (including other health units) experiences; and the provision of supervision and support from specialist professionals (with an emphasis on nutritionists).

According to Brownson et al. (2018) and Luig et al. (2018), successful implementation of practice in PHC also seems to be directly related to the collective perception, knowledge exchange between stakeholders, teamwork and collaborative interprofessional practice and continuous support from specialists. The implementation of nutritional management is an interprofessional practice based on the combination of different types of knowledge. Among these types of knowledge, it is key to include the knowledge and opinions of users and families as a component of the implementation process in the context of comprehensive health care (Suter et al. 2009; WHO 2010; Agreli et al. 2016).

The fourth and final step in the implementation process was the use of a patient-centred approach. This presupposes the active participation of the patient in the decision-making process, horizontal communication, attentive and qualified listening and a perception of patients’ willingness and readiness to get involved with the proposed interventions. There must be a reciprocal relationship between individuals in the catchment area and the health unit to which they are linked, helping to shape those health services to the users’ needs under the perspective of comprehensiveness (Brownson et al. 2018).

This study has two limitations. First, we were unable to find the full-text versions of three studies that met the inclusion criteria, which meant these studies were not included in the analysis. In addition, the search strategy was limited to articles written in Spanish, Portuguese or English; this geographic scope excluded literature published in other languages.

The interventions and programs related to evidence-based nutritional management implementation emerging from the 26 studies in this review address topics that are relevant to health systems worldwide, given their high prevalence among users, families and communities in most countries. These topics include weight control (overweight/obesity), infant feeding, alcohol consumption, breastfeeding, care for diabetic patients and nutritional risk/malnutrition.

It has been demonstrated that the implementation of nutritional management within PHC settings demands a broad view of the process, going beyond the boundaries of the specific nutrition management activity. It is necessary to use an implementation design that goes from pre-intervention to follow-up, using interprofessional work, a patient-centred approach and continuing education, always taking into consideration the local reality of the patients, their needs and the resources of the PHC service.

The main recommendations arising from this review are the four steps of the implementation process, which go beyond the mere dissemination of the evidence and are key for the adoption of evidence-based nutritional management in clinical practice.

The authors declare that they have no conflicts of interest.

This research did not receive any specific funding.