Community Activities in Primary Care: A Literature Review

Abstract

Community health promotion activities are a useful tool for a proactive approach to healthy lifestyles. However, the implementation of these types of activities at health centers is not standardized. The aim of this review was to analyse the characteristics of community activities undertaken in the primary care setting and substantiate available evidence on their health impact. We conducted a bibliographic review until November 15th, 2023 in the TRIPDATABASE, MEDLINE, EMBASE, and DIALNET databases. We included original papers on interventions, community activities, and actions and/or social prescriptions which had been implemented in a Primary Care setting, included a group approach in at least one session, and described some type of evaluation of the intervention applied. Studies targeted at professionals and those without involvement of the primary care team were excluded. The search identified 1912 potential studies. We included a total of 30 studies, comprising 11 randomized clinical trials, 14 quasi-experimental studies, 1 cohort study, and 4 qualitative studies. The issues most frequently addressed in community activities were healthy habits, physical activity, cardiovascular diseases and diabetes. Community activities can improve the physical and psychological environment of their participants, as well as their level of knowledge about the issues addressed. That said, however, implementation of these types of interventions is not uniform. The existence of a professional community-activity liaison officer at health centers, who would help integrate the health system with the community sector, could serve to standardize implementation and maximize the health impact of these types of interventions.

Impact Statement

This review serves to clarify which community activities are most effective for being undertaken in primary care (PC), and will also help health professionals conduct these interventions for the community with greater prospects of success. This will improve the population’s healthy behaviors, boost empowerment for self-care purposes, and reduce the overload on the healthcare system.

Introduction

Growing population aging, along with a higher incidence of chronic diseases, raises the need for a more pro-active healthcare model that addresses health determinants more comprehensively. ¹ Lifestyle is the main determinant of the status of population health. ² Unhealthy behaviors like alcohol consumption and smoking are risk factors for high-prevalence diseases, such as cancer and cardiovascular diseases, which substantially affect people’s quality of life.^{3 -6} Currently, promotion of healthy lifestyles from a community perspective is advocated as the most effective approach for preventing chronic diseases and achieving holistic and integrated care of the individual.^7,8

Community activities (CA) are defined as “all those intervention and participation activities that are carried out by groups that have common characteristics, needs or interests and are aimed at promoting health, increasing quality of life and social well-being, enhancing the capacity of individuals and groups to address their own problems, demands or needs.” ⁹ CA-based interventions have succeeded in improving health behaviors related to regular physical exercise, ¹⁰ dietary habits,^11,12 and emotional state.^13,14

Given its accessibility and function as a gateway to the health system, the PC healthcare environment enjoys a privileged position for implementation of CA targeted at promoting health-related behaviors in the community. ¹⁵ Yet, evidence on the conduct of PC-led community activities is unclear. It is necessary to unify the action criteria governing their implementation and ascertain which CA, with participation of PC teams (PCTs), generate the greatest health benefits. Hence, the aim of this study was to analyse the characteristics of CA undertaken in PC settings, and examine the available evidence on the health impact of such activities.

Methods

Search Strategy

We conducted a search in the TRIPDATABASE, MEDLINE, EMBASE, and DIALNET databases until November 15th, 2023 (Figure 1). The search strategy used for TRIPDATABASE, MEDLINE and EMBASE was: (“community activity” OR “community program” OR “community intervention” OR “social prescription” OR “social prescribing” OR “social intervention”) AND (“primary care” OR “primary health care”). In addition, the search terms used in DIALNET were: social prescription, community action, community activity, community intervention, and intervention in the community.

Figure 1.

PRISMA 2009 flow diagram of the original studies included in the review.

Inclusion and Exclusion Criteria

We included all papers in which the intervention met the agreed CA definition drawn up by experts. ⁹ We selected all original papers on interventions, community activities, and actions and/or social prescriptions (SPr) which had been implemented in a PC setting, included a group approach in at least one session, and described some type of evaluation of the intervention applied. The following were excluded: studies brief or one-time intervention whose CA were exclusively targeted at professionals; those where the PCT’s action was limited to the capture of participants; and those in which the selection criteria could not be ascertained after consulting the corresponding author.

Data-extraction and Analysis

We applied a two-step inclusion process. Firstly, the references found were separately reviewed by pairs of reviewers (D.G.M.M., A.R.F., S.N.), after perusal of the title and abstract.

Secondly, after a reading of the full text, papers that failed to meet the selection criteria were discarded. The authors of papers were contacted in cases where there were missing study data that might have allowed for the papers’ inclusion among those selected. Differences of opinion were discussed and settled by the reviewers. (A.R.F., S.N., D.G.M.M.).

The data were extracted by one of the authors, and (D.G.M.M.) variables relating to CA, the target population and PCT were analyzed by reference to the classification of their characteristics made by the authors (Supplemental Table S1).

Results

Characteristics of the Studies Selected

Figure 1 shows the search process and the results obtained with respect to CA undertaken in primary care. Once all duplicated results had been eliminated, 1912 references were identified; and after application of the pre-established selection criteria, a total of 30 papers were finally selected. Additional details about the characteristics of the papers selected are shown in Tables 1 and 2.

Table 1.

Main Characteristics of the CA of the Studies.

Author	Country	Topic	Objective	Study design	Type of intervention	Type of evaluation	Effectiveness of intervention	Number of sessions	Duration of intervention	Funding
Björkelund et al 25	Sweden	CV risk	To asses the effectiveness of a lifestyle modification intervention	Quasi-experimental	HE and PA	Process and results	Improved diet and exercise	12	3 months	Yes
Gorguet Pi et al 41	Cuba	Alcohol consumption and physical violence	To assess the impact of a communitarian intervention	Quasi-experimental	HE with educational lectures	Process and results	Positive modification of alcohol-dependents’ criteria and attitudes	24	6 months	No
Pujiula Blanch et al 20	Spain	Fall prevention	To evaluate the effectiveness of a multifactorial, community-based intervention program	Quasi-experimental	CA, approach to professionals and individual activities in consultation and at home	Process (with feedback and satisfaction) and results	Reduction of the consequences, but not of the number of falls	NA	24 months	No
Ariza Copado et al 35	Spain	DM II	To assess the metabolic control and cardiovascular risk factors	RCT	HE and PA	Process and results	Improved control, adherence and patient attitude	8	6 months	Yes
Chan et al 21	China	Self-care in chronic diseases	To evaluate the effectiveness of a program to improve self-management	Quasi-experimental	HE	Process and results	Improved self-care, self-efficacy and health status	6	6 weeks	Yes
López Castañón et al 45	Spain	Osteoporosis	To evaluate the effectiveness of a health education program	Quasi-experimental	HE (group workshops on menopause, osteoporosis, balanced diet, PA, and lifestyles)	Process and results	Improvement of self-care, knowledge, skills, and attitudes	4	8 months	No
López-Téllez et al 22	Spain	PA and quality of life	To evaluate the effectiveness of a socio-motor program	Quasi-experimental	HE (lectures, PA and social events)	Process and results	Improved walk, flexibility, strength, dynamic balance and quality of life	57	6 months	NA
Arauz Boudreau et al 27	USA	Child obesity	To assess the feasibility and effectiveness of a intervention to control body weight	RCT	HE	Process and results	No change for metabolic markers of obesity, BMI or PA	6	7.5 months	Yes
Galaviz et al 24	Canada	PA	To assess the effectiveness of an intervention to promote PA	Quasi-experimental	PA	Process and results	Brief PA counseling and/or PA prescription is effective for improving PA	8	2 months	No
Madridejos Mora et al 19	Spain	Cardiovascular health	To assess the effectiveness of a training program supplemented by a web site and community activities in order to improve the knowledge	RCT	Classroom course, Web support and complementary activities	Process (with satisfaction) and results	Improved PA and knowledge of CVRF and decrease in the number of Primary Care visits	8	1 month	No
González González et al 26	Spain	Health promotion	To evaluate the effectiveness of a health education program for improving knowledge	Quasi-experimental	HE (lectures on healthy diet, PA, CPR, CVRF, stress, smoking, sexuality; and reading, discussion and video groups)	Process and results	Improved knowledge about diet, PA, CVRF, basic life support, stress management, sexuality and menopause	9	NA	NA
Lussier et al 36	Canada	Chronic patient management	Evaluate the effectiveness of educational approaches based on “e-Learning WEB” on doctor-patient communication	RCT	“e-Learning WEB” vs “e-Learning WEB + nursing workshop”	Process (with satisfaction) and results	Improved doctor-patient relationship and increased patient participation in clinical encounters	2	19 months	Yes
Arija et al 16	Spain	CV disease prevention	To evaluate the effectiveness of a PA program	RCT	PA and sociocultural activities on diet and CVRF	Process and results	Improved systolic blood pressure, total cholesterol, LDL levels, REGICOR score; and increased PA and fewer CV events	72	9 months	Yes
Camps et al 29	Spain	Healthy habits	To assess the effectiveness of an intervention based on healthy lifestyles to reduce the body weight	Quasi-experimental	HE and PA	Process and results	Increased knowledge, but no improvement in body weight	20	15 months	Yes
Livingood et al 32	USA	Child obesity	To assess the useful of digital communication interventions	Qualitative study	Photo-voice interviews and focus groups	Process and results	Digital technology improving adolescent nutrition and PA health promotion	18	36 month	Yes
Calderón Larrañaga et al 34	Spain	Oral health	To evaluate effectiveness of a promotion program to improve knowledge and behavior	Quasi-experimental	HE	Process and results	Enhanced oral health knowledge and increased consumption of healthy foods at breakfast	6	18 months	No
Pérez Bazán et al 18	Spain	Functionality of the frail elderly	To assess the impact of a multidisciplinary intervention on physical function	Cohort study	PA, nutrition, HE and accuracy medical treatment	Process and results	Improved physical function	10	3 months	Yes
Pons-Vigués et al 33	Spain	Healthy habits (EIRA Project)	To evaluate the effectiveness of an intervention on health promotion	Qualitative study	Individual and community intervention (SPr) + Web and HE brochures + SMS	Process (with satisfaction) and results	Increased motivation and healthy behaviors	NA	7 months	Yes
Calatayud et al 43	Spain	Cognitive impairment	To analyze the efficacy of a cognitive stimulation program	RCT	Cognitive stimulation	Process and results	Improvement in MEC score	10	26 months	No
Miklavcic et al 40	Canada	DM II	To evaluate the effect of a CA on physical functioning, mental health, depressive symptoms, anxiety, self-efficacy, self-care, and health costs	RCT	HE, PA and complementary activities	Process and results	Improvements in mental functioning only in participants with worse mental health	15	6 months	Yes
Bhatti et al 31	Canada	Self-determination	To explore the impact of SPr on patients’ health and wellbeing	Qualitative study	SPr	Process (with satisfaction) and results	Improved mental health and ability in self-management of chronic conditions	3	12 months	Yes
Gómez-Soria et al 37	Spain	Cognitive impairment	To assess the effectiveness of an intervention based on cognitive stimulation	RCT	Cognitive stimulation program	Process and results	Improvement cognitive performance	10	10 weeks	No
López-Martí et al 38	Spain	Functional physical condition	To evaluate the effectiveness of an active aging program	Quasi-experimental	HE, PA and social activities	Process and results	Improved functional fitness (walk, flexibility, strength and dynamic balance)	39	4 months	Yes
Martín-Doménech et al 39	Spain	PA	To assess the effectiveness of prescription of PA to improve the self-esteem and health-related quality of life	Quasi-experimental	Prescription of PA	Process and results	Improvement in quality of life, health perception and self-esteem	24	3 months	Yes
Represas-Carrera et al 23	Spain	DM (EIRA Project)	To evaluate the effectiveness of a multicomponent intervention on glycemic control	RCT	Focus groups, videoconference and telephone interviews	Process and results	No significant changes in glycemic control or BP, sedentary lifestyle, smoking and quality of life. Improved adherence to Mediterranean diet	2 (group sessions)	12 months	Yes
Rodríguez-Romero et al 44	Spain	Loneliness	To assess the impact of CA on loneliness, perceived depression, social support and quality of life	RCT	Educational workshops, mindfulness, yoga, walks and visits to urban gardens	Process and results	Improved perception of loneliness, depressive symptoms, social support and mental health component of quality of life	18	6 months	Yes
Lapena et al 17	Spain	Social isolation	To evaluate the effectiveness of the intervention “School of Health for Older People”	Quasi-experimental	HE (Discussions on health, including biological, psychological and social topics)	Process (with satisfaction) and results	Improved mental health and maintained quality of life and social support	22	6 months	Yes
López-Téllez et al 42	Spain	Quality of life	To assess the effectiveness of a social-physical activity program	RCT	PA, healthy habits and social activities	Process and results	Improved the health-related quality of life	39	4 months	Yes
Mosteiro-Miguéns et al 28	Spain	Functional physical condition and quality of life	To evaluate the effectiveness of PA intervention	Quasi-experimental	PA (including strength, mobility, balance and flexibility exercises)	Process and results	Improvement in both static and dynamic balance, expressed pain, health self-assessment, and social interaction	16	2 months	No
Yous et al 30	Canada	Diabetes self-management	To assess the experiences and perceived impacts of the “Aging, Community and Health Research Unit-Community Partnership Program” (ACHRU-CPP)	Qualitative study	HE	Process and results	Improved diabetes self-management behaviors and social support	NA	6 months	Yes

Abbreviations: BMI, body mass index; BP, blood pressure; CPR, cardiopulmonary resuscitation; CV, cardiovascular; CVRF, cardiovascular risk factors; DM, diabetes mellitus; HE, health education; NA, not available; PA, physical activity; RCT, randomized clinical trial; SPr, social prescription.

Table 2.

Main Characteristics of the Target Population, Participation of the PCT and Professionals Involved in CA.

Author	Target population	Study size		Age (years)		Sex (% female)		Level of participation	Reason for dropping out	Level of involvement PCT	Involved professionals
		Initial n	Final n	Initial n	Final n	Initial n	Final n
Björkelund et al 25	Women 45-64 years old with CVRF	n = 383 (IG = 114; CG = 269)	n = 318 (IG = 103; CG = 269)	NA	NA	100	100	Passive attendant	NA	R + E	N; M; Athletics; Domestic teachers; Nutrition
Gorguet Pi et al 41	Alcoholics users of Primary Health Care	n = 60	NA	39.8	NA	NA	NA	Passive attendant	NA	R + D + E	M
Pujiula Blanch et al 20	Population ≥ 70 years old	n = 3727 (IG = 2515; CG = 1212)	n = 602 (IG = 292; CG = 310)	NA	NA	NA	NA	Passive attendant	NA	R + D + E	N; M; Social services
Ariza Copado et al 35	Population aged 40-70 years old, with HbA1c ≤ 8.5%, BP < 160/90 and BMI ≤ 45	n = 120	n = 108 (IG = 81; CG = 27)	62.3	NA	59.3	NA	Passive attendant	Exitus	R + D + E	N; M; Nutrition;PA expert
Chan et al 21	Patients ≥ 55 years old, with ≥ 1 chronic disease	n = 772 (IG = 407; CG = 365)	n = 600 (IG = 302; CG = 298)	NA	IG = 72.6; CG = 76	NA	IG = 76.8; CG = 82.9	Passive attendant	Rejection; illness; change of address; exitus; loss of contact, institutionalized and other	D	N; SW; Lay leaders; Older volunteers with chronic diseases; Retirees
López Castañón et al 45	Women 40-75 years old users of Primary Health Care	n = 140	n = 111	NA	59	100	100	Passive attendant	No loss	R + D + E	N; M
López-Téllez et al 22	Patients > 65 years old with social risk criteria	n = 29	n = 25	69.9	70.6	NA	NA	Passive attendant	Health and personal reasons	R + D + E	N; M; SW; Physical education teacher
Arauz Boudreau et al 27	Hispanic children 9-12 years old who are overweight or obese	n = 41 (IG = 23; CG = 18)	n = 26 (IG = 14; CG = 12)	IG = 10.2; CG = 10.4	IG = 10.2; CG = 10.4	NA	IG = 64.3; CG = 58.3	Passive attendant	Incompatibility of schedules, lack of transportation and child care	R + D	Health educator; Nutrition; Pediatrician; Physiotherapy
Galaviz et al 24	Women 25-45 years old, with BMI ≤ 35 kg/m2	n = 42	n = 35	NA	36.4	100	100	Passive attendant	NA	R + D	M
Madridejos Mora et al 19	Patients aged 55-70 years old, with ≥ 1 CVRF, DM II, smoking, BP > 140/90 mm Hg, dyslipidemia or BMI > 25 kg/m2	n = 300 (IG = 150; CG = 150)	n = 202 (IG = 118; CG = 84)	IG = 64.2; CG = 64.8	NA	IG = 45.8 CG = 46.4	NA	Passive assistant and self-management (by expert patient)	NA	R + D + E	N; M; Expert patient; Pharmacy
González González et al 26	Women > 18 years old, unemployed and with dependent people in charge	n = 51	n = 37	Age range 22-58 years old	NA	100	100	Passive attendant	Scheduling issues	R + D + E	N; M; Librarian
Lussier et al 36	Hypertensive, type II diabetic or dyslipidemic patients	n = 322 (IG = 214; CG = 108)	n = 221 (IG = 115; CG = 106)	58.2	NA	36.8	NA	Passive attendant	Failure to attend meetings and perform assigned tasks	R + D	N; M
Arija et al 16	Adults users of Primary Health Care	n = 419 (IG = 305; CG = 114)	n = 364 (IG = 260; CG = 104)	IG = 64.5; CG = 66.7	NA	IG = 78.7; CG = 71.9	NA	Passive attendant	Recent pathology; change of address and loss of interest	R + D	N; PA expert
Camps et al 29	Women primary caregivers between 15-70 years old with obesity/overweight	n = 25	n = 13	NA	NA	NA	NA	Passive attendant	Not attending workshops	R + D + E	N; M; SW; Chef; Dance teacher
Livingood et al 32	Hispanic children aged 9-12 years old who were overweight or obese	n = 30	n = 16	NA	NA	NA	NA	Collaboration and self-management	Abandonment and loss of contact	D	M; Self-trained young people
Calderón Larrañaga et al 34	Children 5-6 years old and their parents	n = 191 (IG = 82; CG = 109)	n = 155 (IG = 61; CG = 94) (At 18 months)	5.7	5.9	53	52.3	Passive attendant	School absenteeism	D + E	PCT unspecified; Teachers
Pérez Bazán et al 18	Population ≥ 80 years old with ≥ 1 sign of frailty	n = 134	n = 112	NA	80.9	NA	67.9	Passive attendant	Refusal to follow up, hospitalization, falls, exitus and others	R + D	Geriatrician; Physiotherapy
Pons-Vigués et al 33	Population aged 45-75 years old with chronic diseases attended in primary health care	n = 13	NA	59.1	NA	NA	NA	Passive attendant	NA	R + D + E	N; M; SW; Administrative staff
Calatayud et al 43	Population ≥ 65 years old with MEC ≥ 28	n = 201 (IG = 101; CG = 100)	n = 87* (IG = 51; CG = 36) *(After one-year follow-up)	IG = 72.1; CG = 73.7	NA	IG = 68.3; CG = 63	NA	Passive attendant	Family burdens; lack of interest; non-attendance and sickness	R + D	Occupational Therapy
Miklavcic et al 40	Population ≥ 65 years old with DM II, and ≥ 2 chronic diseases	n = 132 (IG = 70; CG = 62)	n = 121 (IG = 65; CG = 56) (At 6 months)	42% were 75 years or older	NA	55	NA	Passive attendant	Unable to contact; exitus; change of province; care of children, and not complete final survey	R + D	N; M; Informal Caregivers; Nutrition; Older Adults
Bhatti et al 31	Patients who participated in a SPr	n = 96	NA	61-80 years old (57.3%)	NA	61.5	NA	Passive attendant	NA	E	PCT unspecified
Gómez-Soria et al 37	Patients > 65 years old with mild cognitive impairment	NA	n = 29 (IG = 15; CG = 14)	NA	IG = 71.5; CG = 73.9)	NA	IG = 86.7; CG = 71.4)	Passive attendant	No loss	R + D + E	Occupational Therapy
López-Martí et al 38	Patients > 65 years old with social risk	n = 102 (IG = 51; CG = 51)	n = 80 (IG = 46; CG = 34)	NA	71.5	NA	91.3	Passive attendant	Own or relative’s illness and lack of motivation	R + D + E	N; M; SW; Physical education teacher
Martín-Doménech et al 39	Population 18 years old with sedentary lifestyles	n = 82	NA	65.5 (women); 69.9 (men)	NA	74.4	73.1	Collaborator and self-management (in the field trip activity)	Illness; family and other problems	R + D	City Hall professionals; Community representatives; Unspecified PCTs
Represas-Carrera et al 23	Patients with DM aged 45-75 years old with ≥ 2 unhealthy habits	n = 694 (IG = 338; CG = 356)	n = 540 (IG = 263; CG = 277)	IG = 60; CG = 60	NA	IG = 37.9; CG = 37.6	NA	Passive attendant	Revocation of consent, personal reasons; not complete final evaluation and unknown cause	R + D + E	N; M
Rodríguez-Romero et al 44	Population ≥ 65 years old with perception of loneliness	n = 55 (IG = 29; CG = 26)	n = 55 (IG = 29; GC = 26)	IG = 80.2; CG = 79.8	IG = 80.2; CG = 79.8	IG = 87.3; CG = 76.9	IG = 87.3; CG = 76.9	Passive attendant	No loss	R + D + E	N; M; SW; Neighborhood community agents
Lapena et al 17	Population ≥ 60 years old living in low-income neighborhoods	n = 158 (IG = 87; CG = 71)	n = 135 (IG = 70; CG = 65)	NA	NA	NA	IG = 74.3; CG = 86.2)	Passive attendant	Death; hospital admission; change of address and having to take care	R + D + E	N; M; SW; Neighborhood or markets associations
López-Téllez et al 42	Patients > 65 years old with social risk	n = 102 (IG = 51; CG = 51)	n = 80 (IG = 46; CG = 34)	NA	IG = 72; CG = 71)	NA	GI = 91.3; CG = 91.2)	Passive attendant	Illness and lack of motivation	R + D + E	N; M; SW; Physical education teacher
Mosteiro-Miguéns et al 28	Patients > 65 years old	n = 20	n = 13	NA	74.4	NA	76.9	Passive attendant	NA	R + D + E	N; Administrative staff
Yous et al 30	Older adults with diabetes and multiple chronic conditions	n = 45	NA	71.1	NA	55.6	NA	Passive attendant and collaboration (they advised the research team)	No loss	R + D + E	N; Community agents; Nutrition

Abbreviations: BMI, body mass index; BP, blood pressure; CG, control group; D, development; E, evaluation; HbA1c, glycated hemoglobin; IG, intervention group; M, medicine; MEC, “Mini-Examen Cognoscitive”; N, nursing; NA, not available; PCT, primary care team; R, recruitment; RF, risk factor; SPr, social prescription; SW, social work.

Characteristics of Community Activities

The issues most frequently addressed by CA were healthy lifestyles and health promotion,^26,29,33 engagement in physical activity,^{22,24,28,38,39} cardiovascular diseases or their risk factors,^16,19,25 diabetes,^23,30,38,40 and childhood obesity.^27,32

In terms of the type of intervention carried out, only 2 CA exclusively based on SPr were identified.^24,25 Another 2 studies—both of which stemmed from the EIRA Project—included some SPr-type activity that complemented the implementation of the CA.^23,33

Use of technologies was observed in 5 of the studies selected, with online training programmes^19,33,36 and specific mobile applications being used.^23,32

Only 8 studies formed part of a project within the framework of a community health promotion strategy: these were the “PAS a PAS” project, ¹⁶ EIRA Project,^23,33 “+Agil Barcelona,” ¹⁸ “PROGRAMA CONECTA ACTIUS PER A LA SALUT,” ³⁹ “Alianza health and wellbeing model for healthier communities” programme, ³¹ “Barcelona Health in the Neighborhoods” ¹⁷ and “Aging, Community and Health Research Unit-Community Partnership Program” (ACHRU-CPP). ³⁰

In all the studies, the process was evaluated by means of monitoring attendance and outcomes. Only 6 studies, however, analyzed the participants’ opinions about or satisfaction with the CA.^{17,19,20,31,33,36}

Effectiveness of Community Activities

The CA were effective in 22 of the 30 studies selected, with 7 having a positive effect on healthy lifestyles,^{16,24,25,32 -34,41} 3 on physical condition,^18,28,38 4 on self-care behavior,^21,30,31,35 1 on the doctor-patient relationship, ³⁶ 4 on cognitive performance or mental health,^17,37,40,43 5 on quality of life,^{17,22,39,42,44} and 3 in terms of improvement in knowledge about the topic addressed.^19,26,45

PCT Participation Level

The PCT took part both in the capture of participants, and in the implementation and evaluation of CA in 17 of the studies selected.^{17,19,20,22,23,26,28,29,30,33,35,37,38,41,42,44,45}

Professionals Involved

Medical, nursing^{16,17,19,20 -22,25 -30,32,35,38,40,42,44} and social services^{20,21,22,29,38,44} professionals participated in most of the CA. In addition, other profiles as varied as physical activity professionals,^{16,22,35,38,42} teachers, ³⁴ and neighborhood and town council community agents also took part.^17,30,39,44 The figure of the “expert patient” was likewise used: this consists of a patient, who suffers from the health problem addressed in the CA, contributing his/her views and experience to those of the rest of the participants. ¹⁹

Target Population and Type of Participation of Participants

The studies were undertaken in Spain (20), Canada (5), USA (2), Cuba (1), Hong Kong (1) and Sweden (1). The target population at which the CA were aimed was diverse, and depended in turn on the CA’s proposed topic and goal (Table 1).

The reasons for withdrawal most widely cited by participants were lack of interest or refusal to participate,^{16,18,21,36,38,42,43} health or personal problems^{16,17,18,22,23,38,39,42,43} and timetable clashes.^26,27 No withdrawal was recorded in 5 studies.^{30,33,37,41,44}

In terms of type of participation, 26 studies described a passive type of participation, and only in 4 studies did the participants play an active participatory role, that is, self-management as members of work groups within the context of a community-based participatory research (CBPR) approach, ³² self-management in walking activities, ³⁹ advising the research team ³⁰ or through the medium of the expert patient. ¹⁹

Discussion

To our knowledge, this is the first review to analyse the impact of CA undertaken in primary care, without restrictions in terms of target population, topic, or type of participation. Our results show that CA can improve participants’ physical and psychological environment, as well as their level of knowledge about the topics addressed. The most frequent CA in PC settings are linked to healthy habits, physical activity, cardiovascular diseases and diabetes, in which only the passive participation of participants is required.

To activate health promotion, the Ottawa Charter proposes the following 5 key strategies: build healthy public policy; create supportive environments; develop personal skills; reorient health services; and strengthen community actions. ⁴⁶ Current evidence shows that the use of community assets improves quality of life and recognizes the need for these assets to be integrated into standard healthcare practice.^47,48 Institutional implementation of CA in a PC environment boosts the use of health assets, contributes to the population’s empowerment for self-care purposes, and constitutes the community health-promotion approach demanded by health authorities. ⁴⁹

The concept of CA has gradually evolved over time. Although stress was initially laid on health promotion targeted at the community, ⁵⁰ currently the emphasis is on group action, of a non-specific nature, which adopts an approach aimed at boosting the health and wellbeing of the population.^{9,51 -54} According to previous studies, CA with active participation in which the community is involved, are those that have a greater health impact. ⁵³ Even so, the most frequent CA are characterized by passive participation. ⁷ Hence, the inclusion of these types of activities allows us to obtain a real picture of the CA implemented in PC. For this reason, this review did not apply restrictions to the type of participation of the target population.

This study selected CA in which the role of PC was not exclusively limited to the selection of participants and where the PCT itself was required to be actively involved in the implementation and/or evaluation of the process. We feel that this criterion is necessary to reflect the PCT’s potential as a promoter of healthy behaviors in the community.

Moreover, this review looks into a currently pivotal type of CA, namely, SPr^55,56: “This salutogenic process focuses on promoting well-being by referral to a range of non-medical approaches, from exercise on prescription, to arts-based activities and beyond.” ⁵⁷ In it, the PCT identifies participants’ non-medical needs and assesses their suitability for the activity. ⁵⁸ Despite incurring possible selection bias that might undermine the evaluative quality of these activities, ⁵⁹ pre-selection of the target population could enhance the effectiveness of these types of interventions as compared to the rest of CA. ⁶⁰

Undertaking these types of interventions requires the application of a uniform method, yet the studies analyzed show the existence of heterogeneity when it comes to their implementation. This agrees with related studies that display a lack of standardization and methodological deficits in the design and selection of the target population.^{9,53,61 -64}

Lack of evaluation of CA poses an obstacle to conducting such interventions and rendering them more visible. ⁶⁵ Our study selected health-centered CA which could have been evaluated, with the aim of analyzing these interventions by reference to the coherence and the utility of the findings reported. ⁶⁶ Evaluating participants’ degree of satisfaction and opinions is useful for ascertaining points pending improvement, a phase that is indispensable when it comes to facilitating standardization and maximizing the effectiveness of such interventions. ⁶⁷

Most of the CA conducted at health centers do not form part of any community health project. This shows that their implementation could be due to the public spiritedness of the professionals themselves. ⁵² Furthermore, the absence of timetables with exclusive PCT dedication to the community approach, plus the healthcare overload and the lack of specific training for professionals hinder the standardization of these types of interventions.^{68 -70} Strategic community health-promotion projects lay the foundation for institutionalized implementation of CA.^71,72

The reasons for withdrawal described by participants are varied, ⁷³ as confirmed by our review. Adherence of the target population may be determined by the type of professional who leads the CA ⁷⁴ and by the existence of professional health system-PC liaison staff. ⁷⁵

The use of new technologies is observed in CA undertaken from 2014 onwards. As technological development of health applications progresses and the CA target population becomes more familiar with their use, these resources could be extended and converted into essential tools by virtue of their dynamism and versatility. Along these same lines, there is evidence of the effectiveness of new technologies ⁷⁶ in smoking cessation programs. ⁷⁷

This review has the following limitations. Firstly, the majority of the studies selected were conducted in Spain. This may suggest that a health system such as Spain’s, operating on 2 healthcare levels (primary and specialized care), favors the undertaking of CA targeted at the promotion of healthy behaviors. ⁷⁸ Secondly, given that the majority of CA are not evaluated, this review could be influenced by publication bias, inasmuch as there may be CA that are not identifiable by biomedical search engines.

Conclusion

CA undertaken in a PC environment are an effective instrument for enhancing the collective health of the community. Even so, institutional implementation of CA is limited. The studies reviewed report the effectiveness of CA for fostering the development of healthy lifestyles, improving self-care in chronic/long-lasting diseases, quality of life, and level of knowledge of the topic addressed. There is a predominance of CA with passive participation, and the most frequent issues are healthy habits, physical activity, cardiovascular diseases and diabetes. Lack of standardization of CA may limit the impact on participants’ health.

The evaluation of the impact of CA is essential to improve its implementation and to generate the necessary evidence to facilitate the standardization of its development. A CA resource person at the health center, who would act as liaison between the health system and the community, would serve to increase the spread of CA and the involvement of community agents, foster the adherence and active participation of the target population and the evaluation of these interventions. Furthermore, the setting-up of a specific electronic register on PC-based CA would furnish up-to-date information when it comes to planning standardized implementation of these types of interventions. There is a need for community health strategies, with institutional backing, that would provide the PCT with support for unifying action criteria, carry out rigorous evaluations and boosting the health impact of CA in PC settings.