Table 1.
Characteristics of included reviews
| First author, year (reference) Title Review type |
Aims and objectives | Inclusion and exclusion criteria | • Number and type of included studies • Description of study screening and abstraction process • Description of study selection or flow diagram? |
• Synthesis method • Quality assessment? Any rating or commentary? • Theory used/considered? • Perspective(s) |
Barriers/facilitators/both |
|---|---|---|---|---|---|
| Guideline implementation and evidence-based practice | |||||
| Novins DK 2013 [15] Dissemination and implementation of evidence-based practices (EBPs) for child and adolescent mental health: a systematic review Systematic review |
To identify key findings from empirical studies examining the dissemination and implementation of EBPs for child and adolescent mental health | Inclusion criteria Included were English language empirical journal articles that examined the dissemination and implementation of EBPs in child and adolescent mental health between 1991 and December 2011 |
• 60 (quantitative and qualitative) • Yes • Yes |
• Framework analysis • Yes • Yes (analysis) EPIS model/framework and CFIR • Unclear |
Facilitators only |
| Zwolsman S 2012 [66] Barriers to GP’s use of evidence-based medicine: a systematic review Systematic review |
To determine the barriers encountered by GPs in the practice of evidence-based medicine and to come up with solutions to the barriers identified | Inclusion criteria Studies about barriers in the practice of evidence-based medicine (EBM); studies with GP as subjects; reported outcomes, barriers to the practice of evidence-based medicine/more than one of the EBM steps. Exclusion criteria Studies that had primary care physicians as subjects and in which the outcomes of GPs were not presented separately. Studies describing the application or use of specific guidelines |
• 22 (9 qualitative, 12 quantitative and one mixed methods) • Yes • Yes |
• Analysis based on Model of evidence-based decision-making in GPs • Yes (criteria used by another similar review on EBM) • No • GPs |
Barriers only |
| Mickan S 2011 [3] Patterns of ‘leakage’ in the utilisation of clinical guidelines: a systematic review Systematic review |
To review evidence in different settings on the patterns of ‘leakage’ in the utilisation of clinical guidelines using Pathman’s awareness-to-adherence model. To summarise any identified barriers to guideline implementation |
Inclusion criteria Studies that look at the utilisation of one or more clinical practice guideline recommendation(s), that measure awareness and agreement and either adoption or adherence (or both); Design: any primary survey or cross-sectional study; Response rate: not specified as we wished to include internet surveys, and determining the denominator is not always possible; Outcome measures: both objective and self-reported Specialty or area: any area of health care Health care objective: any (e.g. diagnosis, prevention, screening) |
• 11 surveys (8 mailed surveys, 2 internet surveys, 1 was given to participants after a personal interview) • Clearly stated • Yes |
• Unclear • Yes (using a proforma quality criteria) • Yes (Pathman’s awareness-to-adherence model) • Physicians |
Facilitators and barriers |
| Ogundele M 2011 [52] Challenge of introducing evidence-based medicine into clinical practice: an example of local initiatives in paediatrics |
To review the available literature on how clinicians meet the daily challenge of translating medical information into clinical evidence-based medicine | Inclusion criteria Unclear Exclusion criteria None stated |
• Unclear • Unclear • Unclear |
• Narrative • No • No • Professionals |
Facilitators and barriers |
| Lineker SC 2010 [100] Educational interventions for implementation of arthritis clinical practice guidelines in primary care: effects on health professional behaviour Systematic review |
To evaluate the influence of educational programmes designed to implement clinical practice guideline for osteoarthritis and rheumatoid arthritis in primary care | Inclusion criteria English articles published between 1994 and 2009 and were related to implementation of arthritis CPG in primary care; prospective evaluation studies that targeted primary care providers working with adults with rheumatoid arthritis or osteoarthritis and if they reported behavioural outcomes that ensured actual knowledge utilisation in primary care Exclusion criteria None stated |
• 7 (6 randomised controlled trials (RCTs) and 1 before and after study) • Unclear • No |
• Narrative • Yes (Modified Philadelphia Panel grading system) • No • GPs |
Barriers only (not stated as an objective; data found in results and discussion) |
| Kendall E 2009 [68] When guidelines need guidance considerations and strategies for improving the adoption of chronic disease evidence by general practitioners Literature review |
To investigate barriers to guideline uptake and dissemination practices and options for improving the process of embedding evidence into practice | Inclusion criteria Peer-reviewed journals between January and April 2008 Studies that explored the barriers and issues associated with the use of guidelines in general practice Exclusion criteria Unclear |
• Unclear • Not stated • Not given |
• Unclear • No • Yes (discussion) Uptake model • GPs |
Facilitators and barriers |
| Langberg JM 2009 [59] Interventions to promote the evidence-based care of children with attention deficit-hyperactivity disorder (ADHD) in primary-care settings Review |
To review the efficacy of intervention models that designed to improve physician use of the evidence-based recommendation for evaluating and treating children with ADHD | Inclusion criteria Interventions that specifically target the improvement of evidence-based ADHD-related physician practice behaviours, and not mental health care in general and only intervention that published quantitative outcomes were included Exclusion criteria School and community based approaches for improving the identification and management of children with ADHD that have been proposed but not evaluated formally |
• 9 (2 observational, 1 RCT, 1 cluster RCT, 5 interrupted time series) • Not stated • Not given |
• Unclear • No (quality not discussed) • No • Physicians |
Facilitators and barriers (not stated as an objective) |
| Dulko D 2007 [35] Audit and feedback as a clinical practice guideline implementation strategy: a model for acute care nurse practitioners Systematic review |
To evaluate the effectiveness of audit and feedback as a guideline implementation strategy | Inclusion criteria Articles published in English between 2001 and 2005; focused on physical symptoms related to cancer or cancer treatment Exclusion criteria None stated |
• 16 (unclear) • Not stated • Not given |
• No • No • Yes (discussion) Change theory • Nurse practitioners |
Facilitators and barriers |
| McKenna H 2004 [38] Barriers to evidence-based practice in primary care: a review of the literature Narrative review |
To examine evidence-based practice in primary and review the barriers encountered by professionals when attempting to introduce evidence into practice | Inclusion criteria Articles related to terms such as primary care, barriers to research utilisation and evidence-based practice and those that focus on policy and research papers, the role of patients and client in the planning and delivery of primary care Exclusion criteria None stated |
• Unclear • Not stated • Not given |
• Narrative • No • Yes (discussion) Kitson’s conceptual framework enabling implementation of evidence-based practice • Health professionals |
Facilitators and barriers |
| Parsons J 2003 [75] Evidence-based practice in rural and remote clinical practice: where is the evidence? Systematic review |
To review the evidence regarding barriers to implementing research findings in rural and remote settings | Inclusion criteria Articles that included information on the barriers to the implementation of evidence faced in rural and remote areas; interventions for implementing evidence-based practice or an element of evidence-based practice in rural and remote areas Exclusion criteria – |
• 2 (survey) • Not stated • Not given |
• Narrative • Quality of the included studies and their applicability were discussed • No • Health professionals |
Barriers only |
| Cabana MD 1999 [39] Why don’t physicians follow clinical practice guidelines? A framework for improvement Systematic review |
To review barriers to physician adherence to clinical practice guidelines To examine candidate titles of papers describing theories of physician behaviour change to find constructs useful in describing barriers |
Inclusion criteria Articles that focused on clinical practice guidelines, practice, parameters, clinical policies, national recommendations or consensus statements, and that examined at least 1 barrier to adherence. Only barriers that could be changed by an intervention were included. Exclusion criteria None |
• 76 (surveys and qualitative studies) • Yes • Yes |
• Theory based analysis • No (quality was discussed) • Yes (analysis) The knowledge, attitudes, behaviour framework • Physicians |
Barriers only |
| Wensing M 1998 [83] Implementing guidelines and innovations in general practice: which interventions are effective? Systematic review |
To evaluate the effectiveness of interventions in influencing the implementation of guidelines and adoption of innovations in general practice | Inclusion criteria Studies were included if one or more interventions were used to improve professional behaviour in general practice and if the effect on actual behaviour was measured RCTs, controlled trials, controlled before and after studies Exclusion criteria Non-randomised controlled trials that did not perform pre-intervention measurement in intervention or control group |
• 61 “best evidence” studies (143 studies identified) (quantitative) • Yes • Yes |
• Narrative • Yes (no checklist was used—selection of “best evidence” studies were made) • No • Unclear |
Barriers only (in discussion; quality not relevant) |
| Davis AD 1997 [89] Translating guidelines into practice. A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines (CPG) Systematic review |
To explore the variables affecting physicians’ adoption of clinical practice guidelines and describe outcomes of trials of educational interventions to change physicians’ behaviour or health care outcomes | Inclusion criteria Studies of CPG implementation strategies and reviews of such studies were selected |
• Unclear • No • No |
• Descriptive/narrative • No • No • Professionals |
Facilitators and barriers |
| Grilli R 1994 [88] Evaluating the message: the relationship between compliance rate and the subject of a practice guideline Literature review |
To explore the relationship between providers’ compliance and some key aspects of the clinical messages in practice guidelines | Inclusion criteria Papers had to present compliance rates with practice guidelines developed by official organisations and had to target providers as the audience |
• 23 • No • No |
• Narrative • No • Yes (diffusion of innovation mentioned in the introduction) • Physicians |
Barriers only |
| Management of care | |||||
| Lovell A 2014 [101] Advanced care planning (ACP) in palliative care: a systematic literature review of the contextual factors influencing its uptake 2008–2012 Systematic review |
To identify the contextual factors influencing the uptake of Advanced care planning in palliative care | Inclusion criteria Only primary research reporting on ACP within palliative care was included. Studies on the views of organisations involved in aged and end of life care were also included Exclusion criteria Studies that evaluated a novel intervention, tool or model of ACP were excluded |
• 27 (half or 13 included studies used qualitative methodology; 3× mixed methods; 11× quantitative methods) (10 studies conducted in USA, UK 8, Australia 4, Belgium 2, Netherlands 1, China and Taiwan 2) • Yes • Yes |
• Thematic synthesis • Yes (NICE quality appraisal checklist) Quality of the studies varied. Few based their work on explicit theoretical frameworks PRISMA checklist was used to conduct this review • No • Primary care health care professionals |
Facilitators and barriers |
| Holm AL 2012 [71] Chronic care model (CCM) for the management of depression: synthesis of barriers to and facilitators of success Systematic review |
To identify barriers to, and facilitators of success when implementing the CCM for the management of depression in primary care | Inclusion criteria Published in English, implementation or use of the CCM, and primary care and depression as one of the chronic illnesses covered Exclusion criteria Not using CCM, chronic illnesses not including depression, and reviews (also studies published in books and dissertations) |
• 13 (quantitative and qualitative) • Unclear • Yes |
• Thematic analysis • Yes (adapted a framework from both quantitative and qualitative research traditions; quantitative: sample size, reliability, validity, and transferability. Qualitative: trustworthiness, credibility, confirmability, dependability and transferrability • No • Professionals and administrative staff |
Facilitators and barriers |
| Sales AE 2012 [102] The use of data for process and quality improvement in long-term care and home care: a systematic review of the literature Systematic review |
To determine how the resident assessment instrument minimum data set (RAI) have been used in process or quality improvement activities in the continuing care sector | Inclusion criteria Discussed continuing care in a long-term care and health care setting; involved some form of intervention relating to quality or process improvement, and used RAI data in the quality or process improvement intervention. |
• 24 (quantitative) • Yes • Yes |
• Descriptive/narrative • No • No • Unclear |
Barriers only (in discussion; quality not relevant) |
| Zhang J 2012 [103] System barriers associated with diabetes management in primary care Systematic review |
To explore system barriers to diabetes management in primary care and solutions that overcome the system barriers and the role of nurse practitioners in addressing these system barriers | Inclusion criteria English only articles and articles specifically focused on system barriers for diabetes management in primary care settings were included Exclusion criteria None stated |
• 31 (both systematic reviews and primary studies) • Not stated • Not given |
• Unclear • Not stated • No • Unclear |
Facilitators and (largely) barriers |
| Hoare K 2012 [53] The role of government policy in supporting nurse-led care in general practice in the UK, New Zealand and Australia: an adapted realist review Systematic review and realist review |
Realist review to examine the theory that clinical governance was the main driver to stimulate practice nurse development To examine the role of government policy in primary care and its association with nurse-led care in the UK, New Zealand and Australia between 1998 and 2009 |
Inclusion criteria Systematic review—the study had to report primary research involving practice nurses or demographical statistics of nurse-led clinics in general practice |
• 45 (mixed study types including policy documents) • Yes • Yes |
• Realist synthesis • Realist synthesis—the reviewer reads the paper to search for evidence that may support the initial theory and so contribute to fuller development of an explanatory model. No quality assessment tools were suitable for the systematic review • No • Unclear |
Facilitators and barriers |
| Nam S 2011 [78] Barriers to diabetes management: patient and provider factors Systematic review |
To summarise existing knowledge regarding various barriers of diabetes management from the perspectives of both patients and clinicians | Inclusion criteria Cross-sectional studies, RCTs, observational studies and qualitative studies. Studies had to be relevant to type 2 diabetes or patient and health care providers’ barriers to diabetes management Exclusion criteria Review articles and epidemiological studies were largely excluded, unless they were directly relevant to the themes that were part of this review |
• 80 • Not stated • Not given |
• Narrative synthesis • No • No • Clinicians |
Barriers |
| Addington D 2010 [16] Facilitators and barriers to implementing quality measurement in primary mental health care Systematic review |
To identify facilitators and barriers to implementing quality measurement in primary mental health care | Inclusion criteria The study need to focus on primary care and refer to a quality improvement tool, or the process of implementing quality measurement, quality indicator, or quality improvement Exclusion criteria None |
• 57 (qualitative case studies, interviews, RCTs, focus groups, cross-sectional qualitative/quantitative surveys, quasi-experimental studies, prospective cohorts, cluster analyses, controlled before and after trials, audits) • Yes • Yes |
• Content analysis; descriptive • No • No • GPs, nurses and administrative staff |
Facilitators and barriers |
| Koch T 2010 [79] Rapid appraisal of barriers to the diagnosis and management of patients with dementia in primary care: a systematic review Systematic review |
To systematically investigate current evidence about the barriers to dementia diagnosis in primary care | Inclusion criteria Studies related to barriers to the recognition of dementia. Exclusion criteria Studies about pharmacological interventions (for dementia or Alzheimer’s disease), studies related to the validity or usefulness of specific cognitive function tests, studies not related to primary care setting, clinical discussion about dementia diagnoses or care, letters, publications in languages other than English |
• 11 (6 qualitative, 3 quantitative, 2 mixed methods) • Yes • Yes |
• Thematic analysis • No • No • Primary care physicians |
Facilitators and barriers |
| Zwar N 2006 [104] A systematic review of chronic disease management Systematic review |
To investigate the facilitators and barriers to effective interventions for chronic disease in primary health care (one of the three research questions) | Inclusion criteria Systematic reviews, RCTs, controlled clinical trials, controlled before-and-after studies and interrupted time series studies involving adults aged 18 years and over with one or more of the following chronic conditions: hypertension, coronary heart disease, type 2 diabetes, lipid disorders, asthma, chronic obstructive pulmonary disease, arthritis and osteoporosis Exclusion criteria Studies published before 1990, in a language other than English or pertaining only to a change in patient knowledge |
• 141 studies and 23 systematic reviews • Yes • Yes |
• Narrative • Yes (Joanna Brigg’s institute and EPOC criteria) • Yes • Unclear |
Facilitators and barriers |
| Johnston G 2000 [67] Reviewing audit: barriers and facilitating factors for effective clinical audit Literature review |
To assess the main facilitators and barriers to conducting the audit process | Inclusion criteria Papers which addressed empirical evidence from studies of clinicians’ views, and also theoretical discussions were included in this study. Exclusion criteria – |
• 93 (qualitative only) • Yes • Yes (flow chart not given) |
• Thematic analysis • No • No • Professionals and managers |
Facilitators and barriers |
| Renders CM 2001 [87] Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings (Cochrane review) Systematic review |
To examine the effectiveness of different interventions, targeted at health professionals or the structure in which they deliver care To determine which intervention strategy or parts of intervention strategies are the most effective and what do they have in common |
Inclusion criteria Population—health care professionals (including physicians, nurses, pharmacists) taking care of non-hospitalised patients with type I or II diabetes in primary care, outpatients and community settings Type of interventions—organisational, professional and financial interventions; patient oriented interventions that included alongside professional and organisational interventions (all compared to usual care) Exclusion criteria Solely patient oriented interventions including patient education, mail order pharmacies, consumer participation in health care organisation |
• 41 (RCTs, controlled before and after studies, interrupted time series) Outcomes: Health professional performance, e.g. blood markers, making a follow-up, referral, exam of the feet Patient outcomes, e.g. cardiovascular risk factors, hospital admissions, mortality, no. of complications Self-report subjective measures, e.g. patient/provider satisfaction, quality of life) • Yes • Yes |
• Narrative • Yes (EPOC checklist/quality criteria) • No • Unclear (barriers not main objective) |
Barriers only |
| E-health technology | |||||
| Gagnon MP 2014 [14] Barriers and facilitators to implementing electronic prescribing: a systematic review of user groups’ perceptions Systematic review |
To identify user groups’ perceptions of barriers and facilitators to implementing electronic prescription (e-prescribing) in primary care | Inclusion criteria Studies with an empirical design, either qualitative, quantitative, or mixed methods. Studies should present a clearly stated data collection process as well as research methods and measurement tools used. Studies focused on the users’ (physicians, clinical staff, nurses, pharmacists, pharmacy staff and others such as patients IT staff and managers) experience of e-prescribing implementation Primary care, including ambulatory or community health care settings. Studies had to provide data on barriers and facilitators to e-prescribing implementation in their results or discussion sections to be included Exclusion criteria Editorials, comments, position papers, unstructured observations |
• 34 publications (28 individual studies) Surveys (42.9 %; n = 12) and qualitative methods (39.9 %; n = 11); mixed methods (17.9 %; n = 5) >1/3 of the studies (35.7 %) included a theoretical framework 12 studies (42.9 %) exclusively involved physicians, 2 studies targeted exclusively pharmacists, 6 studies included physicians and their staff, 3 studies involved pharmacists and their staff, 5 studies include more than one of these groups • Yes • Yes |
• Use of logical model of health care quality proposed by Donabedian, coupled to the themes proposed by Barber et al.) • Yes. Mixed methods appraisal tool (MMAT) • Yes. Data extraction developed used both inductive and deductive methods, following theoretical concepts like the technology acceptance model and the diffusion of innovations theory • Professionals and staff |
Facilitators and barriers |
| Hage 2013 [94] Implementation factors and their effect on e-health service adoption in rural communities: a systematic literature review Systematic review |
To contribute our understanding of the implementation factors that determine successful e-health adoption in rural communities | Inclusion criteria Papers focused on rural context, implementation, e-health content, adoption outcomes Empirical studies addressing implementation published in peer-reviewed journals. Papers were written in English |
• 51 (26 quantitative approach, 14 qualitative, 11 mixed approach) • Yes • Yes |
• See below • Yes (two checklists used) • Use of a theoretical framework for analysis (context, process, content, adoption outcomes) • Unclear |
Facilitators and barriers |
| Lau F 2012 [58] Impact of electronic medical record on physician practice in office settings: a systematic review Systematic review |
To examine the impact of electronic medical records (EMR) in the physician office, factors that influenced their success and the lessons learned | Inclusion criteria Studies that were published in English, evaluated use of an EMR in an office-based setting, were based on original data, had physicians as primary end users, focused on clinical functions, reported impact on practice performance, patient outcomes, or physician-patient interactions Exclusion criteria Studies were excluded if their EMRs were part of the hospital information systems or were hospital ambulatory clinic settings or if there were only survey studies |
• 43 (27 controlled and 16 descriptive studies) • Yes • Yes |
• Use of the Clinical Adoption Framework as a conceptual scheme • No • Yes • Physicians |
Factors |
| Gagnon MP 2012 [31] Systematic review of factors influencing the adoption of information and communication technologies (ICT) by health care professionals Systematic review |
To review factors that are positively or negatively associated with ICT adoption by health care professionals in clinical settings | Inclusion criteria Qualitative, quantitative, or mixed method methodology used to collect original data was described; the intervention for promoting the adoption or the use of a specific ICT in health care settings was described; the outcomes measured included barriers and/or facilitators to the adoption of a specific ICT application by health care professional, including professionals in training. Studies reported in French, English or Spanish |
• 101 (quantitative and qualitative) • Yes • Yes |
• Narrative synthesis using inductive and deductive methods • Yes (Pluye mixed methods review scoring checklist) • Yes • Professionals (physicians and nurses) |
Facilitators and barriers |
| Pereira JA 2012 [72] Barriers to the use of reminder/recall (RR) interventions for immunizations: a systematic review Systematic review |
To identify providers’ perceived barriers to use of reminder/recall measures to address patient under-immunisation and improve coverage | Inclusion criteria Studies that examined the perceptions of health care providers regarding barriers towards implementing either provider-directed RR or patient-directed RR interventions for childhood and/or adult immunisations Surveys, focus groups or interviews. English; contained original data, and described studies using quantitative and/or qualitative methodologies Exclusion criteria Reviews, editorials, commentaries, and practice guidelines, conference abstracts |
• 10 (perceptions of family physicians, nurse practitioners, paediatricians, and other immunisation staff) (5 surveys, 1 interview, 2 focus groups, 2 mixed methods) • Yes • Yes |
• Thematic analysis • Yes (CASP) all studies were moderate-high quality • No • Professionals and staff (family physicians, nurses, administrators) |
Barriers only |
| Saliba V 2012 [105] Telemedicine across borders: a systematic review of factors that hinder or support implementation Systematic review |
To systematically identify factors that hinder or support implementation of cross-border telemedicine services worldwide in the last two decades | Inclusion criteria Studies which described the use of telemedicine to deliver cross-border health care and described the factors that hinder or support implementation of cross-border telemedicine services All study designs |
• 94 (quantitative and qualitative) • Yes • Yes |
• Narrative synthesis (using adapted framework developed by a project for the economic and social research council methods programme) • Yes • Yes • Unclear |
Facilitators and barriers |
| Fontaine P 2010 [51] Systematic review of health information exchange (HIE) in primary care practices Systematic review |
A systematic review of literature related to the adoption of HIE by ambulatory and primary care practices, with an emphasis on benefits, barriers and the overall value to the practice | Inclusion criteria The content dealt with electronic HIE in the US; the HIE involved at least one stakeholder in an ambulatory office or primary care practice, or described benefits, barriers or concerns relevant to ambulatory practices |
• 64 (quantitative and qualitative) • Yes • Yes |
• Themes emerged from the publications • No • No • Primary care professionals |
Facilitators and barriers |
| Ludwick DA 2009 [77] Adopting electronic medical records in primary care: Lessons learned from health information systems implementation experience in seven countries Systematic review |
To identify the current state of knowledge about health information systems (HIS) adoption in primary care To understand factors and influencers affecting implementation outcomes from previous HIS implementations experiences |
Inclusion criteria Peer-reviewed and grey literature published during the period 2000 to the end of 2007 from Canada, the USA, Denmark, Sweden, Australia, New Zealand and the UK; articles about implementation of health informatics systems Exclusion criteria None stated |
• 86 (study types unknown) • Yes • Yes |
• Narrative • No • Yes (socio-technical perspective) • Users including physicians |
Facilitators and barriers |
| Mollon B 2009 [74] Features predicting the success of computerised decision support system (CDSS) for prescribing: a systematic review of randomised controlled trials Systematic review |
To determine which features of system design or implementation were associated with the success or failure of prescribing (Rx) CDSS implementation, change in provider behaviour, and change in patient outcomes | Inclusion criteria Reports of RCTs of prescribing CDSS published in English. They only considered systems which intervened before a drug therapy had been chosen by a physician or had the ability to suggest alternate therapies to be a RxCDSS Outcomes: implementation, change in provider behaviour, and change in patient outcomes Exclusion criteria Systems whose sole purpose was to offer ‘fine tuning’ advice on a pre-defined therapy, usually dose modification were not included. Systems primarily focused on diagnosis, vaccination, or nutrition were also excluded |
• 41 (quantitative) • Yes • Yes |
• Narrative • Yes (modified scale adapted from Garg et al.) • No • Unclear |
Facilitators only |
| Waller R 2009 [106] Barriers to the uptake of computerised cognitive behavioural therapy (cCBT): a systematic review of the quantitative and qualitative evidence Systematic review |
To systematically examine the barriers to the uptake of cCBT from a wider range of source types that previous reviews, including the NICE guidelines | Inclusion criteria Studies of a variety of research designs and from both primary and secondary care settings on cCBT, defined as interventions where the computer took a lead in decision-making and was more than a medium. Data on acceptability, accessibility and adverse consequences were extracted Exclusion criteria – |
• 36 (quantitative and qualitative studies) • Yes • Yes |
• Narrative • Yes (EPOC, criteria of Mays and Pope, criteria of Crombie) • No • Professionals and staff |
Barriers only |
| Adaji A 2008 [17] The use of information technology (IT) to enhance diabetes management in primary care: a literature review Literature review |
To review the impact of IT on diabetes management in primary care and to identify the barriers and facilitators to using IT in this role | Inclusion criteria Only original studies which evaluated the use of IT interventions (web based programmes, electronic medical records, messaging systems) for diabetes management in medical practice published after 1996 in English were reviewed. RCTs or observational (non RCTs, pre-post studies, post-intervention studies) or qualitative methods Exclusion criteria Studies evaluating the use of IT for other chronic diseases, reviews papers which described other studies and commentary; studies evaluating the use of telemedicine (videoconferencing and telephone based consultations between patients and physicians) |
• 29 (quantitative and qualitative) • Yes • Yes |
• Unclear (narrative) • No • No • Professionals and staff |
Facilitators and barriers |
| Fitzpatrick LAD 2008 [40] Understanding communication capacity—communication patterns and ICT usage in clinical settings Literature review |
To review the literature on inter-clinician communication problems, impacts on clinical workflows, ICT usage and barriers to communication and information systems | Inclusion criteria Studies that discussed inter-clinician communication, patterns of ICT use, the effects of ICT use on workflow and/or the barriers to adopting ICTs in traditional health care settings Exclusion criteria Studies that focused on clinician-patient communication |
• 98 (qualitative and quantitative studies) • Yes (no descriptions of screening process) • Yes |
• Narrative • No • No • Unclear |
Barriers only |
| Jarvis-Selinger S 2008 [56] Clinical telehealth across the disciplines: lessons learned Literature review |
Key lessons learned related to programme (technology) adoption and organisational readiness | Inclusion criteria None stated |
• 225 (quantitative and qualitative) • Not clearly described • Not given |
• Unclear • No • No • Unclear |
Facilitators and barriers |
| Jimison H 2008 [90] Barriers and drivers of health information technology use for the elderly, chronically ill, and underserved Systematic review |
To review the evidence on the barriers and drivers to the use of interactive consumer health information technology (IT) by specific populations, namely the elderly, those with chronic conditions or disabilities, and the underserved | Inclusion criteria Studies of all designs that described the direct use of interactive consumer health IT (a consumer interacts directly with the technology, the computer processes the information in some way, a consumer receives or has access to patient-specific information in return) by at least one of the populations of interest Outcomes: technology use, health related behaviours, health service utilisation, disease status, quality of life and functional outcomes |
• 52 on barriers; 60 on facilitators (qualitative and quantitative) • Yes • Yes |
• Analysis based on frameworks as recommended by Popay et al. • Yes (quality rating criteria developed by the US Preventive Services Task Force and the Common Drug Review Process) • No • Not specified |
Facilitators and barriers |
| Orwat C 2008 [84] Towards pervasive computing in health care—a literature review Literature review |
To provide an overview of recent developments and implementations of pervasive computing systems in health care | Inclusion criteria Prototypes, tests, pilot studies and case studies conducted in health care settings, or systems involving prospective end users, clinical trials as well as systems already in routine use Exclusion criteria Experiments in non-medical settings as well as mere descriptions of concepts, designs or architectures |
• 69 (unclear study types) • Yes • Yes |
• Narrative (approach of Cruz-Correia et al. was partly adopted) • No • No • Not specified |
Facilitators and barriers |
| Broens TH 2007 [34] Determinants of a successful telemedicine implementations: a literature study Literature review |
To identify the determinants that influence the implementation of telemedicine applications | Inclusion criteria Limited to studies published after the telemed 2004 conference held in London, which they consider to be representative of telemedicine initiatives in Europe Exclusion criteria – |
• Unclear • Yes • Not described |
• Analysis based on the knowledge barriers categorisation of Tanriverdi and Iacono. • No • Yes (see above) • Not specified |
Facilitators and barriers |
| Yarbrough A 2007 [43] Technology acceptance among physicians: a new take on TAM Systematic review |
To look at the literature on physician acceptance of information technology | Inclusion criteria English and peer-reviewed publications only Exclusion criteria Not directly pertaining to physician IT, physician barriers to technology, the technology acceptance model Non-physician-specific technology acceptance articles, physician-specific articles, especially the users targeted were not physicians, articles attempting to create typologies of physician users. Case studies of organisations that were purely descriptive in nature and limited to less than two sites were excluded, as were review articles that only summarised findings |
• 18 (quantitative and qualitative) • Yes • Yes (flowchart not given) |
• Analysis based on the Technology acceptance model (TAM) • No • Yes • Professionals and staff |
Facilitators and barriers |
| Yusof M 2007 [44] Health information systems adoption: findings from a systematic review Systematic review |
To identify the most important factors of health information system adoption | Inclusion criteria Study design: case study Intervention: any computer based information systems that involves human interaction used in health care settings Exclusion criteria Study design: experimental and survey All computers or knowledge based training and education systems for professionals (not directly related to clinical care) |
• 55 (quantitative and qualitative studies, e.g. documentations, questionnaire, interview, observations) (participants include managers, clerical staff, doctors and nurses) • Unclearly described • Yes |
• Qualitative analysis using a theoretical framework (Human, Organisation and Technology-fit framework) • Yes (qualitative research appraisal criteria); majority—sound quality • Yes • Users including physicians and staff |
Facilitators and barriers |
| Ohinmaa A 2006 [64] What lessons can be learned from telemedicine programmes in other countries? Literature review |
To identify examples of successful telemedicine programmes | Inclusion criteria Articles that showed a scientific basis for successful telemedicine. The review focused on applications benefiting significant segments of the health care population, rather than those restricted to a targeted population or geographical area Exclusion criteria Programmes from developing countries that were seen to be difficult to implement in the US health care system; articles discussing non-medical applications |
• Unclear • Unclearly described • No |
• Unclear • Unclear • No • Unclear |
Facilitators and barriers |
| Leatt P 2006 [41] IT solutions for patient safety—best practices for successful implementation in health care Narrative review |
To review the literature on the facilitators and barriers to successful implementation of electronic medical records, electronic medication administration records and computerised provider order entry | Inclusion criteria Unclear |
• Unclear • No • Not described |
• Analysis based on framework by Klein et al. (managerial support, financial resource availability, implementation climate and implementation policies and practices) • No • Yes • Unclear |
Facilitators and barriers |
| Peleg M 2006 [37] Decision support, knowledge representation and management in medicine Narrative review |
To review the literature to find trends in CDSS that were developed over the last few decades and give some indication of future directions in developing successful, usable clinical decision support systems | Inclusion criteria Papers that were published during the past 5 years with the words Decision support systems appearing in the title and used our own knowledge of the field for earlier work |
• Unclear • No • Not described |
• Unclear • No • No • Unclear |
Facilitators only |
| Shekelle P 2006 [69] Costs and benefits of health information technology Evidence report |
To examine the barriers that health care providers and health care systems encounter that limit implementation of electronic health information systems | Inclusion criteria Qualitative studies that were primarily focused on barriers and studies that collected quantitative data on barriers were included Exclusion criteria Topic not about health information technology, outcomes not relevant. Studies in which barriers were briefly discussed but were not a primary focus were excluded |
• 20 (quantitative and qualitative studies) • Yes • Yes |
• Narrative • No • No • Professionals and staff |
Barriers only |
| Garg AX 2005 [65] Effects of computerised clinical decision support systems on practitioner performance and patient outcomes Systematic review |
To review controlled trials assessing the effects of computerised clinical decision support systems (CDSSs) and to identify study characteristics predicting benefit | Inclusion criteria Randomised and non-randomised controlled trials that evaluated the effect of a CDSS compared with care provided without a CDSS on practitioner performance or patient outcomes Exclusion criteria - |
• 100 trials • Yes • Yes |
• Narrative • No (not on studies of barriers/facilitators) • No • Unclear |
Facilitators and barriers |
| Kawamoto K 2005 [73] Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success Systematic review |
To identify features of clinical decision support systems critical for improving clinical practice | Inclusion criteria Studies had to evaluate the ability of decision support systems to improve clinical practice. RCTs Exclusion criteria Less than 7 units of randomisation per study arm; study not in English; mandatory compliance with decision support system; lack of description of decision support content or of clinician interaction with system; and score of <5 points on a 10-point scale assessing 5 potential sources of study bias |
• 70 (quantitative only) • Yes • Yes |
• Descriptive and meta-regression (and frequency) analysis to identify independent predictors of success • Yes • No • Unclear |
Facilitators and barriers |
| Lu YC 2005 [42] A review and a framework of handheld computer adoption in health care |
To review the literature on issues related to adoption of Personal digital assistants (PDA) in health care and barriers to PDA adoption | Inclusion criteria Articles addressing all health care professionals and their uses of PDAs and mobile computing devices were identified Exclusion criteria – |
• Unclear • Unclear • Not described |
• Analysis based on the technology acceptance model • No • Yes • Professionals and staff |
Facilitators and barriers |
| Johnson K 2001 [76] Barriers that impede the adoption of paediatric information technology Literature review |
To review the literature to better elucidate barrier that are likely to affect the adoption of IT by paediatric professionals | Not stated | • Unclear • No • No |
• Analysis based on framework (modified) • No • Yes (conceptual framework by Knapp: situational, cognitive, legal and attitudinal) • Physicians |
Barriers only |
| Preventative care and public health | |||||
| Zheng MY 2014 [107] Physician barriers to successful implementation of US preventive services task force routine HIV testing recommendations Literature review |
Focuses on physicians’ barriers to HIV testing | Inclusion criteria Literature related to HIV testing guidelines, physician adherence to HIV testing guidelines and physician barriers to HIV testing for adult primary care setting. Literature was also gathered from the HIV literature ListServ released by Dr Robert Malow, a well-known resource within the field of HIV/AIDS research Exclusion criteria Articles related to HIV testing exclusively in prenatal, paediatric, and/or emergency settings. Non-US based studies since physicians in other countries may face different and unique barriers |
• Not stated (quantitative and qualitative studies) • Unclear • Not described |
• See below • No (no discussion of quality of papers) • Analysed using Cabana’s model, knowledge, attitudes and behavioural skills • Physicians |
Barriers only |
| Child S 2012 [86] Factors influencing the implementation of fall prevention programmes: a systematic review and synthesis of qualitative studies Meta-ethnography |
To identify key factors that act as barriers and facilitators to the effective implementation of evidence-based best practice in relation to the prevention of falls among community-dwelling older people | Inclusion criteria Studies that examined influences on the implementation of fall prevention programmes among community-dwelling older adults and used recognised qualitative methods of data collection and analysis Exclusion criteria Editorials, opinion papers, conference abstracts |
• 19 qualitative studies (6 studies—perspective of health care professionals; 12 from the experiences of community- dwelling older adults; 1 study—perspectives from both patients and health care workers in a falls clinic) • Yes • Yes |
• Meta-ethnography • Yes (structured approach to describe quality by Wallace et al.) • Unclear • Health care professionals |
Facilitators and barriers |
| Eisner D 2011 [57] Screening and prevention in Swiss primary care: a systematic review Systematic review |
To identify barriers and facilitators for physicians to participate in any preventive measures | Inclusion criteria Articles that addressed screening and prevention activities in Swiss primary care. Studies which were conducted in settings in which a primary care provider played a key role were also included. Exclusion criteria No/implicit GP setting Main prevention aspects other than medical (e.g. economic) |
• 49 (45 descriptive studies; 4 RCTs) Areas covered: infectious disease, lifestyle changes, cardiovascular risk factors, cancer, HIV, osteoporosis, addiction and others • Yes • Yes |
• Narrative • Yes (CONSORT) (low quality in general) • No • GPs |
Facilitators and barriers |
| Johnson M 2011 [61] Barriers and facilitators to implementing screening and brief intervention for alcohol misuse: a systematic review of qualitative evidence Systematic review |
To synthesise qualitative evidence for barriers and facilitators to effective implementation of screening and brief intervention for alcohol misuse in adults and children over 10 years | Inclusion criteria Studies that addressed screening and/or brief intervention with alcohol users over the age of 10 years Exclusion criteria Studies that focused on educational interventions and school-based interventions due to their inclusion in recent UK guidance. Reports of interventions of >30 min in duration, or that were carried out by specialists |
• 47 qualitative studies • Yes • Yes |
• Narrative summary • Yes (source of quality checklist unknown) (very good or good quality largely) • No • Primary care teams (largely GPs and nurses) |
Facilitators and barriers |
| Taylor CA 2011 [60] Enhancing delivery of health behaviour change interventions in primary care: a meta-synthesis of views and experiences of primary care nurses Meta-synthesis |
To systematically find an synthesise qualitative studies that elicited the views and experiences of nurses involved in the delivery of HBC interventions in primary care, with a focus on how this can enhance delivery and adherence of structured HBC interventions | Inclusion criteria Studies using qualitative methods to elicit nurses’ views and experiences of delivering HBC interventions, aiming to facilitate adoption of physical activity and/or healthy eating by adult patients (age 16–65 years) within primary care. Studies were included if they utilised qualitative methods for the collection and analysis of data. This included qualitative studies as components of wider trials Exclusion criteria Not a qualitative study; intervention not delivered by nurses/does not state; not primary care |
• 9 qualitative studies • Yes • Yes |
• Meta-synthesis • Yes (CASP tool for qualitative research) (good quality in general) • No • Primary care nurses |
Facilitators and barriers |
| Vedel I 2011 [70] Barriers and facilitators to breast and colorectal cancer screening of older adults in primary care: a systematic review Systematic review |
To determine the barriers and facilitators to breast and colorectal cancer screening of older adults, from the perspectives of patients and primary care physicians | Inclusion criteria Studies that used a quantitative design that reported barriers and/or facilitators to CRC and breast cancer screening for older adults; the participants included physicians working in primary care and/or older adults in primary care Exclusion criteria Editorials, comments, letters, case reports, reviews, guidelines, consensus statements; studies of treatment approaches or case findings; studies assessing interventions or PCP’s actual screening performance or patient-physician communication without information on the decision-making process |
• 42 (quantitative and qualitative; questionnaires and 21 on PCP’s point of view) • Yes • Yes |
• Narrative • Yes (STROBE, MOOSE) • No • Primary care physicians |
Facilitators and barriers |
| Stead M 2009 [80] Factors influencing European GPs’ engagement in smoking cessation: a multi-country literature review Literature review |
To explore the extent of GPs’ engagement in smoking cessation and the factors that influence their engagement | Inclusion criteria Studies needed to report the extent to which GPs engage in smoking cessation activity or explore factors, of any sort, influencing this engagement Studies that correlated the relationship between a particular factor and their provision of smoking cessation advice. Studies that explored GP’s own perceptions of salient issues that constrained or facilitated their engagement. Qualitative and quantitative Exclusion criteria Discussion and papers that did not report original research |
• 205 (100 academic and 105 grey), reporting on 188 different studies) Pre-specified categories of influencing factors: GP characteristics, patient characteristics, structural factors, and cessation-specific knowledge and skills. • Yes • Yes (flow chart not given) |
• Analysis based on pre-specified categories • No • No • GPs |
Facilitators and barriers |
| Berry JA 2008 [62] Make each patient count. Overcoming barriers to clinical preventive services Literature review |
To explore barriers to wider implementation of clinical preventive services | Inclusion criteria English language studies from 1987 |
• Unclear • Not described • Not described |
• Descriptive/narrative • No • No • Professionals (physicians and nurse practitioners) |
Barriers only |
| Durlak JA 2008 [32] Implementation matters: a review of research on the influence of implementation on programme outcomes and the factors affecting implementation Literature review |
To assess the impact of implementation on program outcomes and to identify factors affecting the implementation process | Inclusion criteria The primary focus was on prevention and health promotion programmes for children and adolescents related to the following topics: physical health and development, academic performance, drug use, and various social and mental health issues Qualitative and quantitative studies and only English language articles were included. Studies with control groups and one group pre-post designs were included. Commentaries of several authors based on their extensive research or field experiences were included Exclusion criteria None |
• 81 qualitative and quantitative studies (The review also assess impact of implementation on outcomes, e.g. high vs. low implementation, well vs. poorly implemented programmes—not relevant to this review of review; not extracted) • Not described • Yes |
• Analysis based on Wandermann’s framework • No • Yes (Wandersmann’s “ecological framework for understanding effective implementation) • Unclear |
Factors |
| Hearn LA 2006 [82] Review of evidence to guide primary health care policy and practice to prevent childhood obesity Literature review |
To identify key barriers to effective engagement of primary health care (PHC) providers and families in promoting healthy weight among children aged 2–6 years, and to examine promising interventions to identify policy goals to over these barriers | Inclusion criteria RCTs, process, impact, parallel and intuitive evidence were included Primary care providers included general practitioners, practice nurses, community/child/maternal health nurses, allied health professional (e.g. dieticians, physiotherapists and exercise physiologists), multicultural and indigenous health workers, and health education/promotion specialists Interventions aimed to reduce risk factors for obesity in children aged 2–6 years, focused on prevention and early intervention, were non-commercial, involved PHC providers as key facilitators of change, encouraged participation of family members, evaluated the intervention outcomes, process and/or acceptability Exclusion criteria – |
• 45 (unclear study types) • Yes • Yes |
• Unclear • Yes (all selected interventions were appraised and categorised as high, medium, or low standard using a scoring system with pre-set criteria (secondary appraisal to capture promising interventions), based on the method of Flynn et al.) • Yes (various theories described) • Primary health care providers |
Barriers only |
| Nilsen P 2006 [36] Effectiveness of strategies to implement brief alcohol intervention in primary health care Systematic review |
To evaluate the effectiveness of promoting brief alcohol implementation by health care providers in primary health centres and evaluates the results in relation to the implementation strategies employed | Inclusion criteria The study had to: be based on health care providers’ practices within PHC settings; include training components for physicians and/or nurses to implement brief intervention; measure the effectiveness of implementation in terms of material utilisation rate, screening rate, brief intervention rate; measure the effectiveness either before and after or only after the implementation, with or without a control group; be pragmatic (i.e. the procedures were integrated into the routine practice of the PHC office); be published in English, in a peer-reviewed scientific journal Exclusion criteria Studies that involved staff training but relied on additional on-site personnel for administering the screening of patients were not deemed naturalistic enough to warrant inclusion in this systematic review |
• 11 (of which 5 are RCTs, 5 non randomised studies, 1 quasi-experimental study) • Yes • Yes |
• Descriptive/narrative • No • No • Professionals |
Barriers only [from discussion] |
| Integration of new role | |||||
| Sangster-Gormley E 2011 [54] Factors affecting Nurse practitioner role implementation in Canadian practice settings: an integrative review Integrated review |
To review the literature about the Canadian experience with nurse practitioner role implementation and to identify influencing factors at the practice setting level | Inclusion criteria Published and unpublished Canadian NP implementation studies between 1997 and July 2010 were included Qualitative and quantitative studies of implementation or integration of the NP role in acute, primary health and long-term care settings Exclusion criteria Early studies of NP role implementation prior to legislation and regulation of the role. Role development studies were excluded. Discussion papers, theoretical papers and studies of extended or expanded nursing roles were also excluded Definition Role implementation refers to the process used to establish the NP role in a practice setting and is a component of role integration |
• 10 published studies and two provincial papers (of which 5 papers are in primary care, and only these results are extracted) (quantitative and qualitative) • Yes • Yes |
• Thematic analysis • No • No • Unclear |
Facilitators and barriers |
| DiCenso A 2010 [55] Factors enabling advanced practice nursing role integration in Canada Scoping review |
To develop a better understanding of advanced practice nursing role, their current use, and the individual, organisational and health system factors that influence their effective integration in the Canadian health care system | Inclusion criteria Data from the literature were synthesised from 1990 onwards, to identify enablers to role development and implementation across the different types of advanced practice nurses: clinical nurse specialists, primary health care nurse practitioners and acute care nurse practitioners |
• 468 (largely primary studies, essays, editorials) • Yes (study screening/selection) • Yes (flow diagram) |
• Descriptive/narrative • No (scoping review) • No • Advanced practice nursing, e.g. nurse practitioners, primary health care nurse practitioners, advanced practice nurse |
Facilitators and barriers |
| Clarin OA 2007 [108] Strategies to overcome barriers to effective nurse practitioner and physician collaboration Systematic review |
To review common barriers to effective NP and physician collaboration to identify the strategies to overcome these obstacles | Inclusion criteria English articles published within the past 10 years; published worldwide; descriptive studies showing inter-professional relationships of NPs and physicians; stories of collaboration Settings: acute care and primary practice Exclusion criteria Articles on nurses and physician collaboration and involving NP collaboration with other health care members aside from physicians |
• 12 (6 based in primary care setting) (unclear study types) • No • No |
• Unclear • No • No • Physicians and nurse practitioners |
Barriers only |
| Halcomb E 2004 [85] Australian nurses in general practice based heart failure management: implications for innovative collaborative practice Narrative review |
To describe the current and potential role of the practice nurse in heart failure (HF) management | Inclusion criteria Only articles which focused on the development of the practice nurse role and nursing interventions or the role of the practice nurse in the management of HF were included in the review Exclusion criteria Articles that examined the role of general practice in chronic disease management or the use of evidence-based guidelines in general practice |
• 12 (survey) • No • No |
• Descriptive/narrative • No (quality was discussed in the main text) • No • GPs and nurse practitioners |
Facilitators and barriers |
| Prescribing behaviour | |||||
| Mason A 2008 [33] New medicines in primary care: a review of influences on general practitioner prescribing Systematic review |
To explore the determinants of uptake, the causes of geographical variations and the influence of price, costs and financial incentives on prescribing behaviour | Inclusion criteria Studies need to evaluate factors affecting the uptake of new medicines in primary care; quantitative and qualitative study designs were included Exclusion criteria Not about new medicines, not about factors affecting prescribing, reviews, focused on secondary care, articles that were unobtainable |
• 28 (quantitative and qualitative) • No • Yes |
• Analysis based on Bonair and Persson’s framework • No • Yes • GPs |
Facilitators and barriers |
| Others | |||||
| Davies SL, 2011 [109] A systematic review of integrated working between care homes and health care services Systematic review |
To evaluate the different integrated approaches to health care services supporting older people in care homes, and identify barriers and facilitators to integrated working | Inclusion criteria Interventions designed to develop, promote or facilitate integrated working between care home or nursing home staff and health care practitioners. Interventions that involved staff going in to provide education/training to care home/nursing home staff were included as long as there was some description of joint working or collaboration For a study to be included there had to be evidence of at least 1 of the following: Clear evidence of joint working, joint goals or care planning, joint arrangements covering operational and strategic issues, shared or single management arrangements, joint commissioning at macro and micro levelsStudies also had to report at least one of the outcomes pre-defined in the protocol Exclusion criteria Studies where staff were employed specifically for the purpose of the research without consideration of how the findings might be integrated into ongoing practice |
• 17 (10 quantitative, 1 mixed methods, 2 process evaluations, 3 qualitative, 1 action research) • Yes • Yes |
• Framework analysis • Yes (Cochrane) • No • Unclear |
Facilitators and barriers |
| Xyrichis A 2008 [110] What fosters or prevents inter-professional teamworking in primary and community care? A literature review Literature review |
To explore the factors that inhibit or facilitate inter-professional teamworking in primary care and community care | Inclusion criteria Papers from non-acute health care areas such as primary care and community care, as well as from countries outside the UK. Exclusion criteria Articles not relevant with the topic under investigation, not written in English, dated prior to 1994, non-research articles and papers that were not published in accessible journals |
• 10 (survey, qualitative studies) • Yes • Yes |
• Thematic analysis • Yes (unclear source; limitations were discussed, per study) • No • Primary care staff |
Facilitators and barriers |
| Baker R 2010 [63] Tailored interventions to overcome identified barriers to change: effect on professional practice and health care outcomes Cochrane review (update) Systematic review |
To assess the effectiveness of interventions tailored to address identified barriers to change on professional practice or patient outcomes | Inclusion criteria RCTs that studied the effect of tailored interventions to address identified barriers (undertaken before the design and delivery of the intervention) to change on professional practice Studies had to involve a comparison that did not receive a tailored intervention (no intervention/intervention that is not tailored to identified barriers, or intervention targeted at both individual and social/organisational barriers vs. intervention target at only individual barriers) Barriers may be identified by methods including observation, focus group discussions, interviews or surveys of the involved health care professionals, and/or through analysis of the organisation/system in which care is provided |
• 26 (of which 15 trials were based in primary or community care, 7 in hospital/specialist care, 3 in both, 1 in nursing home) • Yes • Yes |
• Descriptive • Criteria described by EPOC for RCTs and the EPOC data collection checklist • Yes (a number of theories were described) • Unclear |
Barriers only |