Table 3.

Selected quotations from primary studies to illustrate each theme

Theme	Quotations	Contributing studies
Defining own primary role
Duty to prescribe medication	“… but it’s not prevention if you think that it’s just diet and physical exercise … if we don’t provide medical treatment for them …”34 “Some GPs regarded themselves as responsible for the care and treatment of the patient and would intervene when necessary. They would act as active coaches and prescribe adequate medical treatment when needed to prevent cardiovascular complications.”34 “Non-pharmaceutical treatment is not effective and it is important, in primary prevention, to avoid negative impacts on quality of life through changes in lifestyle, since we are mostly dealing with people who feel healthy before they get treatment.”20	19 20 32 34
Refraining from risking patients’ lives	“he would always recommend preventative medication to their patients, saying ‘I don’ t take the slightest risk with someone else’ s life”22 “Professional vigilance: Provider’s attention and alertness to seek and review information or knowledge about a patient’s risk”21 “it is worth treating anyone at risk of cardiovascular disease (with the patient’s co-operation and full knowledge of the facts), however small the risk”19 “the drug would ‘reduce the chance of further coronary events’”70	19 21 22 70
Mediating between patients and specialists	“I am really trying to, as a primary care doctor, work on … the importance of preventing cardiovascular disease… and the increased risk with these inflammatory conditions … So I think that’s a good co-manage thing, where the rheumatologist can stress that, and then I can keep going with it”21 “Providers who felt comfortable contacting one another through familiarity or ‘shared’ patients (conditions) were sometimes described as ‘co-managing,’ working together on CVD prevention”21	21
Delegating responsibility to patients	“Our job is to advocate for nutrition change. Tell them about the risk if they continue eating the same way. Provide the literature and keep doing the tests. That is all we can do until the patient wants to take action. You could call us the influencers.”23 “I control the information, the prescribing decision is shared, but whether or not they then purchase and take the medicines, I don’t control that …”20 “I don’t consider myself having the right to demand that people stop smoking. I think it is presumptuous to make such strong demands.”20	20 23 28 29 34
Providing holistic care	“Few interviewed doctors reported that the provision of nutrition education was part of their medical role. These doctors used words such as ‘holistic’ and statements such as ‘we are carers for the total patient’ to describe this role.”23 “Here, the doctor’s persuasive attitude towards the patient, creating a positive expectation, was considered important.”20 “The doctor has the main responsibility, because he or she has the adequate skills and enjoys the patient’s confidence to make the decisions, and because the patients sometimes make themselves dependent and are unwilling to decide.”20	20 23 26 29 78
Trusting external expertise
Depending on credible evidence and opinion	“I’m comfortable to be guided by the experts rather than try and invent too much on what might be dodgy assumptions on my part.”25 “Firm trust in the scientific documentation of effectiveness for the individual and of cut-off points as true levels of increased predictable risk.”20 “Some doubts about the effectiveness for the individual, but acceptance of the guidelines as rules to obey (even if they change over time), hoping and wishing that one is doing the best for the patient.”20 ‘‘I think the strength of the absolute risk concept is that it improves the targeting of certain interventions, so that you have a greater accuracy when you’re prescribing things like Statins but also a greater accuracy and confidence when you prescribe just behavioral measures like diet and exercise …”67	20 24 25 29 34 40 67 70 78
Entrusting care to other health professionals	“… doctors reported that the provision of nutrition care was outside their interest and expertise. These GPs described themselves as ‘generalists’ and viewed ‘nutrition education as a specialty service’.”23 “[T]rained support staff to help us deal with these issues, who can sit down and speak with people about modification of lifestyle or risk factors. And who could then have follow-up for them also.”81 “If I got a letter from [a cardiologist] saying that ‘we really find drug Y is superior in this situation’ then that would influence me to use it.”78 “I can only do so much for this patient because I have 15 min … so that team-based model … I think the program got that team approach.”26	23 26 34 40 78 80 81
Integrating into patient context	“[Absolute risk assessment] doesn’t take into account your family history, your weight, if you’re active or not … when you’ve been in this game for as many years as I have you like to get a big picture.”25 “… you have to rely on your clinical gut feeling about that patient. Taking all the information that you have gathered to date, put it all together and compute it in your mind and then decide how hard you are going to chase each of these risk factors …”71 “The role [of] multivitamins is very important, as diet [is] often inadequate, and [it is] very difficult to get this age group to change. In saying that I sent a very motivated 83 year old to [a] dietitian.”72	19–21 25 33 34 70–72 76 78 79
Motivating behavioural change for prevention
Highlighting tangible improvements	“I’m trying to convince them that they’re eating too much and not exercising enough and they’re trying to convince me that they are…but the ones that take it on board and make progress … they feel positive … encouraged … rewarded … motivated to keep going.”27 “You want somehow to give them something positive to cling to … that if I can do this and that and I can stop smoking or I can go down in weight or if I can be a little more physically active, I will have lots to gain”’20 “… ive got one program where you can show the patient how the risk changes as you run the blood pressure down, or change the cholesterol. It’s quite a powerful tool …”71	20 27 71
Negotiating patient acceptance	“This is a partnership not a dictatorship so it has to be something that’s on your agenda as well as mine.”27 “Three GPs had a ‘negotiator’ tendency, but the negotiations were mostly focused on lifestyle too: ‘We insisted again on diet and exercise”40 “Clearly the evidence around the world is that the primary care practitioner/patient relationship is the magic ingredient in the health system. There’s continuity and there’s trust. You get better outcomes and part of that is that people are more willing to commit to treatment plans. I think the General Practitioner’s role is key in promoting adherence”66	19 20 27 28 30 31 40 66 67 71 72 74 81
Enabling autonomy and empowerment	“Reassuring people a bit and helping them to understand that they can control their risk factors either with or without medication and then I think that gives them a sense of empowerment, a bit of control.”27 “You’ve just got to allow people to make an informed decision and leave it up to them”75	27 7575)
Harnessing the power of fear	“I am a hard master, I’m a very scary person … and I won’t let you get away with things. But it’s only because I care and because I want good things for you.”27 “I like to … put a little fear into them … if they don’t ‘pull up your socks’ (sic) bad things can happen to them … if you don’t want that kind of scenario you do what I tell you.”27 “… absolute risk charts and calculators were used by some GPs to ‘scare’ patients into taking action to reduce their risk of CVD, either through lifestyle change or medication.”27	27 31 34 82
Disappointment with futility of advice	“But then there are probably an equal number of patients from whom we give this advice and they never want to hear it in the first place, and having heard it they have no intention of doing anything about it…. I am not convinced that we do as much good as we like to think we do. I am fairly depressed that what we do is probably a complete waste of time … are we really preventing disease by what we do?”29	29
Recognising and accepting patient capacities
Ascertaining patient’s drive for lifestyle change	“They all want a pill (laughter) for everything and that’s the main challenge we find … not many patients are willing to change their lifestyle unfortunately … they want the easy way out. A pill for everything.”33 “I try to have a discussion with people to find out how much they want to use lifestyle modification and I think in situations it is very important to have the patient try the lifestyle to see if it will work and then treat them, to give them the option … I try to determine their preferences”22 “Trying to work out what barriers there are, so it means digging in a bit deeper into what makes this happen, what do you normally do, finding out more about their life and why they, what they can feasibly do”30	19 22 23 30 33 40 67
Conceding to ingrained habits	“Because most patients you see in real life are elderly, and there you only find high levels, and you realize that you can give this advice about their lifestyle, but they will not be very effective on this person so you’d better prescribe pharmaceuticals”20 “I think that in some circumstances you can be outstandingly effective, because I have had some patients who have done very well as a result of it. But I think in general terms it is very difficult to change people’s established patterns of behavior”29	20 29 30 67
Prioritising urgent comorbidities	“Other patients had more important problems than CVD risk, either acute conditions that dominated one-off consultations or competing chronic issues such as mental health. In these situations, absolute risk was often not assessed until the patient was ready to discuss CVD risk”27 “Diabetic patients or hypertensive patients may already be on several medications already … and then if you are inflicting another tablet, then it’s difficult and you are given the realms of polypharmacy. It can be very difficult and I am sure the compliance must drop considerably for such patients.”32	21 23 27 31 32 66 69 78 81
Tailoring to patient environment and literacy	“I think people with a higher education level are much more interested in perhaps in absolute figures and like to see the chart or the risk calculator and see how things can change. Whereas if you’ve got … someone who is less educated then you need to be a little bit more … simplistic in your description of risk and changing risk.”27 “The environment many of our patients live in is not conducive to making lifestyle behavioral changes … multiple fast food outlets, pavements may not be safe, lack of cycle ways etc.”31 “… prevention of CVD should be based on the reduction of RF through educational programmes that promote balanced diets, exercise and smoking cessation.”68	19 27 29 31 68
Avoiding overmedicalisation
Averting long-term dependence on medications	“Only that I think one of the most important things is this smoking cessation. I guess again because of the people I see, being young, that is what I hammer.”19 “… but there is a pharmaceutical industry that puts pressure on us, it’s in newspapers etc, we are continually fed with this … and I think it is as much my duty to sit here and tone down the risks for the young ones, above all. It doesn’t seem reasonable that the majority of the population should take medicines”20 “Above all to give up smoking. That is the most important, as I see it…”73	19 20 32 34 73 79 81
Preventing a false sense of security	“You cannot do one thing without the other … no use starting those tablets if you go overboard with the diet, I mean people say ‘oh it doesn’t matter, take the tablets I can do anything I like’. That’s not true … you have to have a good diet as well as taking the tablets. The tablets alone is not going to fix everything.”33 “It also can encourage people to believe that they are immortal almost and that the drug is going to protect them and that is not actually what it does, and it may actually encourage people to take less responsibility for their own illness which again is not good.”32	20 32 33 79 81 82
Minimising stress of sickness	“If the patient was highly anxious about their health, they may interpret even a low risk as something to be concerned about.”27 “Then of course there are patient factors … medicalization of society, the philosophical thing really in that you are perfectly well until you go to the doctor and come out with high cholesterol. It’s a bit like treating asymptomatic hypertension.”32 “We are putting fear into people in order to achieve objectives which we are being paid for. And we have created, as a profession, a very frightened population … So I am skeptical”29	20 24 25 29 32 34 40 73
Minimising economic burdens
Avoiding unjustified costs to patients	“From every point of view, from patient care, cost … if you can make the changes which have the least amount of cost to everyone then I think that’s usually lifestyle. So that’s usually the way that I start with and then use medication if we’re not getting there.”33 “The down side for the practice is that it is expensive and it’s a lot of patients who will be on it for life. Once you start someone on it, it is for life, so it is expensive in terms of cost of drugs …”32 “… it must be the medicines that did it, mustn’t it, it saved lots of money, I think, it’s costly intensive care, MI and stroke and those things”20	20 22 32 33 66 73 75
Delivering practice within budget	“I would only prescribe it if it doesn’t count on my medication budget!”74 “I think there is massive external pressures on us for every single thing we prescribe and I think the statins thing is rather bizarre in that we were heavily penalized for overspending on our drug budgets when we were spending heavily on statins, and we still have that pressure on drug budgets with negative budgets and target payments and all the rest of it”32 “I think in terms of cost–benefit, it is an appropriate approach because people with an existing disease you are going to save lives and quality of life for less money spent in preventing. Primary prevention is going to be less cost-effective because the number of people you need to prescribe to prevent one event, so in that respect yes it is right, but whether it is right from an ethical point of view is difficult to answer.”32	19 24 31 32 68 74
Alleviating healthcare expenses	“at the moment we don’t have the resources to actually give the rehabilitation that we could do if we had the extra nurse time … we have the protocols, we have the expertise, but we don’t have the nurse hours to take that on”77 “It is time-consuming in terms of following up because people do need to be followed up and they do need to have blood tests”32	29 32 77 80

CVD, cardiovascular disease; GPs, general practitioners; MI, myocardial infarction; RF, rheumatic fever.