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      Implementation of the BETTER 2 program: a qualitative study exploring barriers and facilitators of a novel way to improve chronic disease prevention and screening in primary care

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          BETTER (Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care) is a patient-based intervention to improve chronic disease prevention and screening (CDPS) for cardiovascular disease, diabetes, cancer, and associated lifestyle factors in patients aged 40 to 65. The key component of BETTER is a prevention practitioner (PP), a health care professional with specialized skills in CDPS who meets with patients to develop a personalized prevention prescription, using the BETTER toolkit and Brief Action Planning. The purpose of this qualitative study was to understand facilitators and barriers of the implementation of the BETTER 2 program among clinicians, patients, and stakeholders in three (urban, rural, and remote) primary care settings in Newfoundland and Labrador, Canada.


          We collected and analyzed responses from 20 key informant interviews and 5 focus groups, as well as memos and field notes. Data were organized using Nvivo 10 software and coded using constant comparison methods. We then employed the Consolidated Framework for Implementation Research (CFIR) to focus our analysis on the domains most relevant for program implementation.


          The following key elements, within the five CFIR domains, were identified as impacting the implementation of BETTER 2: (1) intervention characteristics—complexity and cost of the intervention; (2) outer setting—perception of fit including lack of remuneration, lack of resources, and duplication of services, as well as patients’ needs as perceived by physicians and patients; (3) characteristics of prevention practitioners—interest in prevention and ability to support and motivate patients; (4) inner setting—the availability of a local champion and working in a team versus working as a team; and (5) process—planning and engaging, collaboration, and teamwork.


          The implementation of a novel CDPS program into new primary care settings is a complex, multi-level process. This study identified key elements that hindered or facilitated the implementation of the BETTER approach in three primary care settings in Newfoundland and Labrador. Employing the CFIR as an overarching typology allows for comparisons with other contexts and settings, and may be useful for practices, researchers, and policy-makers interested in the implementation of CDPS programs.

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          Most cited references 16

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          Interprofessional teamwork: professional cultures as barriers.

           Ian P Hall (2005)
          Each health care profession has a different culture which includes values, beliefs, attitudes, customs and behaviours. Professional cultures evolved as the different professions developed, reflecting historic factors, as well as social class and gender issues. Educational experiences and the socialization process that occur during the training of each health professional reinforce the common values, problem-solving approaches and language/jargon of each profession. Increasing specialization has lead to even further immersion of the learners into the knowledge and culture of their own professional group. These professional cultures contribute to the challenges of effective interprofessional teamwork. Insight into the educational, systemic and personal factors which contribute to the culture of the professions can help guide the development of innovative educational methodologies to improve interprofessional collaborative practice.
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            Qualitative inquire and research desing: choosing among five approaches

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              Doinggrounded theory: Issues and discussions


                Author and article information

                Implement Sci
                Implement Sci
                Implementation Science : IS
                BioMed Central (London )
                1 December 2016
                1 December 2016
                : 11
                [1 ]Department of Family Medicine, University of Alberta, 6-10 University Terrace, Edmonton, Alberta T6G 2T4 Canada
                [2 ]Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, ON M5G 1V7 Canada
                [3 ]School of Public Health, University of Alberta, 3-291 Edmonton Clinic Health Academy, Edmonton, AB T6G 1C9 Canada
                [4 ]Primary Healthcare Research Unit, Memorial University of Newfoundland, Health Sciences Centre, 300 Prince Phillip Drive, St. John’s, Newfoundland, A1B 3V6 Canada
                [5 ]Ontario Institute for Cancer Research, 661 University Avenue, Suite 510, Toronto, ON M5G 0A3 Canada
                [6 ]Covenant Health, Grey Nuns Community Hospital, 1100 Youville Drive Northwest, Edmonton, Alberta T6L 5X8 Canada
                © The Author(s). 2016

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

                Funded by: Canadian Partnership Against Cancer
                Award ID: 11143
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                © The Author(s) 2016


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