Adult community health-promoting interventions in primary health care: A systematic review

Highlights

• We review health-promotion interventions carried out in primary care.

• We identify community interventions which show evidence of effectiveness.

• A lack of evidence in some areas is detected.

• We describe difficulties in research and publishing about community interventions.

Abstract

Objective

To examine evidence on the effectiveness of health-promoting community interventions carried out in primary health care.

Methods

Systematic review of originals and systematic reviews of health-promoting community interventions with the participation of primary health care. A working definition of community activities was used in the inclusion criteria. Databases searched up to 2013: PUBMED, EMBASE, CINHAL, Web of SCIENCE, IBECS, IME, and PSICODOC. No restrictions on year of publication or design. Articles were reviewed by separate researchers to identify risks of bias.

Results

Fifty-one articles published between 1966 and 2013 were included: 11 systematic reviews and 40 originals that described 39 community interventions.

There is evidence on the effectiveness of community interventions in reducing cardiovascular risk factors, encouraging physical exercise, preventing falls and improving self-care among chronic patients compared with usual individual care. The effectiveness of some interventions increases when the community is involved in their development. Most assessments show positive results despite design limitations.

Conclusions

The community approach may be more effective than the individual in usual preventive interventions in primary care. There is a lack of evidence on many community interventions in primary care and further research is needed.

Introduction

The increase in life expectancy in all countries in the last century, together with the drop in nativity, has led to population ageing (Fernández-Ballesteros et al., 2013). This underlines the importance of active, healthy-ageing strategies whose lines of action necessarily involve providing people with tools to better manage their health, and thus to develop health-promoting interventions even though there are questions regarding the efficacy of these types of interventions (Renehan et al., 2012).

According to the Ottawa charter (WHO, 1986), health promotion consists of providing people with the means necessary to improve and exercise more effective control over their health. Its conception is linked to the idea of community action, as its focus is generally on the population and attempts to raise awareness and encourage community responsibility and involvement in their own activities. In turn, these ideas are closely linked to the origins and development of primary health care (PHC). This level of care is, in many countries like Spain, the foundation of the health system, mostly because of his role as a gatekeeper. It is ideally placed to develop health-promoting community interventions (Starfield et al., 2005) and is accessible to the majority of the population. It consists of multidisciplinary teams grouped in health centres located throughout the territory which, from a biopsychosocial perspective, allow comprehensive health care to the community.

Nevertheless, community interventions are underdeveloped in PHC and there are various reasons for this (March et al., 2014, Rubio-Valera et al., 2014, Guldan, 1996). There are barriers between professionals (doubts about effectiveness, self-efficacy to carry them out, low motivation, lack of training, etc.), community issues (resistance or reluctance among the population to take part in certain interventions, previous experiences of failure, cultural or linguistic barriers, etc.), institutional matters (biomedical model hegemony, guided incentives) and political aspects (political and economic context, health department priorities).

In recent decades, diverse initiatives have emerged to pool information on the effectiveness of health-promoting community interventions (Task Force on Commnity Preventive Services (TFCPS), 2005, National Institute of Health and Clinical Excellence (NICE), 2008, CTB The Community Tool Box, n.d) although most of these are not particular to PHC and are specific to certain types of intervention.

The aim of this review is to describe the available evidence on the effectiveness of health-promoting community interventions carried out with the participation of PHC in the adult population to promote active healthy ageing. So, our purpose is to explore the research developed about this topic to detect difficulties, limitations and future lines of research in this field.