Many of the PHC staff members participating in the study expressed commitment to working with lifestyle issues and find it challenging. Work with health promotion/prevention is organized in a way perceived by staff members as satisfying at most of the units, and staff expressed confidence in how to handle patients presenting with lifestyle-related conditions. Initiating a discussion about lifestyle with a patient attending the centre with a non-lifestyle-related condition is perceived as problematic. Additional resources in terms of manpower seem to increase the possibilities of handling the issue in a structured way.
The CLT, introduced to facilitate a more general screening and identify potentially harmful lifestyle behaviour, is not seen as an essential part in health promotion/prevention in PHC 2 years after its introduction. When evaluated after 9 months, compatibility with existing routines was one of the factors associated with a successful implementation [20
]. It is possible that perceived lack of compatibility resulted in little interest in incorporating the CLT into routine practice despite a commitment to addressing lifestyle issues. At some of the units other tools for lifestyle screening are used and found feasible.
Patients, caregivers, managers and politicians are considered to have responsibilities regarding how lifestyle issues are handled. Among staff, there is a disappointment regarding unrealistic goals set by politicians, and with evaluations giving higher value to quantity than quality in care.
In earlier research, a number of barriers to addressing lifestyle issues in PHC were identified [7
], and health care staff have expressed how structures, values and lack of resources are limiting their chances to promote health [13
]. Possibilities or facilitators identified include commitment to work with health promotion/prevention, knowledge, resources and attitudes [14
]. The present study shows how these possibilities, at most of the PHC units included in the study, have been converted into health promotion/prevention activities perceived by staff as satisfying. Awareness about lifestyle issues might have been influenced by participation in the study, but most of the commitment and activities described are not connected to the CLT, which is merely seen as a complement or as one tool among others used to address lifestyle issues. Other such tools have been evaluated and found feasible, e.g. a single checklist reminder or the Health Square [25
]. It seems that, when staff at the local unit find tools that fit their organization and are perceived as compatible with existing routines, they incorporate them in their practice [27
When the staff in the present study discussed responsibilities, they clearly stated that patients, staff and politicians all play important roles. They saw themselves as providers of knowledge and guidance to patients with respect for patient autonomy, and they also try to fulfil expectations from stakeholders; however, the latter is not always considered possible. Demands in health care organizations are continuously increasing, and it takes strong leaders to maintain engagement among staff under those circumstances [28
]. Staff in the present study called for manager commitment, showing a demand for strong leadership. Another important issue mentioned in the interviews was that stakeholders do not always value quality in care, but use quantitative measures as a basis for economic incentives. Among the staff, quality is perceived more important than quantity, and to provide adequate help to a patient in need is seen as a reward.
In earlier studies, PHC staff expressed that additional resources for lifestyle intervention are needed but not always provided [12
]. In the present study, some units had received additional resources, others had not. The general impression was that, where resources were provided, these had been utilized as intended, and staff felt content with the situation. Among those who had not received additional resources, staff seemed to use available resources in a judicious way. However, if so called lifestyle clinics are to be put into practice additional resources seem to be crucial.
Staff members in PHC, according to this study, feel well prepared to handle patients presenting with lifestyle-related conditions. PHC staff also seemed confident about their respective professional and individual roles; they know when to act on their own and when to refer to a colleague. This kind of team-based practice has been found to improve patients’ perceptions of quality of care and confidence in the system [29
]. However, general screening for lifestyle issues among patients seemed not to be prioritized.
Addressing lifestyle issues seemed to be more complicated at one of the units than the others. At this particular unit, there had been a flourishing activity until a couple of years ago, when two staff members, enthusiastic and committed to health promotion/prevention, quit their employment. Program champions have been found to be very important for organizational change [30
], but results from the present study shows the vulnerability associated with building activities on a few enthusiastic individuals.
The study was performed using a qualitative method in accordance with the RATS guidelines [31
]. Some limitations need to be taken into account in the interpretation of the results. Results from qualitative research are not generalizable to other settings, and to enable the reader to evaluate whether the results could be applied in a similar context, the setting and the participants are described as thoroughly as possible without revealing their identity. Quotations from the interviews are provided throughout the results section to obtain credibility and authenticity. During the analysis, the authors repeatedly discussed the interpretation of findings to ensure criticality and integrity. These measures are taken to develop trustworthiness of a qualitative study as suggested by Guba and Lincoln [32
]. Most of the quotes represent GPs and nurses, which only partly reflects the composition of the focus groups; NAs and APs constituted almost a third of the participants. GPs and nurses, however, were those who contributed most to the discussion; NAs did not participate as actively as the others. Performing the interviews in mixed groups might have limited the contribution of data from some of the participants due to hierarchic structures among staff. However, the authors believed that it was important that the different professionals could interact and describe their collaboration, and thus mixed groups were considered the most appropriate method for the study. Another limitation is the use of a convenience sampling method, which may have limited the representativeness of the informants. The results could also have been influenced by the fact that the researcher moderating the interviews was the same person who introduced the CLT [19
]. A suggestion for further research in this area is to assess managers’ views on how lifestyle-related conditions should be addressed in PHC, and also to compare the opinions of the different professional groups.
The results of the study show that PHC staff perceive addressing lifestyle issues as important and challenging, and they express confidence in handling patients with lifestyle-related conditions. The most problematic issue for the staff is addressing alcohol, and they call for a structured method of handling this issue.