In the last two decades, health sciences have been regarded as the area of knowledge with the most notable growth in scientific production.1 Despite the increasing prevalence of studies in health sciences, the impact on healthcare outcomes does not match these efforts. Chronic noncommunicable diseases, for example, are still one of the major health challenges of the 21st century. According to data from the World Health Organization (WHO) World Report, in 2012, chronic non-communicable diseases were still the main cause of death in the world.2
The science of nutrition is not far behind in regards to the production of scientific knowledge; quite the opposite, there is a representative increase in the number of studies related to food and nutrition.3 In a study carried out by Olinto et al.4 between 2007 and 2009, 2168 articles were published in the sub-area “nutrition” in national and international journals, with the Qualis-CAPES level varying between A1 and B5. (Qualis-CAPESis a Brazilian official system of classifying scientific production, maintained by the Coordenadoria de Aperfeiçoamento de Pessoal de Nível Superior [CAPES].)
Despite the innovative strategies seeking to strengthen the links between research, policies and practices, research results are only disseminated exclusively after they are obtained.5 Usually research results remain restricted to the academic community, with insufficient repercussions on public policy and health professional practice. It remains uncertain as to what extent the quantitative gains in scientific research are accompanied by qualitative gains in the capacity to solve health issues.5
A Brazilian study6 identifies two distinct fields of understanding and intervention. The first relates to the factors that hinder translation of basic scientific findings for clinical studies. The second refers to the existence of factors impeding translation of clinical studies to professional practice and decision-making processes in health systems.6 The author6 also argues that healthcare services and healthcare systems may not be prepared to incorporate research findings into clinical practice. Another barrier to the translation of research evidence into practice is the existence of professional behaviors that maintain practice based on “absolute” and outdated truths.7
Evidence-based practice is characterized by searching for the scientific basis to guide clinical practice, aiming to improve the health status of the global population through the delivery of health care based on the best available evidence.8 In order to implement evidence-based practice, health practitioners need to know how to obtain, interpret and integrate evidence into the reality of the patient or family unit.9,10
Primary healthcare represents the first level of contact between individuals, families and communities with the health system, whereby healthcare is taken as closely as possible to the places where people live and work. It is first-contact, accessible at the time of need, continued (focused on the long-term health of a person), comprehensive (range of services appropriate to common problems) and coordinated (articulation with the healthcare network).11,12 Therefore, it is the responsibility of the primary care providers to apply well-founded behaviors in their practice, with regard to scientific methods, technologies and approaches that incorporate interactions and social determinants, to ensure that quality of healthcare and nutritional management should be considered in this context.
In primary healthcare settings, general practitioners (GPs) are usually the patient's preferred source of nutrition information. However, studies of weight management in primary care have revealed that GPs are scarcely involved in providing interventions in this respect.13,14 According to Brotons et al.,15 GPs consider that overweight and obese patients are usually the worst group of patients on whom to test the success of dietary advice. A questionnaire to assess attitudes and willingness of GPs to treat obese patients confirmed that only 15% reported spending one to 10 minutes discussing weight management with patients.13 On the other hand, practice nurses (PNs) usually spend more time discussing weight-related issues with obese patients.13 Nevertheless, PNs tend to give very general advice about healthy eating rather than tailored advice, and very few use a good quality clinical protocol regarding nutritional management.16
Primary care providers often lack the training, skills, confidence and time required to implement evidence-based nutrition and lifestyle interventions.14 Heavy workload and lack of time are examples of important barriers, but the involvement of different health practitioners, such as practice nurses, nutritionists and psychologists can contribute to the collaborative approach and has the capacity to solve health issues.13,15,16
While it is important to mention that nutritionists hold competencies to propose suitable dietary guidelines and to adapt these guidelines to the different health needs of users, families and community,17 other health professionals may also have ownership of nutritional management and disseminate these guidelines. However, there is lack of knowledge about the following topics: How evidence-based nutritional management has been implemented? What are the barriers or facilitators in the use of evidence-based nutritional management in primary healthcare settings? Which health professionals are more involved in the use of evidence-based nutritional management in primary care settings?
A scoping review has been chosen as the methodology as it can provide valuable information about the range of ways in which evidence-based nutritional management has been applied in professional practice of primary healthcare settings. The scoping review aims to map evidence that has been produced so far, allowing researchers to examine the extent, range and nature of research activity in their chosen area.18
Previous systematic reviews in the area of food and nutrition have helped to develop evidence reports involving nutritional management that have been used as practice guideline recommendations.19,20 Other systematic reviews compile studies about implementation of practices, but have not referred to evidence-based practice.21,22 This scoping review aims to take a further step, analyzing the implementation of evidence-based nutritional recommendations in clinical practice in the context of primary care services.
The researchers did not find protocols and systematic review reports with the same or similar title or review questions after a thorough search in the JBI Database of Systematic Reviews and Implementation Reports, Cochrane Library, and PROSPERO website.
This review will consider studies that include any healthcare practitioner working in primary health care settings, regardless of education level (elementary level, middle level or higher level), provided that they are responsible for the implementation.
This review will consider:
- Studies about implementation of practices that discuss issues related to food and nutrition, not exclusively, with regard to dietary recommendations and/or nutritional counseling within the context of evidence-based practice (evidence-based nutritional management), even if these studies do not report the involvement of health professionals with the implementation process and/or outcome of the intervention.
- Barriers and facilitators to implementation processes to be incorporated in our analysis whenever described in the studies.
A wider range of components are also involved in implementation processes, such as organizational and contextual elements. We understand that given the complexity of implementation processes, inserting “barriers and facilitators” under inclusion criteria could limit the sources of evidence (e.g. studies that follow all other inclusion criteria, with descriptions of implementation processes, but do not highlight barriers and facilitators). As the implementation process is a key element in our study, in seeking to address our research questions we will consider all studies that describe implementation processes of evidence-based programs of nutritional management in primary healthcare settings.
We will select studies in which the use of evidence-based nutritional recommendations is clearly stated by the use of the term “evidence-based” or similar (e.g. recommendation supported by a high level of evidence) or by pointing to specific sources that based the nutritional management implementation.
This review will not consider:
- Studies that do not include the implementation of practices involving nutritional management (dietary recommendations and/or nutritional counseling).
- Studies that deal with dietary recommendations and/or nutritional counseling but do not refer to evidence-based practice.
- Studies that analyze only the preceding steps of nutritional management, such as nutritional assessment.
- Studies that only point out dietary recommendations and/or nutritional counseling to be followed for the prevention or treatment of a particular pathology.
- Studies that state merely opinions about the importance of evidence-based nutritional management.
This review will focus on the context of primary healthcare. Therefore, it will consider studies that include primary healthcare among other levels of care, covering all countries and health systems. We will include studies that mention the term “primary care” (e.g. primary health care settings) or similar (e.g. community health services). Due to this, secondary and tertiary levels of healthcare can be also present in the studies.
Types of studies
The sources of information will include original research articles (using any methodology). Gray literature of relevance to the review also will be included. The search will also be limited to the Spanish, Portuguese and English languages. Year of publication will not be limited.
The search strategy will follow the three-step process recommended by the Joanna Briggs Institute.8 The first of these steps has been already undertaken and involved an initial search of six online databases (Portal of the Virtual Health Library (VHL), PubMed, Embase, CINAHL, PsycINFO and ERIC) that work with indexed terms. This step aims to capture the index terms used to describe the articles and keywords contained in the title and abstract of retrieved papers (analysis of at most twenty papers in each of the cited databases). A second search using all identified keywords and index terms will then be undertaken across all included databases. In a third step, the reference list of all identified articles will be searched for additional studies as well as a search for unpublished studies (gray literature). Appendix I shows an example of a search strategy, with the initial terms and keywords to be used, as well as combinations of these through the Boolean operators OR and AND.
The selected databases are: PubMed, CINAHL, Embase, LILACS, PsycINFO, ERIC and Scopus. The sources of gray literature chosen will be: CAPES Thesis Bank, Government website “Portal RedeNutri”, and Open Access Theses and Dissertations. The included studies will be stored using a reference management software package and duplicates will be removed.
OBS3 is the government website “Portal RedeNutri” is a social network aimed at professionals responsible for implementing food and nutrition actions in the Unified Health System (SUS). It is a virtual space for problematization, formulation and exchange of experiences in order to facilitate the dialogue between the different subjects that integrate it and consolidating itself as a community of good practices in nutrition in SUS.
If necessary, the reviewers will contact the authors of the primary studies through email or the website “Researchgate”.
The process of conducting a scoping review is often iterative, requiring a reflexive approach to each stage as the researchers become increasingly familiar with the literature,18 and so potentially useful search terms may be discovered and incorporated in a later stage into the search strategy.
The process of selecting original research articles will be implemented over two stages. The first stage will consist of three reviewers applying the inclusion and exclusion criteria to all titles and abstracts. Each one will read a sub-set of titles and abstracts in order to classify the studies as “included”, “excluded” or “uncertain”. In the second stage of the selection process, studies classified as “included” or “uncertain” will have their titles and abstracts double-checked by two different reviewers, excluding those who did the initial screening. Should differences arise in this check, the reviewers will consult a fourth reviewer to reach consensus. When consensus is not reached, those articles will be included in the review.
For gray literature, firstly, only titles will be reviewed by three reviewers to determine eligibility based on the defined inclusion and exclusion criteria. For example, titles that indicate that the context is not primary healthcare will be removed. At this primary stage of the selection, any uncertainty with a title will not eliminate the reference for consideration in the second stage. Secondly, the three reviewers will assess the abstracts. Lastly, studies classified as “included” or “uncertain” will also have their titles and abstracts double-checked by two new reviewers. Selected gray literature that may have already become original research articles will be excluded.
A formal assessment of the quality of included studies will not be undertaken due to the fact that scoping reviews aim to provide a map of what evidence has been produced rather than seeking only the best available evidence to answer a particular question related to policy and practice.18
Charting the results
The charting process aims to generate a descriptive summary of the results that corresponds to the aims and research questions of the scoping review.18 A draft charting form (see Appendix II) has been developed at the protocol stage to aid in the collection and sorting of key pieces of information from the selected articles.
Data to be extracted from selected studies will include standard information (such as title, author, year of publication, country of origin, study design), and results or findings relevant to the review (scoping review PCC [Population, Concept, Context]). Additional information may also emerge during the data collection, and the data extraction form will also allow reviewers to record emergent information that will be discussed and refined during research team meetings. This may be further refined at the review stage and the charting form may be updated accordingly.
As the purpose of a scoping review is to present an overview of all the information collected, particular attention has been paid to how the large amount of data will be summarized and presented. There are inherent challenges in determining a framework for presenting a narrative account. A narrative summary will accompany the tabulated and/or charted results and describe how the results relate to the review objective and questions. Three presentation strategies will be employed: i) a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram to present all results from the search process; ii) a basic numerical account of the amount, type and distribution of the studies included in the review; and iii) a narrative description of the results, discussing them regarding the existent literature.18
Appendix I: Search strategy for PubMed
Appendix II: Draft data charting form
1. Aguiar MJ, Caramelli B. Ranking of the scientific production in Brazilian universities in the health science area – 1996 to 2011. Rev Assoc Med Bras
2013; 59 6:525–527.
2. World Health Organization (WHO). Global status report on non-communicable diseases 2014 [internet]. Geneva: 2014 [cited 2016 Jul. 01]. Avaliable from: http://apps.who.int/iris/bitstream/10665/148114/1/9789241564854_eng.pdf
3. Vasconcelos FAG. The science of nutrition in transit: from nutrition and dietetics to nutrigenomics. Rev Nutr
2010; 23 6:935–945.
4. Olinto MTA, Lira PIC, Marchini JS, Kac G. Human resources, research and scientific production of Brazilian Graduate Programs in Nutrition, 2007-2009. Rev Nutr
2011; 24 6:917–925.
5. Borde E, Akerman M, Pellegrini Filho A. Mapping of capacities for research on health and its social determinants in Brazil. Cad Saúde Pública
2014; 30 10:2081–2091.
6. Guimarães R. Translational research: an interpretation. Ciênc Saúde Coletiva
2013; 18 6:1731–1744.
7. Green LW, Ottoson JM, Garcia C, Hiatt RA. Diffusion Theory and Knowledge Dissemination, Utilization, and Integration in Public Health. Annu Rev Public Health
8. The Joanna Briggs Institute. Joanna Briggs Institute Reviewers’ Manual 2014 Edition [internet]. Adelaide: The Joanna Briggs Institute; 2014 [cited 2016 Apr. 12]. Avaliable from: http://joannabriggs.org/assets/docs/sumari/reviewersmanual-2014.pdf
9. Galvão CM, Sawada NO, Mendes IAC. In search of the best evidence. Rev Esc Enferm USP
2003; 37 4:43–50.
10. Potvin L. Why we should be worried about evidence based practice in health promotion. Rev Bras Saude Mater Infant
2005; 5 1:S93–S97.
11. Main terminology [internet]. World Health Organization; 2017 [cited 2017 Jul. 01]. Avaliable from: http://www.euro.who.int/en/health-topics/Health-systems/primary-health-care/main-terminology
12. World Health Organization (WHO). The World Health Report 2008: Primary Health Care
– Now More Than Ever [internet]. Geneva: 2008 [cited 2016 Jul. 01]. Avaliable from: http://www.who.int/whr/2008/whr08_en.pdf
13. Gibbs HD, Broom J, Brown J, Laws RA, Reckless JPD, Noble PA, et al. A new evidence-based model for weight management in primary care: the Counterweight Programme. J Hum Nutr Diet
2004; 17 3:191–208.
14. Blonstein AC, Yank V, Stafford RS, Wilson SR, Rosas LG, Ma J. Translating an Evidence based Lifestyle Intervention Program into Primary Care: Lessons Learned. Health Promot Pract
2013; 14 4:491–497.
15. Brotons C, Bjfrkelund C, Bulc M, Ciurana R, Godycki-Cwirko M, Jurgova E, et al. Prevention and health promotion in clinical practice: the views of general practitioners in Europe. Prev Med
2005; 40 5:595–601.
16. Brown I, Psarou A. Literature review of nursing practice in managing obesity in primary care: developments in the UK. J Clin Nurs
2008; 17 1:17–28.
17. Assis AMO, Santos SMC, Freitas MCS, Santos JM, Silva MCM. The Brazilian Family Health Program: contributions to a discussion about the inclusion of the nutritionist in the multidisciplinary team. Rev Nutr
2002; 15 3:255–266.
18. Peters MDJ, Godfrey CM, McInerney P, Baldini Soares C, Khalil H, Parker D. Methodology for JBI scoping reviews. In: Aromataris, E., editor. The Joanna Briggs Institute Reviewers’ Manual 2015. Adelaide (Australia): The Joanna Briggs Institute 2015 [Internet.] [cited 2016 May 14]: 1-24. Available from: http://joannabriggs.org/assets/docs/sumari/Reviewers-Manual_Methodology-for-JBI-Scoping-Reviews_2015_v2.pdf
19. Copeland KC, Silverstein J, Moore KR, Prazar GE, Raymer T, Shiffman RN, et al. Management of Newly Diagnosed Type 2 Diabetes Mellitus (T2DM) in Children and Adolescents. Pediatrics
2013; 131 2:364–382.
20. Borowitz D, Robinson KA, Rosenfeld M, Davis SD, Sabadosa KA, Spear SL, et al. Cystic Fibrosis Foundation Evidence-Based Guidelines for Management of Infants with Cystic Fibrosis. J Pediatr
2009; 155 (6 Suppl):S73–S93.
21. Bertholet N, Daeppen J, Wietlisbach V, Fleming M, Burnand B. Reduction of Alcohol Consumption by Brief Alcohol Intervention in Primary Care: Systematic Review and Meta-analysis. Arch Intern Med
2005; 165 9:986–995.
22. Bhattarai N, Prevost AT, Wright AJ, Charlton J, Rudisill C, Gulliford MC. Effectiveness of interventions to promote healthy diet in primary care: systematic review and meta-analysis of randomised controlled trials. BMC Public Health