research & reviews a journal of health professions

Research & Reviews: A Journal of Health Professions (rrjoph)

About the journal

Research & Reviews: A Journal of Health Professions [2277-6192(e)]  is a peer-reviewed hybrid open access journal of engineering and scientific journals launched in 2018 and focused on the rapid publication of fundamental research papers in all areas concerning various current and forthcoming radical new health professions across the globe and the latest cutting edge advancements in healthcare.

Journal Specification

Editor spotlight.

Meet Editorial Board

Special Issues

About journal

Journal specification….

Last updated: 2022-07-01

WEBSITE DISCLAIMER

The information provided by Journal Library (“Company”, “we”, “our”, “us”) on https://journalslibrary.com/ (the “Site”) is for general informational purposes only. All information on the Site is provided in good faith, however we make no representation or warranty of any kind, express or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any information on the Site.

UNDER NO CIRCUMSTANCE SHALL WE HAVE ANY LIABILITY TO YOU FOR ANY LOSS OR DAMAGE OF ANY KIND INCURRED AS A RESULT OF THE USE OF THE SITE OR RELIANCE ON ANY INFORMATION PROVIDED ON THE SITE. YOUR USE OF THE SITE AND YOUR RELIANCE ON ANY INFORMATION ON THE SITE IS SOLELY AT YOUR OWN RISK.

EXTERNAL LINKS DISCLAIMER

The Site may contain (or you may be sent through the Site) links to other websites or content belonging to or originating from third parties or links to websites and features. Such external links are not investigated, monitored, or checked for accuracy, adequacy, validity, reliability, availability or completeness by us.

WE DO NOT WARRANT, ENDORSE, GUARANTEE, OR ASSUME RESPONSIBILITY FOR THE ACCURACY OR RELIABILITY OF ANY INFORMATION OFFERED BY THIRD-PARTY WEBSITES LINKED THROUGH THE SITE OR ANY WEBSITE OR FEATURE LINKED IN ANY BANNER OR OTHER ADVERTISING. WE WILL NOT BE A PARTY TO OR IN ANY WAY BE RESPONSIBLE FOR MONITORING ANY TRANSACTION BETWEEN YOU AND THIRD-PARTY PROVIDERS OF PRODUCTS OR SERVICES.

PROFESSIONAL DISCLAIMER

The Site can not and does not contain medical advice. The information is provided for general informational and educational purposes only and is not a substitute for professional medical advice. Accordingly, before taking any actions based upon such information, we encourage you to consult with the appropriate professionals. We do not provide any kind of medical advice.

Content published on https://journalslibrary.com/ is intended to be used and must be used for informational purposes only. It is very important to do your own analysis before making any decision based on your own personal circumstances. You should take independent medical advice from a professional or independently research and verify any information that you find on our Website and wish to rely upon.

THE USE OR RELIANCE OF ANY INFORMATION CONTAINED ON THIS SITE IS SOLELY AT YOUR OWN RISK.

AFFILIATES DISCLAIMER

The Site may contain links to affiliate websites, and we may receive an affiliate commission for any purchases or actions made by you on the affiliate websites using such links.

TESTIMONIALS DISCLAIMER

The Site may contain testimonials by users of our products and/or services. These testimonials reflect the real-life experiences and opinions of such users. However, the experiences are personal to those particular users, and may not necessarily be representative of all users of our products and/or services. We do not claim, and you should not assume that all users will have the same experiences.

YOUR INDIVIDUAL RESULTS MAY VARY.

The testimonials on the Site are submitted in various forms such as text, audio and/or video, and are reviewed by us before being posted. They appear on the Site verbatim as given by the users, except for the correction of grammar or typing errors. Some testimonials may have been shortened for the sake of brevity, where the full testimonial contained extraneous information not relevant to the general public.

The views and opinions contained in the testimonials belong solely to the individual user and do not reflect our views and opinions.

ERRORS AND OMISSIONS DISCLAIMER

While we have made every attempt to ensure that the information contained in this site has been obtained from reliable sources, Journal Library is not responsible for any errors or omissions or for the results obtained from the use of this information. All information in this site is provided “as is”, with no guarantee of completeness, accuracy, timeliness or of the results obtained from the use of this information, and without warranty of any kind, express or implied, including, but not limited to warranties of performance, merchantability, and fitness for a particular purpose.

In no event will Journal Library, its related partnerships or corporations, or the partners, agents or employees thereof be liable to you or anyone else for any decision made or action taken in reliance on the information in this Site or for any consequential, special or similar damages, even if advised of the possibility of such damages.

GUEST CONTRIBUTORS DISCLAIMER

This Site may include content from guest contributors and any views or opinions expressed in such posts are personal and do not represent those of Journal Library or any of its staff or affiliates unless explicitly stated.

LOGOS AND TRADEMARKS DISCLAIMER

All logos and trademarks of third parties referenced on https://journalslibrary.com/ are the trademarks and logos of their respective owners. Any inclusion of such trademarks or logos does not imply or constitute any approval, endorsement or sponsorship of Journal Library by such owners.

Should you have any feedback, comments, requests for technical support or other inquiries, please contact us by email:   [email protected] .

Research & Reviews: A Journal of Health Professions

ISSN: 2277-6192.

Research & Reviews: A Journal of Health Professions (RRJoHP) is an international eJournal focused towards the rapid publication of fundamental research papers on all areas of concerning various current and forthcoming radical new health professions across the globe due to cutting edge advancements in healthcare.

• Research & Reviews: A Journal of Health Professions website (full text articles available online)
• Medicine - Miscellaneous

Identifiers

Linking ISSN (ISSN-L): 2277-6192

URL http://www.stmjournals.com/index.php?journal=RRJoHP

Google https://www.google.com/search?q=ISSN+%222277-6192%22

Bing https://www.bing.com/search?q=ISSN+%222277-6192%22

Yahoo https://search.yahoo.com/search?p=ISSN%20%222277-6192%22

National Library of India http://nationallibraryopac.nvli.in/cgi-bin/koha/opac-search.pl?advsearch=1&idx=ns&q=2277-6192&weight_search=1&do=Search&sort_by=relevance

Resource information

Title proper: Research and reviews: a journal of health professions.

Country: India

Medium: Online

Record information

Last modification date: 29/05/2023

Type of record: Confirmed

ISSN Center responsible of the record: ISSN National Centre for India

downloads requested

Discover all the features of the complete ISSN records

Display mode x.

Labelled view

MARC21 view

UNIMARC view

• STM Journals
• Special Issues
• Conferences

Editorial Board Members

• Reviewers Board Members
• Advisory Panel
• Indexing Bodies
• For Authors
• For Reviewers
• For Editors
• For Advisory Board
• Special Issue Guidelines
• Peer-Review Policy
• Manuscript Submission Guidelines
• Publication Ethics and Virtue

Article Processing Charge

• Editorial Policy
• Advertising Policy
• STM Website and Link Policy
• Distribution and dessemination of Research
• Informed consent Policy

"Connect with colleagues and showcase your academic achievements."

"Unleashing the potential of your words"

 "Explore a vast collection of books and broaden your horizons."

 "Empower yourself with the knowledge and skills needed to succeed."

"Collaborate with like-minded professionals and share your knowledge."

"Learn from experts and engage with a community of learners."

• ICDR Group of Companies

• Training Programs

Research & Reviews: A Journal of Health Professions

ISSN: 2277-6192

Journal Menu

Journal menu, focus and scope.

About the Journal

Research & Reviews: A Journal of Health Professions [2277-6192(e)]  is a peer-reviewed hybrid open access journal of engineering and scientific journals launched in 2018 and focused on the rapid publication of fundamental research papers in all areas concerning various current and forthcoming radical new health professions across the globe and the latest cutting edge advancements in healthcare.

Papers Published

• Audiology:  Audiologic/aural rehabilitation; balance and balance disorders; cultural and linguistic diversity; detection, diagnosis, prevention, habilitation, rehabilitation, and monitoring of hearing loss; hearing aids; cochlear implants; hearing assistive technology; hearing disorders; lifespan perspectives on auditory function, speech perception, and tinnitus. 
• Cardiovascular technology:  Implantable medical devices, hemodynamics, tissue biomechanics, functional imaging, surgical devices, electrophysiology, antiarrhythmic drugs, anticoagulation, atrial fibrillation, atrial flutter, atrial tachycardia, atrioventricular block, electrocardiography, electrocardiogram, epicardial, heart rhythm disorders.
• Clinical chiropractic:  diagnosis, treatment, and prevention of mechanical disorder of musculoskeletal system; spine adjustment; chiropractic treatment techniques; electrical muscles stimulations; therapeutic ultrasound; vertebral subluxation, dry needling, mobilisation, physical therapies. 
• Clinical laboratory technology:  Immunochemistry; toxicology; hematopathology; immunopathology; molecular diagnostics; genetic testing; immunohematology; clinical chemistry; microbiology; clinical pathology; medical genetics; physiology and clinical research; clinical chemistry; transfusion and cell therapy; laboratory informatics, general laboratory medicine, anatomic pathology, urinalysis. 
• Health economics:  production and supply of health services; demand and utilization of health services; financing of health services; determinants of health, such as investments in health and risky health behaviors; economic consequences of ill health; behavioral models of demanders, suppliers, and other health care agencies; evaluation of policy interventions; economic insights; efficiency and distributional aspects of health policy; health insurance and reimbursement; health economic evaluation; health services research; health policy analysis. 
• Healthcare System and Health Policy:  Individual and institutional aspects of health care management; the importance of health care in developing countries; consumer health informatics and mobile health; group modeling and facilitation in healthcare; health quality and evaluation; healthcare design science; operations management; precision healthcare and soft OR; technical architecture of health IT; healthcare management in general, both at an operational and strategic level; the organization and structuring of healthcare services; cultural and behavioral issues; questions about ethics and quality of life; human resource issues like training and deployment; patient safety and risk; health disparities modeling; system dynamics; human-computer interaction in the healthcare system. 
• Interdisciplinary clinical studies, assessment, and outcomes:  Multidisciplinary rehabilitation; biopsychosocial pain rehabilitation; pain management program; interdisciplinary pain rehabilitation program; outcomes domains; data management; trial logistics; design and conduct of trials; statistical methods; the impact of trials on practice and policy; ethics; law and regulation; clinical trial design; management, legal, ethical and regulatory issues; case record form design; data auditing methodologies; clinical or policy impact of all types of the clinical trial; clinical trials/treatment strategies in occupational therapy; clinical trials of drugs; clinical trial management. 
• Medical Laboratory Sciences:  Biomedical Sciences and Laboratory Medicine; Medical Microbiology; Medical Parasitology; Clinical Chemistry; Haematology; Blood group serology; cytogenetics; exfoliation cytology; medical virology; medical mycology; histopathology; laboratory diagnostic reagents; fabricated laboratory hardware; clinical pathology; urinalysis; transfusion medicine; molecular diagnostics; histology; laboratory administration and management. 
• Nutrition and dietetics:  dietetic practice; medical nutrition therapy, community, and public health nutrition; food and nutrition service management; dietetic education; Nutrition across the lifespan; nutritional support and assessment; obesity and weight management; principles of nutrition and dietetics, dietary surveys; Nutritional epidemiology; nutrigenomics and molecular nutrition research; cancer diet; clinical nutrition; bioactive dietary components; dietary supplement; nutrients; nutrition therapy; nutritional policies; human and clinical nutrition; immuno-nutrition; endocrine nutrition. 
• Occupational therapy:  Reliability and validity of clinical instruments used by occupational therapists; assistive technology; community rehabilitation; cultural issues related to occupational therapy practice or education; occupational therapy interventions at the population level; surveys related to occupational therapy practice and education; historical reviews of occupational therapy practice; meta-analysis demonstrating the efficacy of interventions related to occupational therapy; scoping reviews of areas of occupational therapy practice; knowledge translation projects in occupational therapy; professional issues in OT; pilot studies of new approaches to OT practice. 
• Osteopathy:  principles and practice of osteopathic medicine; basic science research, clinical epidemiology, and social science concerning osteopathy; neuromusculoskeletal medicine; pain management; practice management; medical education; neuromusculoskeletal medicine; osteopathic manipulative treatment (OMT); public health and primary care. 
• Physician:  international medicines, randomized controlled trials, prospective cohort studies, health, and clinical practices; case-control studies; Phase I, phase II, and phase III studies, physiological or pharmacological studies. 
• Psychology:  addictive behavior, auditory cognitive neuroscience, cognition, cognitive science, comparative psychology, consciousness research, cultural psychology, decision neuroscience, developmental psychology, eating behavior, educational psychology, emotion science, environmental psychology, evolutionary psychology, forensic and legal psychology, gender, sex and sexualities, health psychology, media psychology, movement science, sport psychology, neuropsychology, organizational psychology, pediatric psychology, perception science, performance science, personality, and social psychology, psycho-oncology, psychology of aging, psychology of clinical settings, psychopathology, quantitative psychology and measurement, theoretical and philosophical psychology, 
• Radiology and ultrasound technology:  Breast imaging, Cardiovascular imaging, Chest radiology, computed tomography, diagnostic imaging, gastrointestinal imaging, head and neck imaging, magnetic resonance imaging, musculoskeletal imaging, nuclear medicine, pediatric imaging, positron emission tomography, radiation oncology, x-ray radiography, echocardiography, sonography, theoretical and experimental aspects of advanced methods and technologies in instrumentation for imaging, doppler measurements, signal processing, pattern recognition, clinical evaluation of new techniques, tissue-parameter measures, mechanism of ultrasound- tissue interactions, transducer technology, calibration and standardization, tissue-mimicking phantoms, elasticity measurement, photoacoustic and acousto-optic technologies, radiation oncology, Elastography, high frequency clinical and pre-clinical imaging, neurosonology, point-of-care ultrasound, public policy, therapeutic ultrasound, Ultrasound education, ultrasound in global health, urologic ultrasound, vascular ultrasound. 
• Speech and language therapy:  speech production and perception; anatomy and physiology of speech and voice; genetics, biomechanics, and other basic sciences of human communication; chewing and swallowing; speech disorders; voice disorders; development of speech and language; hearing in children; normal language processes; language disorders; disorders of hearing and balance; psychoacoustics; anatomy and physiology of hearing. 
• Surgical technology:  General Surgery, Ophthalmic Surgery, Transplantation Surgery, Endocrine Surgery, Cardiothoracic Surgery, Obstetric Surgery, Neurosurgery, Plastic Surgery, Oral and Maxillofacial Surgery, Orthopaedic Surgery, Acute Care Surgery, Gynecological Surgery, Urological Surgery, Robotic Surgery, Perioperative Care, Anesthesiology, innovation and development in instrumentation, surgical technological methods, surgical training and performance metrics, surgical simulation, telemedicine, history of surgical innovation and innovators. 

WEBSITE DISCLAIMER

Last updated: 2022-06-15

The information provided by STM Journals (“Company”, “we”, “our”, “us”) on https://journals.stmjournals.com / (the “Site”) is for general informational purposes only. All information on the Site is provided in good faith, however, we make no representation or warranty of any kind, express or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any information on the Site.

UNDER NO CIRCUMSTANCE SHALL WE HAVE ANY LIABILITY TO YOU FOR ANY LOSS OR DAMAGE OF ANY KIND INCURRED AS A RESULT OF THE USE OF THE SITE OR RELIANCE ON ANY INFORMATION PROVIDED ON THE SITE. YOUR USE OF THE SITE AND YOUR RELIANCE ON ANY INFORMATION ON THE SITE IS SOLELY AT YOUR OWN RISK.

EXTERNAL LINKS DISCLAIMER

The Site may contain (or you may be sent through the Site) links to other websites or content belonging to or originating from third parties or links to websites and features. Such external links are not investigated, monitored, or checked for accuracy, adequacy, validity, reliability, availability, or completeness by us.

WE DO NOT WARRANT, ENDORSE, GUARANTEE, OR ASSUME RESPONSIBILITY FOR THE ACCURACY OR RELIABILITY OF ANY INFORMATION OFFERED BY THIRD-PARTY WEBSITES LINKED THROUGH THE SITE OR ANY WEBSITE OR FEATURE LINKED IN ANY BANNER OR OTHER ADVERTISING. WE WILL NOT BE A PARTY TO OR IN ANY WAY BE RESPONSIBLE FOR MONITORING ANY TRANSACTION BETWEEN YOU AND THIRD-PARTY PROVIDERS OF PRODUCTS OR SERVICES.

PROFESSIONAL DISCLAIMER

The Site can not and does not contain medical advice. The information is provided for general informational and educational purposes only and is not a substitute for professional medical advice. Accordingly, before taking any actions based on such information, we encourage you to consult with the appropriate professionals. We do not provide any kind of medical advice.

Content published on https://journals.stmjournals.com / is intended to be used and must be used for informational purposes only. It is very important to do your analysis before making any decision based on your circumstances. You should take independent medical advice from a professional or independently research and verify any information that you find on our Website and wish to rely upon.

THE USE OR RELIANCE OF ANY INFORMATION CONTAINED ON THIS SITE IS SOLELY AT YOUR OWN RISK.

AFFILIATES DISCLAIMER

The Site may contain links to affiliate websites, and we may receive an affiliate commission for any purchases or actions made by you on the affiliate websites using such links.

TESTIMONIALS DISCLAIMER

The Site may contain testimonials by users of our products and/or services. These testimonials reflect the real-life experiences and opinions of such users. However, the experiences are personal to those particular users, and may not necessarily be representative of all users of our products and/or services. We do not claim, and you should not assume that all users will have the same experiences.

YOUR RESULTS MAY VARY.

The testimonials on the Site are submitted in various forms such as text, audio, and/or video, and are reviewed by us before being posted. They appear on the Site verbatim as given by the users, except for the correction of grammar or typing errors. Some testimonials may have been shortened for the sake of brevity, where the full testimonial contained extraneous information not relevant to the general public.

The views and opinions contained in the testimonials belong solely to the individual user and do not reflect our views and opinions.

ERRORS AND OMISSIONS DISCLAIMER

While we have made every attempt to ensure that the information contained in this site has been obtained from reliable sources, STM Journals is not responsible for any errors or omissions or the results obtained from the use of this information. All information on this site is provided “as is”, with no guarantee of completeness, accuracy, timeliness, or of the results obtained from the use of this information, and without warranty of any kind, express or implied, including, but not limited to warranties of performance, merchantability, and fitness for a particular purpose.

In no event will STM Journals, its related partnerships or corporations, or the partners, agents, or employees thereof be liable to you or anyone else for any decision made or action taken in reliance on the information in this Site or for any consequential, special or similar damages, even if advised of the possibility of such damages.

GUEST CONTRIBUTORS DISCLAIMER

This Site may include content from guest contributors and any views or opinions expressed in such posts are personal and do not represent those of STM Journals or any of its staff or affiliates unless explicitly stated.

LOGOS AND TRADEMARKS DISCLAIMER

All logos and trademarks of third parties referenced on https://journals.stmjournals.com / are the trademarks and logos of their respective owners. Any inclusion of such trademarks or logos does not imply or constitute any approval, endorsement, or sponsorship of STM Journals by such owners.

Should you have any feedback, comments, requests for technical support, or other inquiries, please contact us by email: [email protected] .

Effect of Continuing Professional Development on Health Professionals' Performance and Patient Outcomes: A Scoping Review of Knowledge Syntheses

Affiliations.

• 1 A. Samuel is assistant professor, Department of Medicine and Center for Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, Maryland; ORCID: https://orcid.org/0000-0001-9488-9565 .
• 2 R.M. Cervero is professor, Department of Medicine, and deputy director, Center for Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
• 3 S.J. Durning is professor, Department of Medicine, and director, Center for Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
• 4 L.A. Maggio is associate professor, Department of Medicine, and associate director, Center for Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, Maryland; ORCID: https://orcid.org/0000-0002-2997-6133 .
• PMID: 33332905
• DOI: 10.1097/ACM.0000000000003899

Purpose: Continuing professional development (CPD) programs, which aim to enhance health professionals' practice and improve patient outcomes, are offered to practitioners across the spectrum of health professions through both formal and informal learning activities. Various knowledge syntheses (or reviews) have attempted to summarize the CPD literature; however, these have primarily focused on continuing medical education or formal learning activities. Through this scoping review, the authors seek to answer the question, What is the current landscape of knowledge syntheses focused on the impact of CPD on health professionals' performance, defined as behavior change and/or patient outcomes?

Method: In September 2019, the authors searched PubMed, Embase, CINAHL, Scopus, ERIC, and PsycINFO for knowledge syntheses published between 2008 and 2019 that focused on independently practicing health professionals and reported outcomes at Kirkpatrick's level 3 and/or 4.

Results: Of the 7,157 citations retrieved from databases, 63 satisfied the inclusion criteria. Of these 63 syntheses, 38 (60%) included multicomponent approaches, and 29 (46%) incorporated eLearning interventions-either standalone or in combination with other interventions. While a majority of syntheses (n = 42 [67%]) reported outcomes affecting health care practitioners' behavior change and/or patient outcomes, most of the findings reported at Kirkpatrick level 4 were not statistically significant. Ten of the syntheses (16%) mentioned the cost of interventions though this was not their primary focus.

Conclusions: Across health professions, CPD is an umbrella term incorporating formal and informal approaches in a multicomponent approach. eLearning is increasing in popularity but remains an emerging technology. Several of the knowledge syntheses highlighted concerns regarding both the financial and human costs of CPD offerings, and such costs are being increasingly addressed in the CPD literature.

Publication types

• Education, Continuing*
• Patient Outcome Assessment
• Patient Satisfaction
• Professional Competence*
• Professional Practice / standards*
• Quality Improvement*

• Previous Article
• Next Article

Foundations

Conclusions, critical reviews in health professions education research.

• Split-Screen
• Article contents
• Figures & tables
• Supplementary Data
• Peer Review
• Open the PDF for in another window
• Guest Access
• Get Permissions
• Cite Icon Cite
• Search Site

Renate Kahlke , Mark Lee , Kevin W. Eva; Critical Reviews in Health Professions Education Research. J Grad Med Educ 1 April 2023; 15 (2): 180–185. doi: https://doi.org/10.4300/JGME-D-23-00154.1

Download citation file:

• Ris (Zotero)
• Reference Manager

Health professions education (HPE) has been framed as a field that is not entirely theoretical or practical, as well as one that is not constrained by the worldviews of a single discipline. 1   As such, HPE scholars often need to synthesize knowledge from diverse disciplines or theoretical perspectives to advance thinking about difficult problems. As a result, critical reviews have a robust and valuable history in HPE. Such reviews are methodologically flexible, which enables scholars to advance understanding of complex issues by appraising theory and evidence from an array of sources, rather than prioritizing systematic reporting of everything written within a single discipline.

Within the taxonomy of literature reviews, 2   critical reviews fall under the broad umbrella of narrative reviews. 3   A key feature that often distinguishes critical reviews from other narrative reviews is that they draw on literature and theory from different domains, which enables investigators to reenvision ways of interpreting a problem. Those domains can include multiple disciplines, such as when the fields of psychology, organizational behavior, and behavioral economics were used to help rethink the role of incentives in recruiting and retaining medical clinician educators. 4   Critical reviews can pertain to a specific theory, such as when conversation analysis theory was used to offer a new perspective on the patient-doctor relationship. 5   Or they can be built around a particular empirical finding, such as when patients' priorities for clinical communication were found to not match assumptions about “good” communication. 6   Authors of critical reviews bring an interpretive lens to bear on knowledge synthesis, either through their methods (by designing their review from a specific orientation or theoretical perspective) or analyses (through the development of a new perspective about the focal problem). Thus, in critical reviews, researchers act as research instruments by using their perspectives to appraise and interpret the literature uncovered, rather than primarily acting to describe or summarize it. For this reason, critical reviews are particularly useful for problems that may require a new way of thinking or that require reviewers to use their unique expertise and judgement to take a stance on the information uncovered and where the field ought to go as a result ( Box ).

Dr. Smith, a program director, has been tasked to develop an interprofessional education (IPE) experience for the residency program. She decides that conducting a literature review would be a savvy way to examine the existing evidence and generate a publication potentially useful to others.

After running a Google search using the term “interprofessional education,” Dr. Smith finds more than 11 million hits. Turning to PubMed and using a general subject search with the same term, she identifies 24 000 matches. Dr. Smith randomly samples a few articles and notes the huge diversity of types and approaches, including randomized trials, qualitative investigations, and critical perspectives.

Dr. Smith notices that many of these reports do not always reflect the realities of working with other health professionals. Her experiences suggest that there are often more differences within a “profession” than between professions: she often experiences greater feelings of commonality with social work and health care aide colleagues than with others in her specialty. Dr. Smith wonders how authors within the IPE literature are defining and distinguishing between “professions” and thinks that siloing may do damage by reinforcing interprofessional differences and hierarchies that do not feel real or necessary.

Dr. Smith has an MBA and wonders if any insights can be gleaned from the business literature, where professional roles are more fluid and less defined. She also recalls an introductory psychology course in which the notion of in-groups and out-groups was used to explain social proclivities. Therefore, Dr. Smith decides to conduct a “critical review” as a way to explore, critique, and expand the IPE literature through efforts to draw insights from other fields and paradigms. Dr. Smith's goal is to help reshape the way IPE researchers and educators think about “professions” in a way that might help the field move beyond some of the barriers that have hampered effective IPE for decades.

An additional distinction is that many forms of narrative review focus on exploring how a relatively defined topic has been addressed within a single literature (eg, burnout in medical education 7   or the learning environments experienced by underrepresented minority medical students). 8   In contrast, critical reviewers most often work across multiple disciplines to explore whether each provides unique explanatory value and if comparison between them generates new insights. As an example, Ilgen et al 9   aimed to “define and elaborate the concept of ‘comfort with uncertainty'… in clinical settings by juxtaposing a variety of frameworks and theories in ways that generate more deliberate ways of thinking about, and researching, this phenomenon.” We argue that HPE research has benefited substantially from such engagement with various lenses, by generating insights into multifaceted problems that are unlikely to have simple solutions. 10  

Despite the strength of alignment between critical reviews and the complex problems that drive the HPE field, limited methodological guidance is available, and reporting is highly variable. That state leaves researchers, reviewers, and readers with more questions than answers regarding best practices. 11   To fill this gap, we offer an overview and practical guidance by drawing on existing methodological literature, a scan of recently published critical reviews in HPE journals, and our own experiences reading, writing, and reviewing critical reviews. We began by examining 19 articles that stated a “critical review” methodology and were published within the past 10 years in 4 HPE journals with the highest impact factors: Academic Medicine , Medical Education , Advances in Health Sciences Education , and Medical Teacher . We examined introductions and methods sections to extract and compare authors' stated intents and reported procedures. To offer best practice advice for those reading and conducting critical reviews, we then integrated our findings with the limited methodological literature about critical reviews in HPE and other relevant fields. Modeling the goal of critical reviews, our discussion extends beyond reporting “how others have done it” to offer an argument, grounded in the literature, regarding why certain features or strategies should take precedence. In doing so, we sought to offer best practices on critical review design while maintaining the flexibility needed to tailor these reviews to research questions that do not fit well within more structured methods of knowledge synthesis.

Authors of critical reviews generally adopt a constructivist stance, which acknowledges and capitalizes on their background, expertise, and perspectives. Such is the basis for judgements about the quality and relevance of literature along with how it might be interpreted to build understanding in relation to the focal phenomenon. 12   Thus, critical reviews engage with interpretive qualitative research traditions. The goal is not to create generalizable truth, eliminate bias, or produce perfectly replicable methods; instead, it is to capitalize on the unique outlooks developed by researchers during the review process. Rather than seeking to describe or define “what worked,” the purpose of these reviews is to reconceptualize and question assumptions, which often culminates in a proposal for a new theoretical perspective or model. 2 , 12 , 13  

The necessarily loose boundaries around critical reviews that this approach creates can cause frustration because others exploring the same issues in the same way may not draw upon the same literature or replicate a specific search strategy. More than a necessary evil, that is a strength of critical reviews because the review team and their unique interpretations and methodological decisions are considered valuable components of the research process. Thus, critical reviews are not the right review type for those seeking (as authors or readers) a definitive or final solution to a specific problem.

As with all research processes it is important for authors to try to avoid only marshaling evidence that supports their claims while ignoring contradictory data; doing so does not mean one should attempt to include everything to avoid “biased” selection. Instead, critical reviewers must be reflexive 14   and transparent about how research decisions were made. Rather than seeing disagreements among team members with different expertise or perspectives as problematic, differences can be an opportunity to challenge assumptions and ensure that decisions are well thought out. 15   Determining how literature or theories from fields outside HPE may inform the problem under review requires a deep understanding of how the phenomenon of interest has been understood in HPE. Hence, most critical review tasks cannot be turned over to a research assistant with instructions to follow a particular process.

Despite these complexities, critical reviews are indispensable when established theoretical and methodological approaches have come up short. They allow investigators to experiment by creatively and organically exploring what insights can be drawn from the juxtaposition of broad and diverse literature, to reflect on assumptions that have been built into conceptions of the problem, to consider how perspectives might change when adopting different disciplinary lenses, and to enable the development of new ideas that may “unstick” thinking.

In our analysis of recent critical reviews, methods sections varied widely. In fact, about a third included no discernible methods section at all. Nonetheless, we were able to identify several hallmarks of critical review methods that appear to illustrate best practices. We would urge caution with respect to treating these elements as linear because, in our experience and among the reviews we examined, literature search and analysis in critical reviews are most often concurrent and iterative processes.

As noted, critical reviewers take a constructivist stance. While authors of these reviews rarely state an explicit epistemological or theoretical perspective, many draw on methodological tools from other established review types or from general qualitative research to support their process. As a rare example of explicit methodological blending or borrowing, Pedersen et al drew on philosophical hermeneutics to frame the interpretive processes underlying their review on empathy in medical education. 16   We believe that offering an explicit guiding rationale for the study and evidence of efforts made to extend the authors' thinking beyond their original assumptions is more important than using a specific frame. Labels noting a particular epistemological perspective or theory should not take the place of rich descriptions of what was actually done and why. Addressing the assumptions and logic underlying the methodological decisions not only acknowledges the role of the researcher in the development of their data and interpretations, but also offers the reader more information with which to evaluate the adequacy of the arguments.

As with other review methods, reviewers should explicitly state their research questions or study objectives, 17   to provide clarity of purpose and the opportunity to judge alignment between aims and methodological choices. In the case of critical reviews, research questions are more often explorative than definitive; as such, they tend to evolve over the course of the review. 18   Research questions generally focus on integrating new literature from a variety of disciplinary perspectives to develop a new approach, understanding, or framework for thinking about the focal phenomenon or topic. For example, in striving to understand assessment practices common to graduate medical education, Gingerich et al 19   sought to develop a “synthesis of related research domains focused on understanding the source of variance in social judgments,” with the intent to “stimulate different ways of asking questions about the limitations of rater-based assessments prior to negotiating potential solutions.”

Data Generation

Literature searches conducted for a critical review should focus on identifying sources of particular relevance rather than capturing everything that has been written on the subject. This may mean finding seminal articles, such as highly cited literature reviews, that offer trustworthy overviews of the theory, assumptions, and evidence cited by researchers from several disciplines. Unlike other narrative reviewers, critical reviewers often utilize methodological tools that go beyond standard database searches to ensure exposure to unfamiliar terms and literature. Consultation with individuals with relevant content as well as theoretical or methodological expertise not represented on the review team can guide searches and ensure that the most relevant sources and key features of unfamiliar literature are captured. 16 , 20   Hand-searching reference lists and citations can prove vital in finding central texts from other fields.

In the critical reviews we examined, some authors offered no description of their search approach, while others offered exhaustive lists of search terms and databases. We suggest that reporting should offer a sense of how the search strategy was crafted, who and what resources were consulted, and what the search was (and wasn't) intended to achieve. This information can provide readers with evidence of the review's strengths and limitations. However, given that critical reviews are not intended to be exhaustive or comprehensive, the focus should be on whether the authors are likely to have uncovered valuable and insight-provoking information, not whether others can replicate the search; as such, extensive lists of search algorithm information are rarely necessary.

Appraisal and Sampling

Rather than using predefined, clear-cut inclusion and exclusion criteria, critical reviewers generally use their unique expertise and perspectives to appraise articles for inclusion based on their sense of a source's relevance to the research question and the value added by its information. As in all reviews, many resources uncovered will lack relevance or fail to meet rigor expectations, which will allow them to be easily excluded. However, critical reviewers must also make nuanced and individualized judgments to appraise the literature for quality and relevance. In doing so they will often purposively sample a small subset of the richest and/or most relevant articles gathered from their searches. Quality and information value are more important than quantity. The proximate goal is to reflect the literature well, not to stake claim to a comprehensive description, because the ultimate goal is to gain insight into the topic, not offer conclusive evidence of how often or to what magnitude something is likely to occur. For example, among the reviews we examined, authors determined inclusion in their sample based on their assessment of an article's “representativeness” of a particular discourse or approach, 21   trustworthiness of the evidence it provided, 22 , 23   conceptual contribution to the field, 9   relevance to the problem, 20   or potential for shifting discourse. 7 , 20  

These abstract and subjective evaluations can be difficult to describe concisely. We suggest that authors of critical reviews should strive to define the criteria for their judgements about inclusion and how or if they were guided by concepts such as saturation 24 , 25   or theoretical sufficiency, 26   as commonly applied in qualitative research. In other words, rigor can be demonstrated by showing that the generation of data (through expert consults, searches, and sampling) and analyses appear to do justice to the literature such that continued exploration offers lessening return. This requires investigators to reach a point where they see redundancies in the articles encountered and be able to generate a cohesive representation of the phenomenon under study. Strategies such as regular discussion among team members with diverse backgrounds and combining multiple search approaches (eg, databases, expert consultation, hand-searches) can support reflexivity, which ensures that the review team challenged their own thinking and that their stated results represent a robust picture of relevant concepts.

Analysis methods for critical reviews can align well with, and borrow from, other qualitative research methodologies. For example, in one study the authors drew on content analysis to structure the development of themes from their data. 27   Other authors used forms of discourse analysis to examine how included articles described the concepts under review, rather than focusing on the primary literature's findings or discussion. 28 , 29   Qualitative analytic approaches have great potential to enhance the rigor of critical reviews by offering structure and focus in a way that is familiar to those conducting the review and their readers. It is important that investigators be thoughtful about selecting analytical methods that are congruent with their objectives and other aspects of their methods. For example, discourse analysis might be more appropriate for examining how included sources discuss the phenomenon, whereas other techniques, such as content or thematic analysis, might be more helpful for focusing on what was discussed.

We agree with Grant and Booth that, regardless of analysis methods, a critical review's “product perhaps most easily identifies it” because critical reviews “typically manifest in a hypothesis or a model, not an answer.” 2   The result should leave the reader with a new way of thinking that is coherent and credible, resonates in their context, and has potential to shift their practice. Given that critical reviews are diverse in focus and scope—which is one of their selling points—we found no specific reporting guidelines. To ensure transparent and credible reporting, we direct investigators to general reporting guidelines for qualitative research, such as the article on standards for reporting qualitative research from O'Brien et al, 30   rather than suggesting reporting guidelines for other review types. The latter tend to focus on exhaustive reporting of search methods, rather than articulating the logic used to guide sampling strategies and analysis. Transparency in reporting is critical as there is no absolute roadmap. 18  

The most interesting research questions in HPE, in our opinion, are not “What was done?” or “Does it work?” 31 , 32   but those that instead challenge accepted assumptions about concepts and practices. To better understand the phenomena of interest and, in turn, better direct practice, HPE researchers need to be open to new ways of understanding and thinking. To this end critical reviews offer an invaluable tool for interrogating the boundaries of our approaches and knowledge and for generating novel insights that can yield creative solutions with the potential to shift both research directions and practices.

Recipient(s) will receive an email with a link to 'Critical Reviews in Health Professions Education Research' and will not need an account to access the content.

Subject: Critical Reviews in Health Professions Education Research

(Optional message may have a maximum of 1000 characters.)

Citing articles via

Never miss an issue, get new journal tables of contents sent right to your email inbox.

• Submit an Article

Affiliations

• eISSN 1949-8357
• ISSN 1949-8349
• Privacy Policy
• Get Adobe Acrobat Reader

This Feature Is Available To Subscribers Only

Sign In or Create an Account

• Open access
• Published: 30 August 2022

Barriers and facilitators to clinical behaviour change by primary care practitioners: a theory-informed systematic review of reviews using the Theoretical Domains Framework and Behaviour Change Wheel

• Melissa Mather   ORCID: orcid.org/0000-0001-9746-0131 1 ,
• Luisa M. Pettigrew 2 , 3 &
• Stefan Navaratnam 4  

Systematic Reviews volume  11 , Article number:  180 ( 2022 ) Cite this article

6741 Accesses

10 Citations

11 Altmetric

Metrics details

Understanding the barriers and facilitators to behaviour change by primary care practitioners (PCPs) is vital to inform the design and implementation of successful Behaviour Change Interventions (BCIs), embed evidence-based medicine into routine clinical practice, and improve quality of care and population health outcomes.

A theory-led systematic review of reviews examining barriers and facilitators to clinical behaviour change by PCPs in high-income primary care contexts using PRISMA. Embase, MEDLINE, PsychInfo, HMIC and Cochrane Library were searched. Content and framework analysis was used to map reported barriers and facilitators to the Theoretical Domains Framework (TDF) and describe emergent themes. Intervention functions and policy categories to change behaviour associated with these domains were identified using the COM-B Model and Behaviour Change Wheel (BCW).

Four thousand three hundred eighty-eight reviews were identified. Nineteen were included. The average quality score was 7.5/11. Reviews infrequently used theory to structure their methods or interpret their findings. Barriers and facilitators most frequently identified as important were principally related to ‘ Knowledge ’, ‘ Environmental context and resources ’ and ‘ Social influences ’ TDF domains. These fall under the ‘Capability’ and ‘Opportunity’ domains of COM-B, and are linked with interventions related to education, training, restriction, environmental restructuring and enablement. From this, three key areas for policy change include guidelines, regulation and legislation. Factors least frequently identified as important were related to ‘Motivation’ and other psychological aspects of ‘Capability’ of COM-B. Based on this, BCW intervention functions of persuasion, incentivisation, coercion and modelling may be perceived as less relevant by PCPs to change behaviour.

Conclusions

PCPs commonly perceive barriers and facilitators to behaviour change related to the ‘Capability’ and ‘Opportunity’ domains of COM-B. PCPs may lack insight into the role that ‘Motivation’ and aspects of psychological ‘Capability’ have in behaviour change and/or that research methods have been inadequate to capture their function. Future research should apply theory-based frameworks and appropriate design methods to explore these factors. With no ‘one size fits all’ intervention, these findings provide general, transferable insights into how to approach changing clinical behaviour by PCPs, based on their own views on the barriers and facilitators to behaviour change.

Systematic review registration

A protocol was submitted to the London School of Hygiene and Tropical Medicine via the Ethics and CARE form submission on 16.4.2020, ref number 21478 (available on request). The project was not registered on PROSPERO.

Peer Review reports

Known as the “second translational gap” [ 1 ], a gap in translation between evidence-based interventions and everyday clinical practice has been shown across different clinical areas and international settings [ 2 , 3 , 4 ], with numerous organisational and individual factors influencing clinical behaviour. Existing literature has shown that there is particularly wide variation in clinical behaviour in the primary care setting, which cannot be explained by case mix and clinical factors alone [ 5 , 6 ]. This variation is of particular concern, as it is widely accepted that primary care is the cornerstone of a strong healthcare system [ 7 ], and stronger primary care systems are generally associated with better and more equitable population health outcomes [ 8 , 9 , 10 , 11 ]. With an ageing population and unique evolving challenges faced in primary care, understanding the contextual barriers and facilitators to successful behaviour change by primary care practitioners (PCPs) is vital to inform the design and implementation of successful behaviour change interventions (BCIs), and is likely to offer the greatest potential improvement in quality of care and population health outcomes.

Behaviour change interventions

Changing behaviour of healthcare professionals is not easy, but has been shown to be easier when evidence-based theory informs intervention development [ 12 ]. BCIs aimed at healthcare professionals have traditionally been related to incentivisation schemes, guidelines, educational outreach, audit and feedback, printed materials and reminders [ 13 , 14 ]. These have often emerged from approaches to understanding behaviour change, focused on individual attitude-intention processes [ 15 ] and theories emphasising self-interest [ 16 , 17 ]. However, the impact of these interventions on changing clinicians’ behaviour has been found to variable [ 18 ]. Within the context of primary care, attitude-intention processes may not fully explain (lack of) behaviour change, where PCPs face competing pressures, such as caring for multiple patients with limited time, identifying pathology among undifferentiated symptoms, coping with emotional situations, managing uncertainty and keeping up-to-date with substantial volumes of new evidence. Similarly, theories of self-interest may not fully translate to PCPs. BCIs are often implemented through collective action across teams or based on financial levers [ 19 , 20 , 21 ]; however, the organisational context where PCPs work can vary from a single or group community-based practices with variable payment systems [ 22 ]. Therefore, while other healthcare professionals, patients and carers are likely to offer valuable insights, understanding PCPs’ own perspectives on the barriers and facilitators to behaviour change by PCPs is a vital starting point.

Theoretical Domains Framework and Behaviour Change Wheel

The Theoretical Domains Framework (TDF) of behaviour change [ 23 ] simplifies and integrates 33 theories and 128 key theoretical constructs related to behaviour change into a single framework for use across multiple disciplines. Theoretical constructs are grouped into 14 domains in the final paper by Michie et al. [ 24 ], encompassing individual, social and environmental factors, with the majority relating to individual motivation and capability factors [ 25 ] (Fig. 1 ). Skills can be subcategorised into cognitive and interpersonal, and physical, although cognitive and inter-personal skills are more relevant to primary care (Table 1 ).

The Behaviour Change Wheel (BCW) [ 26 ] (above) and the relationship with the Theoretical Domains Framework (TDF) [ 25 ] (below)

The TDF has been widely used to examine clinical behaviour change in healthcare settings [ 25 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 ]. Key advantages of the TDF include a comprehensive range of domains useful for synthesising large amounts of data [ 24 ] and the domains can be used to identify the types of interventions and policy strategies necessary to change those mechanisms of behaviour, using the Behaviour Change Wheel (BCW) [ 26 ]. Developed by Michie et al., the BCW can be used to characterise interventions by their “functions” and link these to behavioural targets, categorised in terms of capability (individual capacity to engage in the activity concerned), opportunity (all the factors that lie outside the individual that make the behaviour possible or prompt it) and motivation (brain processes that energize and direct behaviour), known as the COM-B System. Capability encompasses not only individual physical capability, but also psychological capability, defined as the capacity to engage in the necessary thought processes using comprehension, reasoning etc. Strategies to modify behaviour can be identified based on salient TDF and COM-B domains [ 35 ].

The evidence gap

Never having been done before, the aims of this systematic review of reviews were to:

Identify barriers and facilitators to clinical behaviour change by PCPs through the theoretical lenses of the TDF and BCW, from the perspective of PCPs.

Help inform the future development and implementation of theory-led BCIs, to embed EBM into routine clinical practice, improve quality of care and population health outcomes.

A systematic review of reviews was deemed an appropriate method to address these aims, as the literature is substantial and heterogeneous. Existing reviews of reviews have looked at different types of effective BCIs, both in primary care [ 36 , 37 ] and in healthcare in general [ 18 ], however none have looked at barriers and facilitators to PCPs’ behaviour change, using both the TDF and BCW models as a theoretical basis.

We aimed to answer the following questions:

Which TDF domains are most frequently identified as important by PCPs when barriers and facilitators to clinical behaviour change by PCPs are mapped to the TDF framework?

What important themes emerge within these TDF domains?

What intervention functions and policy strategies from the COM-B Model and BCW link to these TDF domains, and what are the implication of this?

Guidance presented in the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis [ 38 ] was used as methodological guidance to conduct the review, which provides guidance for umbrella reviews synthesising qualitative and quantitative data on topics other than intervention effectiveness. This guidance, alongside a modified version of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 39 ], were used for reporting (Additional file 1 ).

A comprehensive database search strategy was devised by MM with assistance from a librarian from LSHTM. The search was conducted by MM on April 16th 2020 without date restriction, using the following databases: Embase (1947 to 2020 April 14), MEDLINE (1946 to April week 1 2020), PsychInfo (1806 to April week 1 2020), Health Management Information Consortium (HMIC) (1979 to March 2020) and Cochrane Library (inception to April 2020). The full search strategies are shown in Additional file 2 .

In addition, grey literature was hand-searched by MM on the following websites: Public Health England [ 40 ], the University College London (UCL) Centre for Behaviour Change [ 41 ] and the National Institute for Health and Care Excellence (NICE) Evidence Search [ 42 ]. After screening and selection, reference lists of the included reviews were screened for additional relevant reviews.

Inclusion and exclusion criteria

To be included, articles had to be reviews of qualitative, quantitative or mixed methods empirical studies examining barriers and facilitators to clinical behaviour change by PCPs. Inclusion and exclusion criteria were defined using the PICo framework (Population, phenomena of Interest, Context) [ 43 ], to enable transparency and reproducibility. The element of ‘types of studies’ was added to specify types of evidence included (Table 2 ).

In most HIC settings, general practitioners/family doctors are the main providers of primary care, however often included a mix of PCPs (healthcare professionals working in primary care).

PCPs usually provide the mainstay of care in high-income settings. Common barriers and facilitators across a wide range of high-income settings provides stronger evidence for context-specific recommendations.

Types of studies:

The inclusion of all types of reviews (including but not limited to narrative and realist reviews, meta-ethnography and meta-aggregation) allows for a broader review of available literature and they are not bound by the specificity of systematic reviews [ 44 , 45 ].

Only reviews published in English were included.

Screening and selection

Results from database searches were exported to EndNote X9 software and deduplicated. Titles and abstracts were screened independently by two reviewers (MM and SN). If the abstract contained insufficient information to determine eligibility, a copy of the full text was obtained. The full texts of articles meeting the inclusion criteria were obtained and reviewed. A standardised form including elements of the PICo framework was used at the full text review stage to identify relevant articles in a consistent way. Articles which could not be accessed online were obtained by contacting authors. Authors were also contacted to obtain clarification where eligibility was unclear. Reference lists of included articles were hand searched by MM and SN to identify additional relevant articles, subject to the same screening and selection processes described.

Quality appraisal

The Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Systematic Reviews and Research Syntheses [ 38 ] was used for quality appraisal, conducted independently by MM and SN. This tool was applicable to reviews of observational studies, which constituted the majority of the included articles; therefore, all reviews, regardless of their type, were subject to quality appraisal using the JBI checklist. This also allowed for consistency in scoring and easier comparison between the reviews. A scoring system was pre-defined using a small sample of five articles and guidance in the JBI Manual for Evidence Synthesis [ 38 ]. Some articles fulfilled some but not all of the criteria for each question, which was believed to be reasonable, therefore an additional ‘partial yes’ response was added to reflect this (Additional file 3 ). With a maximum score of 11, scores were used to indicate low (≤ 4 points), moderate (> 4 and < 8 points) and high (≥ 8 points) quality. As outlined by Pope and Mays [ 46 ], the value of specific pieces of qualitative research may only emerge during the synthesis process and may still offer valuable insights despite low quality. No articles were therefore excluded on the basis of low quality scores.

Data extraction

The JBI Data Extraction Form for Reviews of Systematic Reviews and Research Syntheses [ 38 ] was adapted to extract relevant data from included reviews. A citation matrix was created to map the included empirical studies of each review and identify duplicate references.

Data analysis and synthesis

Data analysis was conducted independently by MM and SN. Previously reported analysis methods [ 25 , 47 ] were used to guide data analysis and synthesis methods. A combination of content and framework analysis was used, described in five steps:

Data extraction: full-text versions of the included articles were imported into NVivo software and data were extracted from results and discussion sections and supplementary files. Data included barriers, facilitators and factors which could be both barriers and facilitators.

Deductive analysis: extracted barriers, facilitators and factors were mapped to relevant TDF domains using component constructs of each domain, outlined by Cane et al. [ 24 ]. Almost all reported barriers and facilitators related to skills were cognitive and interpersonal, therefore the TDF domain ‘skills: physical’ was removed.

Counts were used to identify the most frequently-reported TDF domains. Owing to the vast amount of information across the included reviews, counts were also used to identify the TDF domains most frequently reported as important by authors. This was done in three ways: where authors explicitly stated they were important or salient, where they were most frequently reported where authors used frequency counts, and where authors highlighted or focused on them in the discussion section to draw main conclusions.

Inductive analysis: thematic analysis was conducted to identify emergent themes within the TDF domains most frequently identified as important to provide context to the role each barrier, facilitator and factor plays in hindering or facilitating clinical behaviour change. Owing to the vast amount of information across the included reviews, themes reported as important or salient by five or more reviews were labelled as important overall.

TDF domains most frequently identified as important were mapped to the COM-B model of the BCW to identify the associated intervention functions and policy categories.

Discrepancies between reviewers at the screening, selection, quality appraisal and analysis stages were discussed until a consensus was reached.

Search results and selection

Database searches identified 6308 records. After duplicates were removed, there were 4374 records remaining. An additional 14 articles were identified from grey literature and reference list searches. The vast majority of these articles were either not a review of empirical studies, or they did not focus on behaviour change. Where they did focus on behaviour change, they focused on patient behaviour change, rather than that of PCPs. One hundred and nine full-text articles were assessed for eligibility. Clarification was sought from 19 authors on participant roles, search strategies and synthesis methods, and was obtained from 11 authors. Nineteen reviews [ 33 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 ] were included in the data synthesis (Fig. 2 ).

Flow chart [ 66 ] of review process

Characteristics of included reviews

Of the 19 included reviews, 17 [ 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 64 , 65 ] were systematic reviews and 2 [ 33 , 63 ] were narrative reviews. The reviews were all published between 2005 and 2020. Four hundred and one empirical studies were included in total across a wide range of settings and healthcare systems. Almost all studies were conducted in high-income countries, the majority of which were conducted in Europe, USA, Canada, Australia and New Zealand. Five studies (1%) were conducted in upper-middle-income countries, including Jordan, Turkey, South Africa and Bosnia and Herzegovina. Seven reviews [ 48 , 49 , 50 , 51 , 52 , 53 , 65 ] only included qualitative studies, two [ 54 , 55 ] only included quantitative studies, and 10 [ 33 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 ] included qualitative, quantitative and/or mixed methods studies. Most studies were observational, utilising qualitative interviews and/or focus groups, or cross-sectional surveys. A minority of observational studies from six [ 55 , 58 , 59 , 62 , 63 , 64 ] reviews were part of larger intervention studies.

More than 72,000 PCPs were included in total. Seven [ 33 , 48 , 49 , 52 , 55 , 63 , 64 ] reviews only reported general practitioner (GP) or family physician (FP) data and 12 [ 50 , 51 , 53 , 54 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 65 ] reported a mix of PCP data, the majority of which were GPs, FPs, and community paediatrics and obstetrics and gynaecology physicians. Of these, five reviews [ 51 , 56 , 60 , 62 , 65 ] included primary care non-physicians, including nurse practitioners (NPs) and physician assistants. Seven reviews [ 50 , 52 , 53 , 56 , 58 , 61 , 65 ] examined behaviour related to clinical management of a range of topics, of which three specifically examined prescribing behaviour; four reviews [ 33 , 51 , 59 , 63 ] examined diagnostic processes; two [ 49 , 54 ] examined prevention; two [ 55 , 57 ] examined communication and engagement with patients; two [ 48 , 64 ] examined the practice of EBM in general; one [ 62 ] examined collaborative practice; and one [ 60 ] examined service provision. Eighteen studies were referenced by two reviews each due to overlapping phenomena of interest. The most common data synthesis methods were thematic/narrative synthesis and meta-ethnography, used by 13 reviews [ 48 , 49 , 50 , 51 , 52 , 53 , 55 , 56 , 58 , 60 , 61 , 62 , 65 ]. Six reviews [ 33 , 54 , 57 , 59 , 63 , 64 ] used framework synthesis; only three reviews [ 33 , 59 , 64 ] used existing theoretical frameworks or models, such as the TDF and COM-B. A summary of review characteristics is shown in Table 3 . Additional information is shown in Additional file 4 .

Quality of empirical studies

Three reviews [ 33 , 55 , 63 ] did not conduct quality appraisal, two of which [ 33 , 63 ] were narrative reviews. The remaining reviews used a wide range of appraisal tools to suit the type of data they included, which were primarily existing tools in their original or adapted forms. Five reviews [ 56 , 57 , 60 , 62 , 64 ] used more than one tool. The most common appraisal tools used were CASP (Critical Appraisal Skills Programme) Checklists [ 67 ] for qualitative and quantitative research, used by seven reviews [ 48 , 52 , 53 , 56 , 57 , 59 , 65 ]. There was large variation in how authors used the appraisal tools, therefore quality of studies could not be reliably compared between reviews. Detailed information is shown in Additional file 3 .

Quality of reviews

Ten reviews were of high quality, seven were of moderate-quality and two were of low quality using the JBI checklist. The highest score was 10.5/11 and the lowest was 3/11. The average score was 7.5/11, which is considered moderate quality. Reviews generally included well-evidenced recommendations for policy and practice and appropriate directives for future research. On validity, reviews scored highest on appropriate inclusion criteria for the review question, and appropriate methods used to combine studies. Reviews scored poorly on using an appropriate search strategy and assessing for publication bias. Most reviews did not justify search limits and/or did not provide evidence of a search strategy. Scores for each of the criteria are shown in Additional file 3 .

Main findings

A large number of barriers, facilitators and factors were identified by authors, often interacting with each other in a complex way (Table 4 ). As a result, some barriers and facilitators were mapped to more than one TDF domain. All TDF domains were identified. All reviews identified ‘environmental context and resources’ as important, and all but two reviews identified ‘knowledge’ and ‘social influences’ as important. TDF domains identified least frequently as important were ‘goals’, ‘intentions’ and ‘optimism’. Although ‘social/professional role and identity’, ‘skills’ and ‘emotion’ TDF domains were frequently identified, they were less frequently highlighted as important by authors. Table 4 shows how each TDF domain and COM-B domains were mapped to each of the included reviews, as well as which domains were identified as important.

Forty-two themes were identified in total across all TDF domains, 12 of which were labelled as important overall. A theme was labelled as important overall if five or more reviews identified it as important or salient. Within the ‘Knowledge’, ‘Environmental context and resources’, and ‘Social influences’ TDF domains, nine important themes emerged, of which the most frequently cited as important were ‘knowledge, awareness and uncertainty’ and ‘time, workload and general resources’. Across the remaining TDF domains, other important themes included ‘skills and competence’, ‘roles and responsibilities’, and ‘confidence in own ability’. Additional file 5 shows how themes were mapped to each TDF domain and each review, with corresponding quotes.

Capability: psychological (COM-B domain)

Knowledge (tdf domain).

Knowledge, awareness and uncertainty (theme)

Identified as important by 13 reviews [ 33 , 50 , 51 , 52 , 54 , 55 , 58 , 59 , 60 , 61 , 62 , 63 , 65 ] (average quality score 7.2/11).

Inadequate knowledge and awareness and uncertainty were identified as important barriers to depression diagnosis and management [ 51 , 56 ], recognition of insomnia [ 33 ], antibiotic prescribing in childhood infections [ 50 ] and acute respiratory tract infections (ARTIs) [ 65 ], engagement in cancer care [ 58 ], integration of genetics services [ 60 ], discussing smoking cessation [ 55 ], collaborative practice [ 62 ], management of multimorbidity [ 52 ], breast and colorectal screening in older adults [ 54 ] and chlamydia testing [ 59 , 63 ]. This varied from a lack of knowledge of the topic as a whole, to more specific skills or outcomes. For example, PCPs reported a lack of knowledge around the epidemiology and presentation of chlamydia, benefits of testing, how to take specimens, and treatment options [ 59 ]. When prescribing antibiotics for childhood infections and ARTIs, PCPs reported they tend to prescribe “just in case” when they are uncertain of the consequences of not prescribing, such as when the diagnosis is unclear, or where there is no established doctor-patient relationship [ 50 , 65 ]. There was widespread lack of knowledge within the field of genetics, including uncertainty around cancer genetics, genetic testing, genetic discrimination legislation, and local genetics service provision [ 60 ]. As well as a lack of knowledge of national guidelines and strategy [ 60 , 63 ], inadequate guidelines were reported to exacerbate a lack of knowledge. For example, a lack of attention in guidelines on how social problems affect response to depression management was reported to exacerbate PCPs’ uncertainty around their role in managing depression [ 56 ]. Lack of knowledge and uncertainty were frequently reported to cause discomfort, low confidence, and reluctance to fill certain roles.

Opportunity: physical (COM-B domain)

Environmental context and resources (tdf domain).

Time, workload and general resources (theme)

Identified as important by 13 reviews [ 33 , 48 , 50 , 51 , 53 , 54 , 55 , 58 , 59 , 60 , 61 , 63 , 64 ] (average quality score 7.3/11).

A lack of time to implement a variety of different tasks and clinical behaviours was reported, compounded by a large and complex workload and lack of general resources. A prominent barrier was time-pressured consultations, where PCPs reported difficulty in ensuring the clinician and parents are satisfied with the outcome when treating childhood infections [ 50 ], offering alternative interventions [ 53 ], listening to patients with depression [ 56 ], discussing emotions in cancer care [ 58 ] or smoking cessation with patients [ 55 ], introducing chlamydia testing and addressing sexual health-related concerns [ 63 ], recognising, diagnosing and managing child and adolescent mental health problems [ 61 ], and negotiating with patients [ 48 ]. PCPs also reported a lack of time to read and assess evidence and guidelines and reflect on their own practice [ 48 , 64 ].

Guidelines, evidence and decision-making tools (theme)

Identified as important by five reviews [ 48 , 52 , 58 , 64 , 65 ] (average quality score 7.8/11).

Guidelines were a common factor reported to affect clinical behaviour, including a lack of guidelines/guidance, questionable evidence-base, and a disjunction between guidelines and personal experience. For example, PCPs reported difficulty in adapting recommendations to individual patient circumstances and practical constraints of the consultation [ 48 , 51 , 52 ]. PCPs felt that some guidelines lack the necessary flexibility when taking patient preferences and multi-morbidity into account, which can add to complexity and even cause harm in some cases [ 52 , 64 ]. PCPs questioned the evidence-base of the guidelines due to low generalisability and narrow inclusion criteria of trials [ 48 , 64 ] and potential biased sources of research, such as pharmaceutical companies [ 64 ]. The validity of criteria used for depression diagnosis was also questioned, with national guideline criteria defining depressive disorders using symptom counts, as opposed to viewing it as a syndrome requiring aetiological and conceptual thinking [ 51 ]. For non-English PCPs, access to evidence and guidelines in their native language was reported as a major barrier to implementing EBM [ 64 ].

Financial resources and insurance coverage (theme)

Identified as important by 6 reviews [ 49 , 54 , 58 , 61 , 62 , 64 ] (average quality score 8/11).

Poor remuneration and increasing costs were common barriers reported in areas such as PCP involvement in cancer care [ 58 ], child and adolescent mental health [ 61 ] and use of EBM [ 64 ]. A major barrier to recognition and management of child and adolescent mental health problems and cancer in older adults was inadequate insurance coverage, including inadequate coverage of screening tests [ 54 ], restrictions on the number of funded therapy visits, and lack of psychiatrists [ 61 ]. As a result, increased reimbursement was identified as a potential facilitator that could increase child and adolescent mental health diagnoses [ 61 ].

Education and training (theme)

Identified as important by five reviews [ 33 , 59 , 63 , 64 , 65 ] (average quality score 5.7/11).

A lack of education and training was highlighted as an important barrier to chlamydia testing [ 59 , 63 ], recognition of insomnia [ 33 ], antibiotic prescribing [ 65 ], and use of EBM [ 64 ]. PCPs reported that undergraduate sexual health teaching is inadequate [ 63 ] and that they have a lack of appropriate training and skills to discuss sexual health, take a sexual history, offer a test, manage treatment and notify partners. This has led to a reduction in knowledge and confidence to offer testing and discuss sexual health [ 59 ]. More education and training for PCPs and undergraduate students was frequently cited as a facilitator, as PCPs felt this would increase knowledge and confidence to change behaviour. Older male PCPs were identified as potentially in need of specific education on sexual health due to cultural differences with some patients receiving chlamydia testing [ 59 ]. Some PCPs reported that trustworthy and knowledgeable educational sources are important for PCPs to feel added value, with peer-led educational meetings given as an example [ 65 ].

Opportunity: social (COM-B domain)

Social influences (tdf domain).

PCP-patient relationship and patient-centred care (theme)

Identified as important by nine reviews [ 48 , 49 , 51 , 52 , 53 , 57 , 58 , 59 , 65 ] (average quality score 8.2/11).

Some PCPs reported that preservation of the PCP-patient relationship is prioritised over adherence to guidelines, particularly if guidelines recommend rationing services, or if PCPs feel empathetic towards anxious patients [ 48 ]. This dilemma was described as unpleasant and against the principles of patient-centred medicine, but sometimes necessary to avoid the potential litigation that rationing might bring [ 48 ] and loss of patients to other practices [ 53 ]. Similarly, the desire to maintain a good relationship is sometimes in competition with the PCP’s rationing role, leading some PCPs to give patients a “quick fix” when prescribing benzodiazepines [ 53 ]. Although not always reported as important, sensitive and emotive areas of medicine appear to be particularly affected, with PCPs reporting a concern for depriving patients of hope and/or damaging the relationship if they engage in the process of ACP [ 57 ], cancer care [ 58 ], or offer chlamydia testing [ 63 ]. Specifically, PCPs worried about appearing discriminatory and judgemental towards patients by offering chlamydia testing [ 63 ], and being too intrusive and paternalistic in recommending behaviour change to patients to prevent CVD [ 49 ]. This appears to be compounded by different religious and cultural norms between the PCP and patient, particularly if patients are of non-heteronormative orientation [ 63 ].

Establishing a rapport with patients and developing a long-standing, trusting doctor-patient relationship was identified as a facilitator for information-sharing, depression diagnosis [ 51 ], multimorbidity management [ 52 ], changing prescribing behaviour of benzodiazepines [ 53 ] and PCP engagement in ACP [ 57 ].

Patient/carer characteristics (theme)

Identified as important by eight reviews [ 49 , 50 , 53 , 54 , 56 , 59 , 64 , 65 ] (average quality score 8/11).

The majority of reviews identified perceptions of patient/carer perceived ideas, concerns, expectations and motivations as important barriers to preventing CVD [ 49 ], prescribing antibiotics [ 50 , 65 ] and benzodiazepines [ 53 ], chlamydia testing [ 59 ], cancer screening in older adults [ 54 ], and implementing EBM [ 64 ]. Attitudes were often born from stigma towards patients with mental health problems, and cultural diversity between the PCP and patient. For example, PCPs were found to have ambivalent attitudes towards working with depressed people, with some PCPs describing them as “burdens” and “people who bore you” [ 56 ]. Ethnic minorities were also felt to somatise their depression, and patients with social problems were seen to be avoiding work or seeking to medicalise their problems. This was compounded by a perception that management of patients presenting with social problems is complex. These beliefs were considered alongside other complex external factors, such as perceived pressure from parents to prescribe antibiotics [ 50 ], patient expectations different from the evidence [ 64 ], and a reluctance to medicalise unhealthy lifestyles [ 49 ].

Collaboration and communication with other health professionals (theme)

Identified as important by seven reviews [ 49 , 52 , 58 , 59 , 61 , 62 , 65 ] (average quality score 7.8/11).

Poor communication and uncoordinated care between PCPs and specialists were reported to hinder medication overviews, creating a feeling of uncertainty around the role of the PCP [ 52 ]. This was compounded by the perception of hierarchy between doctors and nurses [ 62 ] and negative attitudes towards handing over power [ 59 ]. Co-management with specialists was identified as an important facilitator in CVD prevention, to reinforce specialist advice and strengthen cohesive care [ 49 ]. Specialist input was desired by some PCPs to improve the awareness of the complexity of multimorbidity among specialists and ensure all doctors ‘speak with one voice’ to avoid provoking distrust [ 52 ]. Discussion with peers and personal or local prescribing feedback were identified as important facilitators to changing antibiotic prescribing [ 65 ]. Multiple facilitators to collaboration between nurse and medical practitioners in primary care were also identified [ 62 ]. These ranged from knowing the practitioner and having a good working relationship, reciprocity without hierarchy and control, effective communication including the use of technology, mutual trust and respect, shared responsibility and support from medical practitioners.

Norms, stigma and attitudes (theme)

Identified as important by five reviews [ 56 , 59 , 60 , 63 , 65 ] (average quality score 6.6/11).

The belief that patients would feel stigmatised or embarrassed was identified as an important barrier to depression diagnosis [ 56 ], chlamydia testing [ 59 , 63 ], discussing family history and genetics [ 60 ] and antibiotic prescribing for ARTIs [ 65 ]. Stigma towards depression was seen as an important barrier to addressing psychosocial aspects of depression and commencing treatment amongst patients from the Caribbean and South Asia [ 56 ]. Stigmatising attitudes towards depressed, obese and elderly people was also reported to impact clinical decision-making [ 49 , 56 ] (see ‘Patient and carer characteristics’ section). A major facilitator to reduce stigma and raise awareness was the normalisation of chlamydia testing [ 63 ]. This may include formal policy, guidelines or government programmes, feedback on testing rates, different methods of testing such as urine samples, and the use of non-heteronormative terminology.

BCW intervention functions and policy categories

COM-B components and intervention functions linked to the three TDF domains most frequently identified as important are shown in Table 5 . Based on this, five intervention functions from the BCW were identified as most likely to be successful in changing clinical behaviour by PCPs. Associated with improving ‘capability’ are education (increasing knowledge or understanding), training (imparting skills) and enablement (promoting collective action across networks to overcome barriers, such as behavioural support for smoking cessation) interventions. Associated with improving social and physical ‘Opportunity’ are restriction (using rules to engage in the target behaviour), environmental restructuring (changing the physical or social context) and enablement interventions. The TDF domains ‘intentions’, ‘goals’ and ‘optimism’, which all map to the ‘motivation’ domain of the COM-B, were perceived as the least influential on clinical behaviour change by PCPs. As a result, BCW intervention functions including persuasion, incentivisation, coercion and modelling may be perceived as less relevant by PCPs to change behaviour.

Using the BCW, the three policy categories most commonly associated with supporting the delivery of the five intervention functions identified include guidelines (creating documents that recommend or mandate practice, including all changes to service provision), regulation (establishing rules or principles of behaviour or practice, such as establishing voluntary agreements on advertising), and legislation (making or changing laws, such as prohibiting sale or use) (Table 5 ).

Summary of main results

Evidence across all reviews was heterogeneous, examining 16 different clinical behaviours across a range of primary care settings and healthcare systems. Most reviews were of moderate-to-high quality. All themes identified from the included reviews could be mapped to at least one domain from the TDF. Barriers, facilitators and factors most commonly reported by PCPs were related to ‘knowledge’, ‘environmental context and resources’ and ‘social influences’. Within these domains, ‘knowledge, awareness and uncertainty’ and ‘time, workload and general resources’ were by far the most important themes. Not only did factors affect various clinical behaviours such as diagnosis, management, and communication and collaboration with patients and other healthcare professionals, factors were also linked to each other in a complex way, often exacerbating each other in specific contexts and circumstances. For example, a lack of knowledge and uncertainty amongst PCPs is exacerbated by a poor or unestablished PCP-patient relationship, lack of time and resources, as well as patient characteristics, such as comorbidities and social problems.

Five out of nine intervention functions from the BCW (education, training, restriction, environmental restructuring and enablement) can be linked to the three TDF domains reported as most important by PCPs to help change clinical behaviour. These can be delivered through all seven policy categories of the BCW, although those most frequently associated policy categories with all five intervention categories are guidelines, regulation and legislation.

The TDF domains ‘intentions’, ‘goals’ and ‘optimism’, which all map to the ‘motivation’ domain of the COM-B, were perceived as the least influential on clinical behaviour change by PCPs. The TDF domains ‘behavioural regulation’, ‘memory, attention and decision processes’, ‘emotion’, ‘beliefs about consequences’, ‘reinforcement’, and ‘beliefs about capabilities’ were also perceived by PCPs as less important barriers or facilitators to behaviour change. ‘Behavioural regulation’, and ‘memory, attention and decision processes’ relate to the psychological aspect of ‘capability’ and the others, again, relate to the ‘Motivation’ domain of COM-B. This is a surprising finding, as the central premise of the TDF model is that domains linked to all three areas of the COM-B (capability, opportunity and motivation) model should interact to produce behaviour [ 25 ].

Linked to the automatic and reflective ‘motivation’ domain of COM-B are BCW interventions related to incentivisation, persuasion, coercion and modelling. It is therefore also surprising to find that PCPs did not identify these as important barriers and/or facilitators as substantial evidence exists regarding the widespread use of interventions associated with incentives (e.g. financial pay for performance or reputational league tables—albeit with mixed effects, and those which may utilise persuasion, modelling and even coercion (e.g. peer-to-peer outreach or public reporting) to change aspects of PCP behaviour [ 14 , 68 , 69 , 70 ].

The limited frequency and importance given to aspects of psychological ‘Capability’ and ‘Motivation’ raises questions as to whether PCPs may have less insight into these areas or less desire to identify them as barriers or facilitator. It is possible they may be neglecting the role of brain processes involved in developing psychological capabilities, i.e. the capacity to engage in the necessary thought processes using comprehension and reasoning, and those that energize or direct behaviour, such as habitual processes, emotional responding and automatic decision-making. With most studies using qualitative interviews or cross-sectional surveys, questions may also have focused on domains researchers and BCI designers believed to be relevant, such as external factors including time, guidelines and patients.

Key policy implications

Based on our findings, three TDF domains were most commonly reported across the majority of reviews, regardless of the type of behaviour change and context. This suggests that addressing these common factors through associated BCW intervention functions of education, training, restriction, environmental restructuring and enablement, and applying associated policy categories—namely guidelines, regulation and legislation, if not already addressed, could be prioritised to encourage PCPs to change clinical practice where needed across most clinical behaviours and settings.

Strengths and limitations

The robustness of our findings is supported by several features. A broad, sensitive search strategy maximised the number of eligible reviews identified. Although the extent to which findings are applicable to a specific healthcare system or clinical context is unclear, reviews meeting the inclusion criteria focused on 16 types of clinical behaviours across a breadth of healthcare systems and included over 72,000 PCPs, providing a good starting point to identify commonalities across PCPs from a variety of different primary care settings.

Large amounts of heterogeneous data was summarised in a clear way using two evidence-based frameworks, however precise mapping of barriers, facilitators and factors to the TDF proved challenging, owing to the complex interplay between factors and interpretation of the authors of where they fitted. The integration of the TDF and BCW means important barriers and facilitators can be linked to practical strategies to address them, which does, however, rely on the validity of the frameworks themselves.

Future research

Only a minority of reviews utilised a theory-based framework to synthesise evidence. To maximise the likelihood of intervention success and encourage the use of common terminology and understanding, future research should synthesise evidence using theory-informed frameworks, such as the TDF, paying particular attention to barriers and facilitators to behaviour change associated with PCPs’ own automatic and reflective motivation, and other aspects of psychological capability related to behaviour change. Methods exploring PCP motivation and aspects of psychological capability, as well as methods less reliant on PCPs’ insight, such as direct observation, may provide more valid conclusions.

To the best of our knowledge, this is the first theory-led systematic review of reviews examining barriers and facilitators to clinical behaviour change by PCPs across a variety of primary care settings using the TDF and BCW. From the evidence available, PCPs perceive that factors related to knowledge, environmental context and resources and social influences are influential across a variety of primary care contexts, often interacting with each other in a complex way. It is vital that future research utilises theory-based frameworks and appropriate design methods to explore factors relating to automatic and reflective motivation, such as habitual processes, emotional responding and automatic decision-making that energize or direct behaviour, as well as psychological capability of PCPs, including the capacity to engage in the necessary thought processes using comprehension, reasoning etc. With no ‘one size fits all’ intervention, these findings go some way to offering general, transferable lessons in how to approach changing clinical behaviour by PCPs and improve quality of care and population health outcomes.

Availability of data and materials

All data analysed during this study are included in this published article and its additional information files.

Abbreviations

Acute respiratory tract infection

Behaviour Change Intervention

• Behaviour Change Wheel

Critical Appraisal Skills Programme

Capability Opportunity Motivation Behaviour

Cardiovascular disease

Evidence-based medicine

• Family physician
• General practitioner

Health Management Information Consortium

Joanna Briggs Institute

National Institute for Health and Care Excellence

Nurse practitioner

Primary care practitioner

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Theoretical Domains Framework

Woolf SH. The meaning of translational research and why it matters. JAMA. 2008;299(2):211–3.

Article   CAS   PubMed   Google Scholar  

Sederer LI. Science to practice: making what we know what we actually do. Schizophr Bull. 2009;35(4):714–8.

Article   PubMed   PubMed Central   Google Scholar  

Runciman WB, Hunt TD, Hannaford NA, Hibbert PD, Westbrook JI, Coiera EW, et al. CareTrack: assessing the appropriateness of health care delivery in Australia. Med J Aust. 2012;197(2):100–5.

Article   PubMed   Google Scholar  

Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet. 2003;362(9391):1225–30.

Brookes-Howell L, Hood K, Cooper L, Little P, Verheij T, Coenen S, et al. Understanding variation in primary medical care: a nine-country qualitative study of clinicians’ accounts of the non-clinical factors that shape antibiotic prescribing decisions for lower respiratory tract infection. BMJ Open. 2012;2(4):e000796.

Jaramillo E, Tan A, Yang L, Kuo Y-F, Goodwin JS. Variation among primary care physicians in prostate-specific antigen screening of older men. JAMA. 2013;310(15):1622–4.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Shi L. The impact of primary care: a focused review. Scientifica. 2012;2012:432892.

Starfield B. Policy relevant determinants of health: an international perspective. Health Policy. 2002;60:201–18.

Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970-1998. Health Serv Res. 2003;38(3):831–65.

Niti M, Ng TP. Avoidable hospitalisation rates in Singapore, 1991–1998: assessing trends and inequities of quality in primary care. J Epidemiol Community Health. 2003;57(1):17–22.

Starfield B. Primary care and health: a cross-national comparison. In: Isaacs SL, Knickman JR, editors. Generalist medicine and the US health system, Chapter 11. Princeton: Robert Wood Johnson; 2004. p. 187–96.

Google Scholar  

Abraham C, Kelly MP, West R, Michie S. The UK National Institute for Health and Clinical Excellence public health guidance on behaviour change: a brief introduction. Psychol Health Med. 2009;14(1):1–8.

Grimshaw JMSL, Thomas R, et al. Changing provider behavior: an overview of systematic reviews of interventions. Med Care. 2001;39(8):II2–45.

CAS   PubMed   Google Scholar  

Ahmed K, Hashim S, Khankhara M, Said I, Shandakumar AT, Zaman S, et al. What drives general practitioners in the UK to improve the quality of care? A systematic literature review. BMJ Open Qual. 2021;10(1):e001127.

Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process. 1991;50(2):179–211.

Article   Google Scholar  

Laffont JJ, Martimort D. The theory of incentives: the principal-agent model. Princeton: Princeton University Press; 2009.

Becker G. The economic approach to human behavior. Chicago: University of Chicago Press; 1976.

Book   Google Scholar  

Johnson MJ, May CR. Promoting professional behaviour change in healthcare: what interventions work, and why? A theory-led overview of systematic reviews. BMJ Open. 2015;5(9):e008592.

Thornton PH, Ocasio W, Lounsbury M. The institutional logics perspective: a new approach to culture, structure and process. Oxford: Oxford University Press; 2012. p. 248.

Hernes T. A process theory of organization. Oxford: Oxford University Press; 2014.

Czarniawska B. A theory of organizing. Cheltenham: Edward Elgar Publishing Ltd; 2008.

Berenson RA, Rich EC. US approaches to physician payment: the deconstruction of primary care. J Gen Intern Med. 2010;25(6):613–8.

Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care. 2005;14(1):26–33.

Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7(1):37.

Atkins L, Francis J, Islam R, O’Connor D, Patey A, Ivers N, et al. A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implement Sci. 2017;12(1):77.

Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6:42.

Michie S, Pilling S, Garety P, Whitty P, Eccles MP, Johnston M, et al. Difficulties implementing a mental health guideline: an exploratory investigation using psychological theory. Implement Sci. 2007;2(1):8.

Islam R, Tinmouth AT, Francis JJ, Brehaut JC, Born J, Stockton C, et al. A cross-country comparison of intensive care physicians’ beliefs about their transfusion behaviour: a qualitative study using the Theoretical Domains Framework. Implement Sci. 2012;7:93.

McSherry LA, Dombrowski SU, Francis JJ, Murphy J, Martin CM, O’Leary JJ, et al. ‘It’s a can of worms’: understanding primary care practitioners’ behaviours in relation to HPV using the theoretical domains framework. Implement Sci. 2012;7(1):73.

Duncan EM, Francis JJ, Johnston M, Davey P, Maxwell S, McKay GA, et al. Learning curves, taking instructions, and patient safety: using a theoretical domains framework in an interview study to investigate prescribing errors among trainee doctors. Implement Sci. 2012;7:86.

Bussières AE, Patey AM, Francis JJ, Sales AE, Grimshaw JM, the Canada PPT. Identifying factors likely to influence compliance with diagnostic imaging guideline recommendations for spine disorders among chiropractors in North America: a focus group study using the Theoretical Domains Framework. Implement Sci. 2012;7(1):82.

Murphy K, O’Connor DA, Browning CJ, French SD, Michie S, Francis JJ, et al. Understanding diagnosis and management of dementia and guideline implementation in general practice: a qualitative study using the theoretical domains framework. Implement Sci. 2014;9(1):31.

Ogeil RP, Chakraborty SP, Young AC, Lubman DI. Clinician and patient barriers to the recognition of insomnia in family practice: a narrative summary of reported literature analysed using the theoretical domains framework. BMC Fam Pract. 2020;21(1):1.

Craig LE, McInnes E, Taylor N, Grimley R, Cadilhac DA, Considine J, et al. Identifying the barriers and enablers for a triage, treatment, and transfer clinical intervention to manage acute stroke patients in the emergency department: a systematic review using the theoretical domains framework (TDF). Implement Sci. 2016;11(1):157.

Richardson M, Khouja CL, Sutcliffe K, Thomas J. Using the theoretical domains framework and the behavioural change wheel in an overarching synthesis of systematic reviews. BMJ Open. 2019;9(6):e024950.

Chauhan BF, Jeyaraman MM, Mann AS, Lys J, Skidmore B, Sibley KM, et al. Behavior change interventions and policies influencing primary healthcare professionals' practice-an overview of reviews. Implement Sci. 2017;12(1):3.

Lau R, Stevenson F, Ong BN, Dziedzic K, Treweek S, Eldridge S, et al. Achieving change in primary care—causes of the evidence to practice gap: systematic reviews of reviews. Implement Sci. 2016;11(1):40.

Aromataris E, Fernandez R, Godfrey C, Holly C, Khalil H, Tungpunkom P. Chapter 10: Umbrella reviews. In: Aromataris E, Munn Z, editors. JBI manual for evidence synthesis; 2020.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. 2020. Available from: http://www.prisma-statement.org/ . Accessed 1 June 2020.

PHE. Public Health England (PHE). https://www.gov.uk/government/organisations/public-health-england . Accessed 16 Apr 2020.

Change UCfB. UCL centre for behaviour change. https://www.ucl.ac.uk/behaviour-change/ . Accessed 16 Apr 2020.

NICE. National Institute for Health and Care Excellence (NICE) evidence search: https://www.evidence.nhs.uk/search . Accessed 16 Apr 2020.

Stern C, Jordan Z, McArthur A. Developing the review question and inclusion criteria. Am J Nurs. 2014;114(4):53–6.

Collins JA, Fauser BCJM. Balancing the strengths of systematic and narrative reviews. Hum Reprod Update. 2005;11(2):103–4.

Rycroft-Malone J, McCormack B, Hutchinson AM, DeCorby K, Bucknall TK, Kent B, et al. Realist synthesis: illustrating the method for implementation research. Implement Sci. 2012;7(1):33.

Pope C, Mays N. Qualitative research in health care. Hoboken: Wiley; 2013.

Graham-Rowe E, Lorencatto F, Lawrenson JG, Burr JM, Grimshaw JM, Ivers NM, et al. Barriers to and enablers of diabetic retinopathy screening attendance: a systematic review of published and grey literature. Diabet Med. 2018;35(10):1308–19.

Carlsen B, Glenton C, Pope C. Thou shalt versus thou shalt not: a meta-synthesis of GPs’ attitudes to clinical practice guidelines. Br J Gen Pract. 2007;57(545):971–8.

Ju I, Banks E, Calabria B, Ju A, Agostino J, Korda RJ, et al. General practitioners’ perspectives on the prevention of cardiovascular disease: systematic review and thematic synthesis of qualitative studies. BMJ Open. 2018;8(11):e021137.

Lucas PJ, Cabral C, Hay AD, Horwood J. A systematic review of parent and clinician views and perceptions that influence prescribing decisions in relation to acute childhood infections in primary care. Scand J Prim Health Care. 2015;33(1):11–20.

Schumann I. Physicians’ attitudes, diagnostic process and barriers regarding depression diagnosis in primary care: a systematic review of qualitative studies; 2012.

Sinnott C, McHugh S, Browne J, Bradley C. GPs’ perspectives on the management of patients with multimorbidity: systematic review and synthesis of qualitative research. BMJ Open. 2013;3(9):e003610.

Sirdifield C, Anthierens S, Creupelandt H, Chipchase SY, Christiaens T, Siriwardena AN. General practitioners’ experiences and perceptions of benzodiazepine prescribing: systematic review and meta-synthesis. BMC Fam Pract. 2013;14:191.

Vedel I, Puts MTE, Monette M, Monette J, Bergman H. Barriers and facilitators to breast and colorectal cancer screening of older adults in primary care: a systematic review. J Geriatr Oncol. 2011;2(2):85–98.

Vogt F, Hall S, Marteau TM. General practitioners’ and family physicians’ negative beliefs and attitudes towards discussing smoking cessation with patients: a systematic review. Addiction. 2005;100(10):1423–31.

Barley EA, Murray J, Walters P, Tylee A. Managing depression in primary care: a meta-synthesis of qualitative and quantitative research from the UK to identify barriers and facilitators. BMC Fam Pract. 2011;12:47.

De Vleminck A, Houttekier D, Pardon K, Deschepper R, van Audenhove C, Stichele RV, et al. Barriers and facilitators for general practitioners to engage in advance care planning: a systematic review. Scand J Prim Health Care. 2013;31(4):215–26.

Lawrence RA, McLoone JK, Wakefield CE, Cohn RJ. Primary care physicians’ perspectives of their role in cancer care: a systematic review. J Gen Intern Med. 2016;31(10):1222–36.

McDonagh LK, Saunders JM, Cassell J, Curtis T, Bastaki H, Hartney T, et al. Application of the COM-B model to barriers and facilitators to chlamydia testing in general practice for young people and primary care practitioners: a systematic review. Implement Sci. 2018;13(1):130.

Mikat-Stevens NA, Larson IA, Tarini BA. Primary-care providers’ perceived barriers to integration of genetics services: a systematic review of the literature. Genet Med. 2015;17(3):169–76.

O'Brien D, Harvey K, Howse J, Reardon T, Creswell C. Barriers to managing child and adolescent mental health problems: a systematic review of primary care practitioners’ perceptions. Br J Gen Pract. 2016;66(651):e693–707.

Schadewaldt V, McInnes E, Hiller JE, Gardner A. Views and experiences of nurse practitioners and medical practitioners with collaborative practice in primary health care - an integrative review. BMC Fam Pract. 2013;14:132.

Yeung A, Temple-Smith M, Fairley C, Hocking J. Narrative review of the barriers and facilitators to chlamydia testing in general practice. Aust J Prim Health. 2015;21(2):139–47.

Zwolsman S, te Pas E, Hooft L, Wieringa-de Waard M, van Dijk N. Barriers to GPs’ use of evidence-based medicine: a systematic review. Br J Gen Pract. 2012;62(600):e511–21.

Tonkin-Crine S, Yardley L, Little P. Antibiotic prescribing for acute respiratory tract infections in primary care: a systematic review and meta-ethnography. J Antimicrob Chemother. 2011;66(10):2215–23.

Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097.

CASP. Critical Appraisal Skills Programme (CASP) appraisal checklists. Available from: https://casp-uk.net/casp-tools-checklists/ . Accessed 1 June 2020.

Khan N, Rudoler D, McDiarmid M, Peckham S. A pay for performance scheme in primary care: Meta-synthesis of qualitative studies on the provider experiences of the quality and outcomes framework in the UK. BMC Fam Pract. 2020;21(1):142.

Eijkenaar F, Emmert M, Scheppach M, Schoffski O. Effects of pay for performance in health care: A systematic review of systematic reviews. Health Policy. 2013;110(2-3):115–30.

Campanella P, Vukovic V, Parente P, Sulejmani A, Ricciardi W, Specchia ML. The impact of public reporting on clinical outcomes: a systematic review and meta-analysis. BMC Health Serv Res. 2016;16:296.

Download references

Acknowledgements

LP is funded by a National Institute for Health Research (NIHR) Doctoral Research Fellowship. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

This review was led by MM as her Master’s in Public Health thesis at the London School of Hygiene and Tropical Medicine (LSHTM), no funding was received for this. LP is funded by a NIHR Doctoral Research Fellowship. No funding was received by SN.

Author information

Authors and affiliations.

Maidstone and Tunbridge Wells NHS Trust, Tunbridge Wells Hospital, Tonbridge Road, Pembury, Tunbridge Wells, Kent, TN2 4QJ, UK

Melissa Mather

Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Pl, London, WC1H 9SH, UK

Luisa M. Pettigrew

UCL Department of Primary Care and Population Health, UCL Medical School, Upper Third Floor, Rowland Hill Street, London, NW3 2PF, UK

Northern Devon Healthcare NHS Trust, North Devon District Hospital, Raleigh Heights, Barnstaple, EX31 4JB, UK

Stefan Navaratnam

You can also search for this author in PubMed   Google Scholar

Contributions

MM co-designed the project title and methods, conducted the searches, screening, selection, quality appraisal, data extraction, data analysis and synthesis, and drafted the report. LP co-designed the project title and methods and revised the draft. SN conducted screening, selection, quality appraisal, data extraction and data analysis. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Melissa Mather .

Ethics declarations

Ethics approval and consent to participate.

Not applicable.

Consent for publication

Competing interests.

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1..

PRISMA checklist.

Additional file 2.

Search strategy. Search concepts, keywords and MeSH terms used to derive search strategies. Search strategy.

Additional file 3.

Quality appraisal. Adapted scoring system for the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Systematic Reviews and Research Syntheses. Quality of empirical studies: appraisal instruments and quality scores. Quality appraisal criteria.

Additional file 4.

Additional data. Characteristics of included reviews.

Additional file 5.

Evidence mapping. Mapping of emergent themes to the Theoretical Domains Framework (TDF). Evidence table.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Mather, M., Pettigrew, L.M. & Navaratnam, S. Barriers and facilitators to clinical behaviour change by primary care practitioners: a theory-informed systematic review of reviews using the Theoretical Domains Framework and Behaviour Change Wheel. Syst Rev 11 , 180 (2022). https://doi.org/10.1186/s13643-022-02030-2

Download citation

Received : 13 April 2022

Accepted : 17 July 2022

Published : 30 August 2022

DOI : https://doi.org/10.1186/s13643-022-02030-2

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Primary care
• Family medicine
• General practice
• Family doctor
• Theoretical domains framework
• Behaviour change
• Quality improvement

Systematic Reviews

ISSN: 2046-4053

• Submission enquiries: Access here and click Contact Us
• General enquiries: [email protected]

• 0  ₹ 0 items

Research & Reviews: A Journal of Health Professions

1,450  ₹ – 8,880  ₹

Additional information

About journal.

• Reviews (0)

Research & Reviews: A Journal of Health Professions (RRJoHP)  is a print and e-journal focused towards the rapid publication of fundamental research papers in all areas of concerning various current and forthcoming radical new health professions across the globe and the latest cutting edge advancements in healthcare. It’s a triannual journal, started in 2011 .

pISSN: 2348-9537

eISSN: 2277–6192

Journal DOI no.: 10.37591/RRJoHP

Indexed in:  DRJI, Citefactor, Journal TOC, Google Scholar,  ICV = 64.13

Editor-In-Chief

Prof. Nirmal Kumar Ganguly,

‘Padma Bhushan’, Honorary Senior Research Professor (Clinical Research), Institute of Liver & Biliary Sciences, New Delhi-110070, India. Professor (GRIPMER), The Ganga Ram Institute for Postgraduate Medical Education & Research, Sir Ganga Ram Hospital, New Delhi-110060, India. Visiting Professor of Eminence, Translational Health Science & Technology Institute, Faridabad-121001, India ganguly1nk[at]gmail[dot]com

COMPLETE EDITORIAL BOARD

  Focus and Scope Covers

• Cardiovascular Technology and Chiropractor
• Cytotechnologist and Dietetic
• Podiatry, Radiology (X-Ray) and Respiratory Therapy
• Speech therapy, Surgical (O.R.) Technology and Ultrasound Technology
• Clinical Laboratory Technology
• Medical laboratory science
• Nutrition and Dietetics
• Health care system
• Medication Reconciliation
• Risk management
• Theoretical and Practical Aspects of Health care

All contributions to the journal are rigorously refereed and are selected on the basis of quality and originality of the work. The journal publishes the most significant new research papers or any other original contribution in the form of reviews and reports on new concepts in all areas pertaining to its scope and research being done in the world, thus ensuring its scientific priority and significance.

Peer Review Process

Author Guidelines

Related products

Research & Reviews: A Journal of Immunology

Research & Reviews: A Journal of Toxicology

Research & Reviews: A Journal of Dentistry

Session expired

Please log in again. The login page will open in a new tab. After logging in you can close it and return to this page.

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

• View all journals
• Explore content
• About the journal
• Publish with us
• Sign up for alerts
• BOOK REVIEW
• 29 March 2024

The great rewiring: is social media really behind an epidemic of teenage mental illness?

• Candice L. Odgers 0

Candice L. Odgers is the associate dean for research and a professor of psychological science and informatics at the University of California, Irvine. She also co-leads international networks on child development for both the Canadian Institute for Advanced Research in Toronto and the Jacobs Foundation based in Zurich, Switzerland.

You can also search for this author in PubMed   Google Scholar

You have full access to this article via your institution.

Social-media platforms aren’t always social. Credit: Getty

The Anxious Generation: How the Great Rewiring of Childhood is Causing an Epidemic of Mental Illness Jonathan Haidt Allen Lane (2024)

Two things need to be said after reading The Anxious Generation . First, this book is going to sell a lot of copies, because Jonathan Haidt is telling a scary story about children’s development that many parents are primed to believe. Second, the book’s repeated suggestion that digital technologies are rewiring our children’s brains and causing an epidemic of mental illness is not supported by science. Worse, the bold proposal that social media is to blame might distract us from effectively responding to the real causes of the current mental-health crisis in young people.

Haidt asserts that the great rewiring of children’s brains has taken place by “designing a firehose of addictive content that entered through kids’ eyes and ears”. And that “by displacing physical play and in-person socializing, these companies have rewired childhood and changed human development on an almost unimaginable scale”. Such serious claims require serious evidence.

Collection: Promoting youth mental health

Haidt supplies graphs throughout the book showing that digital-technology use and adolescent mental-health problems are rising together. On the first day of the graduate statistics class I teach, I draw similar lines on a board that seem to connect two disparate phenomena, and ask the students what they think is happening. Within minutes, the students usually begin telling elaborate stories about how the two phenomena are related, even describing how one could cause the other. The plots presented throughout this book will be useful in teaching my students the fundamentals of causal inference, and how to avoid making up stories by simply looking at trend lines.

Hundreds of researchers, myself included, have searched for the kind of large effects suggested by Haidt. Our efforts have produced a mix of no, small and mixed associations. Most data are correlative. When associations over time are found, they suggest not that social-media use predicts or causes depression, but that young people who already have mental-health problems use such platforms more often or in different ways from their healthy peers 1 .

These are not just our data or my opinion. Several meta-analyses and systematic reviews converge on the same message 2 – 5 . An analysis done in 72 countries shows no consistent or measurable associations between well-being and the roll-out of social media globally 6 . Moreover, findings from the Adolescent Brain Cognitive Development study, the largest long-term study of adolescent brain development in the United States, has found no evidence of drastic changes associated with digital-technology use 7 . Haidt, a social psychologist at New York University, is a gifted storyteller, but his tale is currently one searching for evidence.

Of course, our current understanding is incomplete, and more research is always needed. As a psychologist who has studied children’s and adolescents’ mental health for the past 20 years and tracked their well-being and digital-technology use, I appreciate the frustration and desire for simple answers. As a parent of adolescents, I would also like to identify a simple source for the sadness and pain that this generation is reporting.

A complex problem

There are, unfortunately, no simple answers. The onset and development of mental disorders, such as anxiety and depression, are driven by a complex set of genetic and environmental factors. Suicide rates among people in most age groups have been increasing steadily for the past 20 years in the United States. Researchers cite access to guns, exposure to violence, structural discrimination and racism, sexism and sexual abuse, the opioid epidemic, economic hardship and social isolation as leading contributors 8 .

How social media affects teen mental health: a missing link

The current generation of adolescents was raised in the aftermath of the great recession of 2008. Haidt suggests that the resulting deprivation cannot be a factor, because unemployment has gone down. But analyses of the differential impacts of economic shocks have shown that families in the bottom 20% of the income distribution continue to experience harm 9 . In the United States, close to one in six children live below the poverty line while also growing up at the time of an opioid crisis, school shootings and increasing unrest because of racial and sexual discrimination and violence.

The good news is that more young people are talking openly about their symptoms and mental-health struggles than ever before. The bad news is that insufficient services are available to address their needs. In the United States, there is, on average, one school psychologist for every 1,119 students 10 .

Haidt’s work on emotion, culture and morality has been influential; and, in fairness, he admits that he is no specialist in clinical psychology, child development or media studies. In previous books, he has used the analogy of an elephant and its rider to argue how our gut reactions (the elephant) can drag along our rational minds (the rider). Subsequent research has shown how easy it is to pick out evidence to support our initial gut reactions to an issue. That we should question assumptions that we think are true carefully is a lesson from Haidt’s own work. Everyone used to ‘know’ that the world was flat. The falsification of previous assumptions by testing them against data can prevent us from being the rider dragged along by the elephant.

A generation in crisis

Two things can be independently true about social media. First, that there is no evidence that using these platforms is rewiring children’s brains or driving an epidemic of mental illness. Second, that considerable reforms to these platforms are required, given how much time young people spend on them. Many of Haidt’s solutions for parents, adolescents, educators and big technology firms are reasonable, including stricter content-moderation policies and requiring companies to take user age into account when designing platforms and algorithms. Others, such as age-based restrictions and bans on mobile devices, are unlikely to be effective in practice — or worse, could backfire given what we know about adolescent behaviour.

A third truth is that we have a generation in crisis and in desperate need of the best of what science and evidence-based solutions can offer. Unfortunately, our time is being spent telling stories that are unsupported by research and that do little to support young people who need, and deserve, more.

Nature 628 , 29-30 (2024)

doi: https://doi.org/10.1038/d41586-024-00902-2

Heffer, T., Good, M., Daly, O., MacDonell, E. & Willoughby, T. Clin. Psychol. Sci. 7 , 462–470 (2019).

Article   Google Scholar  

Hancock, J., Liu, S. X., Luo, M. & Mieczkowski, H. Preprint at SSRN https://doi.org/10.2139/ssrn.4053961 (2022).

Odgers, C. L. & Jensen, M. R. J. Child Psychol. Psychiatry 61 , 336–348 (2020).

Article   PubMed   Google Scholar  

Orben, A. Soc . Psychiatry Psychiatr. Epidemiol. 55 , 407–414 (2020).

Valkenburg, P. M., Meier, A. & Beyens, I. Curr. Opin. Psychol. 44 , 58–68 (2022).

Vuorre, M. & Przybylski, A. K. R. Sci. Open Sci. 10 , 221451 (2023).

Miller, J., Mills, K. L., Vuorre, M., Orben, A. & Przybylski, A. K. Cortex 169 , 290–308 (2023).

Martínez-Alés, G., Jiang, T., Keyes, K. M. & Gradus, J. L. Annu. Rev. Publ. Health 43 , 99–116 (2022).

Danziger, S. Ann. Am. Acad. Pol. Soc. Sci. 650 , 6–24 (2013).

US Department of Education. State Nonfiscal Public Elementary/Secondary Education Survey 2022–2023 (National Center for Education Statistics, 2024).

Google Scholar  

Download references

Competing Interests

The author declares no competing interests.

Related Articles

• Public health

Use fines from EU social-media act to fund research on adolescent mental health

Correspondence 09 APR 24

AI-fuelled election campaigns are here — where are the rules?

World View 09 APR 24

Why loneliness is bad for your health

News Feature 03 APR 24

Circulating myeloid-derived MMP8 in stress susceptibility and depression

Article 07 FEB 24

Only 0.5% of neuroscience studies look at women’s health. Here’s how to change that

World View 21 NOV 23

Bird flu outbreak in US cows: why scientists are concerned

News Explainer 08 APR 24

Adopt universal standards for study adaptation to boost health, education and social-science research

Correspondence 02 APR 24

Abortion-pill challenge provokes doubt from US Supreme Court

News 26 MAR 24

Equipment Service Technician

Memphis, Tennessee

St. Jude Children's Research Hospital (St. Jude)

Supv-Environmental Services

Biomedical technician, maintenance assistant - liquid nitrogen handling, building automation systems engineer (hvac and lighting).

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Quick links

• Explore articles by subject
• Guide to authors
• Editorial policies

Research & Reviews: A Journal of Health Professions

• Other Journals
• For Readers
• For Authors
• For Librarians
• Announcements
• Author Guideline
• Referencing Pattern
• Sample Research Paper
• Editorial Board
• Manuscript Withdrawal Policy
• STM Copyright Licensing Form
• Publication Ethics & Malpractice Statement

Fill in this form to register with this site.

Click here if you are already registered with this or another journal on this site.

* Denotes required field

Privacy Statement

The names and email addresses entered in this journal site will be used exclusively for the stated purposes of this journal and will not be made available for any other purpose or to any other party.

This paper is in the following e-collection/theme issue:

Published on 9.4.2024 in Vol 26 (2024)

Moderating Effect of Coping Strategies on the Association Between the Infodemic-Driven Overuse of Health Care Services and Cyberchondria and Anxiety: Partial Least Squares Structural Equation Modeling Study

Authors of this article:

Original Paper

• Richard Huan Xu 1 , PhD   ; 
• Caiyun Chen 2 , PhD  

1 Department of Rehabilitation Sciences, Faculty of Health and Social Sciences, Hong Kong Polytechnic University, Hung Hom, China (Hong Kong)

2 Nanjing Academy of Administration, Nanjing, China

Corresponding Author:

Richard Huan Xu, PhD

Department of Rehabilitation Sciences

Faculty of Health and Social Sciences

Hong Kong Polytechnic University

11 Yuk Choi Rd

China (Hong Kong)

Phone: 852 27664199

Email: [email protected]

Background: The COVID-19 pandemic has led to a substantial increase in health information, which has, in turn, caused a significant rise in cyberchondria and anxiety among individuals who search for web-based medical information. To cope with this information overload and safeguard their mental well-being, individuals may adopt various strategies. However, the effectiveness of these strategies in mitigating the negative effects of information overload and promoting overall well-being remains uncertain.

Objective: This study aimed to investigate the moderating effect of coping strategies on the relationship between the infodemic-driven misuse of health care and depression and cyberchondria. The findings could add a new dimension to our understanding of the psychological impacts of the infodemic, especially in the context of a global health crisis, and the moderating effect of different coping strategies on the relationship between the overuse of health care and cyberchondria and anxiety.

Methods: The data used in this study were obtained from a cross-sectional web-based survey. A professional survey company was contracted to collect the data using its web-based panel. The survey was completed by Chinese individuals aged 18 years or older without cognitive problems. Model parameters of the relationships between infodemic-driven overuse of health care, cyberchondria, and anxiety were analyzed using bootstrapped partial least squares structural equation modeling. Additionally, the moderating effects of coping strategies on the aforementioned relationships were also examined.

Results: A total of 986 respondents completed the web-based survey. The mean scores of the Generalized Anxiety Disorder-7 and Cyberchondria Severity Scale-12 were 8.4 (SD 3.8) and 39.7 (SD 7.5), respectively. The mean score of problem-focused coping was higher than those of emotion- and avoidant-focused coping. There was a significantly positive relationship between a high level of infodemic and increased overuse of health care (bootstrapped mean 0.21, SD 0.03; 95% CI 0.1581-0.271). The overuse of health care resulted in more severe cyberchondria (bootstrapped mean 0.107, SD 0.032) and higher anxiety levels (bootstrapped mean 0.282, SD 0.032) in all the models. Emotion (bootstrapped mean 0.02, SD 0.008 and 0.037, SD 0.015)- and avoidant (bootstrapped mean 0.026, SD 0.009 and 0.049, SD 0.016)-focused coping strategies significantly moderated the relationship between the overuse of health care and cyberchondria and that between the overuse of health care and anxiety, respectively. Regarding the problem-based model, the moderating effect was significant for the relationship between the overuse of health care and anxiety (bootstrapped mean 0.007, SD 0.011; 95% CI 0.005-0.027).

Conclusions: This study provides empirical evidence about the impact of coping strategies on the relationship between infodemic-related overuse of health care services and cyberchondria and anxiety. Future research can build on the findings of this study to further explore these relationships and develop and test interventions aimed at mitigating the negative impact of the infodemic on mental health.

Introduction

Covid-19–related mental health problems.

In today’s technologically advancing society, widespread and rapid digitization has led to a substantial increase in the use of social media and the internet. This, in turn, has facilitated the rapid dissemination of all types of information. Although this can be beneficial in filling information gaps quickly, it has its drawbacks. A prominent drawback is the amplification of harmful messages, which can have negative effects on individuals [ 1 , 2 ]. The World Health Organization (WHO) acknowledged the presence of an infodemic during the COVID-19 pandemic and subsequent responses. WHO defines an infodemic as an excessive amount of information, including both accurate and inaccurate content [ 3 ]. This abundance of information makes it difficult for individuals to distinguish reliable sources from unreliable sources and to find trustworthy guidance when they need it.

Excessive use of health care services can have adverse effects on individuals and the overall sustainability of health care systems. Although challenges associated with the overuse of health care services were evident before the COVID-19 pandemic [ 4 , 5 ], the urgent need for sustainable health care systems was exacerbated by the pandemic. Because large portions of the population were instructed to self-isolate at home and had limited access to health care professionals during the pandemic, the internet became the primary source of information for numerous individuals seeking answers to health-related questions. However, the abundance of web-based information, including both true and false content, can leave individuals feeling overwhelmed and struggling to make informed choices. This information overload can lead to depression because individuals bombarded with conflicting messages may feel unsure of what to believe [ 6 - 10 ].

Besides depression, cyberchondria has also emerged as a significant public health challenge since the onset of the COVID-19 pandemic. This refers to the repeated and excessive search for health-related information on the internet, leading to a significant increase in distress or anxiety [ 11 ]. Although the global emergency caused by the COVID-19 pandemic is over, telehealth remains a growing trend. An increasing number of studies have indicated that telehealth can improve health care access, outcomes, and affordability by offering a bridge to care and an opportunity to reinvent web-based care models [ 12 ]. However, increasing internet exposure increases the risk of cyberchondria, especially under conditions of uncertainty and increased risk, due to the large volume of information it contains. Thus, it is crucial to understand how to provide support and guidance to help people adopt appropriate strategies for using web-based resources safely in the context of an infodemic.

Current Research on the COVID-19–Related Infodemic

The harms of infodemic are well documented. An Italian study suggested developing early warning signals for an infodemic, which can provide important cues for implementing effective communication strategies to mitigate misinformation [ 13 ]. Other studies have shown that successful use of coping strategies can help individuals manage stressful events and reduce negative emotions during a pandemic. For example, Yang [ 14 ] found a positive correlation between emotion-focused coping and cyberbullying and depression during the COVID-19 pandemic. A large-scale UK study indicated that supportive coping was associated with a faster decrease in depression and anxiety symptoms [ 15 ]. Shigeto et al [ 16 ] emphasized the importance of training young adults to develop resilience, flexibility, and specific coping skills to offset the psychological effects of significant lifestyle changes resulting from pandemics or other health crises in the future. A recent study used machine learning technology to enhance the accuracy and efficiency of automated fact-checking and infodemic risk management at a strategic level [ 17 ]. However, the impact of coping strategies on the relationship among the infodemic, cyberchondria, and anxiety at an individual level during the COVID-19 pandemic is still unknown.

Importance of Coping Strategies

The ability of individuals to discern and adopt appropriate coping strategies can have a profound impact on their mental health, particularly in relation to conditions such as depression and anxiety. The ability to select and implement coping strategies is not uniform across all individuals, and these differences can significantly influence the trajectory of their mental health outcomes. For some, the ability to effectively choose and implement coping strategies can serve as a protective factor, mitigating the severity of the symptoms of depression or anxiety and promoting overall health and well-being. Conversely, for others, inability or difficulty in selecting and implementing effective coping strategies can exacerbate mental health conditions, leading to increased severity of depression and anxiety. This, in turn, can have detrimental effects on individuals’ overall health and well-being. Therefore, understanding the factors that influence individuals’ ability to select and implement effective coping strategies is of paramount importance in the field of mental health research and intervention [ 18 ].

Research has demonstrated the importance of appropriate coping mechanisms in managing mental health problems. Coping strategies, which are essential for dealing with stress or challenging situations, can be categorized into 3 primary types: emotion focused, problem focused, and avoidant focused [ 19 ]. Emotion-focused strategies are centered around managing and regulating emotions. They serve as a means to cope with stress or difficult situations. These strategies might involve seeking emotional support from others, using relaxation techniques, or practicing mindfulness. In contrast, problem-focused strategies actively address the problem or stressor. These strategies might encompass problem-solving, devising a plan of action, or seeking information and resources to effectively tackle the situation. Avoidant-focused strategies involve evading or distancing oneself from the stressor or problem. These strategies might include denial, distraction, or engaging in activities to escape or avoid contemplating the issue [ 18 ]. The effectiveness of different coping strategies can vary depending on the situation. Individuals often use different or a combination of strategies, tailoring their approach to their circumstances.

Coping Strategies in the COVID-19–Related Infodemic

From a social perspective, this study underscores the importance of mental health in the context of public health emergencies such as the COVID-19 pandemic. It highlights the need for society to recognize and address the mental health burden that such emergencies can place on individuals, particularly in relation to the phenomenon of cyberchondria, which is the unfounded escalation of concerns about common symptoms based on reviews of web-based literature and resources.

Practically, this study provides valuable insights for policy makers and practitioners. It emphasizes the need for the development of effective coping strategies and programs to manage the negative impact of an overload of misinformation and disinformation on mental health. This is particularly relevant in the digital age, where individuals have access to a plethora of information, not all of which is accurate or reliable. Policy makers and practitioners can use the findings of this study to design interventions that not only provide accurate information but also equip individuals with the skills to distinguish reliable sources from unreliable sources and to cope with the anxiety that misinformation can cause. From a research standpoint, this study fills a gap in the literature by assessing the impact of the infodemic on cyberchondria and the moderating effect of coping strategies in this relationship. It opens up new avenues of research into the complex interplay among public health emergencies, infodemic, cyberchondria, and coping strategies. Future research could build on the findings of this study to further explore these relationships and develop and test interventions aimed at mitigating the negative impact of infodemic on mental health.

Objective of the Study

Currently, the association between the overuse of health care services and mental health problems in the context of an infodemic remains unclear, as is the moderating effect of different coping strategies on this association. Thus, this study investigated the moderating effect of coping strategies on the relationship between the infodemic-driven misuse of health care and depression and cyberchondria.

Hypotheses of the Study

The study used a hypothesis-driven format. Specifically, there are five hypotheses: (1) a positive relationship exists between infodemic and the misuse of health care, (2) a positive relationship exists between the misuse of health care and depressive disorders, (3) a positive relationship exists between the misuse of health care and cyberchondria, (4) coping strategies mitigate the negative effect of the misuse of health care on depression, and (5) coping strategies mitigate the negative effect of the misuse of health care on cyberchondria. Hypotheses 2-5 are separately evaluated for the three types of coping strategies: problem focused (H2.1), emotion focused (H2.2), and avoidant focused (H2.3).

Study Design and Sample Size

The data used in this study were obtained from a cross-sectional and web-based survey conducted between April and May 2023 in China.

There is no gold standard for sample estimation in partial least squares structural equation modeling (PLS-SEM). Following Hair et al [ 20 ], we set the significance level at 5% and the minimum path coefficients to between 0.05 and 0.1. Based on these criteria, a minimum sample size of 619 was determined.

Data Source and Collection

A professional surveying company, WenJuanXing, was invited to collect the data through its web-based panel. The panel of WenJuanXing consists of 2.6 million members, with an average of over 1 million questionnaire respondents daily. At the beginning of the project, a survey manager collaborated with the research team to screen and recruit participants using the company’s internal social network platform. All of the eligible panel members received a survey invitation, and a voluntary response sampling method was used. The survey manager checked the data quality using WenJuanXing’s artificial intelligence data quality control system to ensure that respondents met our inclusion criteria and provided valid responses, thus ensuring a high level of data accuracy and integrity. The inclusion criteria were (1) aged older than 18 years, (2) able to understand and read Chinese, and (3) agreed to provide informed consent. All eligible respondents were invited to participate in a web-based survey. The first section of the survey was the informed consent, which the participants were required to read and agree to before proceeding. All the participants who agreed to participate in the survey were asked to complete six questionnaires covering (1) demographics and socioeconomic status, (2) COVID-19 information–related questions, (3) a cyberchondria questionnaire, (4) an eHealth literacy questionnaire, (5) an anxiety questionnaire, and (6) a coping strategy questionnaire. The English translations of the questionnaires are presented in Multimedia Appendix 1 . To ensure data quality, we collaborated with the survey company and implemented various indicators. We monitored completion time, excluding responses that took less than 6 minutes. We also tracked ID addresses, ensuring that each ID address could only complete the questionnaire once. To minimize random errors, we used an artificial intelligence formula developed by the survey company to identify and filter any response patterns that appeared to be generated in parallel.

Ethical Considerations

The study protocol and informed consent process were approved by the institutional review board of the Hong Kong Polytechnic University (HSEARS20230502006). Informed consent was collected from all participants. The survey was conducted anonymously, and no personally identifiable information was collected. No compensation was provided by the research team.

Instruments

Cyberchondria severity scale-12.

The Cyberchondria Severity Scale-12 (CSS-12), derived from the 33-item CSS, was used to measure the severity of cyberchondria. The CSS-12 exhibited equally good psychometric properties as the original version and has been validated in Chinese populations [ 21 ]. The CSS-12 items are scored on a Likert-type scale ranging from 1=“never” to 5=“always,” giving total scores ranging from 12 to 60. A higher score indicates a higher severity of suspected cyberchondria. The psychometric properties of the Chinese version of the CSS-12 were reported by Peng et al [ 22 ].

Generalized Anxiety Disorder Assessment

The Generalized Anxiety Disorder Assessment-7 (GAD-7) was used to screen for generalized anxiety disorder and related anxiety disorders [ 23 ]. This scale consists of 7 items designed to assess the frequency of anxiety symptoms during the 2 weeks preceding the survey. The GAD-7 score is calculated by assigning scores of 0, 1, 2, and 3 to the response categories of “not at all,” “several days,” “more than half the days,” and “nearly every day,” respectively. The scores of the 7 questions are then summed, giving a total ranging from 0 to 21, with higher scores indicating a higher severity of anxiety disorders. Many studies have reported the psychometric properties of the GAD-7 in Chinese populations, such as that conducted by Sun et al [ 24 ].

Coping Orientation to Problems Experienced Inventory

The Coping Orientation to Problems Experienced Inventory (Brief-COPE) is a 28-item self-report questionnaire used to measure effective and ineffective strategies for coping with a stressful life event [ 25 ]. The Brief-COPE assesses how a person deals with stressors in their daily life. The questionnaire measures 3 coping strategy dimensions: problem focused, emotion focused, and avoidant focused [ 26 ]. Each item is rated on a 4-point scale. The scores for the 3 overarching coping styles are calculated as average scores. This is done by dividing the sum of the item scores by the number of items. These average scores indicate the extent to which the respondent engages in each coping style. A higher score indicates that the respondent does not have many coping skills. The Chinese version of the Brief-COPE and its psychometric properties in Chinese populations were reported by Wang et al [ 27 ].

Infodemic- and Misinformation-Driven Overuse of Health Care Services

The COVID-19–related infodemic and misinformation-driven medical misbehavior were assessed using 2 self-developed items. The first item was “Do you believe there is an excessive amount of information regarding the COVID virus and vaccine on a daily basis?” The second item was “Has misinformation or disinformation about COVID-19 led you to engage in the overuse of health care services (eg, frequently visiting the doctor/psychiatrist or buying unnecessary medicine)?” The respondents were required to indicate their response to these 2 questions by selecting 1 of 2 options presented dichotomously: yes or no.

Statistical Analysis

Descriptive statistics were used to describe the participants’ background characteristics. Continuous variables (eg, age) were calculated as means and SDs. Categorical variables (eg, sex) were calculated as frequencies and proportions. The Pearson correlation coefficient ( r ) was used to examine the association between measures, where  r ≥0.3 and  r ≥0.5 indicated moderate and large effects, respectively [ 28 , 29 ].

In this study, we used PLS-SEM to estimate the research model parameters, as it works efficiently with small samples and complex models. Compared with covariance-based structural equation modeling, PLS-SEM has several advantages, such as the ability to handle non-normal data and small samples [ 30 ]. Unlike covariance-based structural equation modeling, which focuses on confirming theories, PLS-SEM is a causal-predictive approach that explains variance in the model’s dependent variables [ 31 ]. To improve the model fit, we used the bootstrapping method with 10,000 replications to obtain the estimates of the mean coefficients and 95% CIs [ 32 ]. Composite reliability rho_a (>0.7), composite reliability rho_c (>0.7), and average variance extracted (>0.5) were used to examine the model performance.

PLS-SEM encompasses measurement models that define the relationship between constructs (instruments) and indicator variables and a structural model. The structural model used in this study is presented in Figure 1 . We hypothesized that the infodemic significantly affects misinformation-driven medical misbehavior, resulting in cyberchondria and high anxiety levels. Furthermore, we speculated that coping strategies significantly modify this relationship. To test these hypotheses, we used 3 models that used the full sample to separately investigate the moderating effect of the 3 types of coping strategies (problem focused, emotion focused, and avoidant focused). We analyzed the data and estimated the PLS-SEM parameters using the “SEMinR” package in R (R Foundation for Statistical Computing). A P value of ≤.05 was considered statistically significant.

Background Characteristics of Participants

A total of 986 respondents completed the web-based survey and provided valid responses, resulting in a response rate of 84%. Among the participants, 51.7% (n=510) were female, approximately 95% (n=933) had completed tertiary education or above, and 71.2% (n=702) resided in urban areas. The participants’ background characteristics are listed in Table 1 .

a A currency exchange rate of 7.23 CNY=US $1 applies.

Mean Scores and Frequency of Responses

The mean score of the GAD-7 was 8.4 (SD 3.8), while the mean score of the CSS-12 was 39.7 (SD 7.5). Problem-focused coping had a higher mean score than emotion- and avoidant-focused coping. Respondents with active employment reported statistically significantly higher mean scores on the GAD and avoidant-focused coping subscale compared to those with nonactive employment. A higher proportion of respondents with chronic diseases experienced an infodemic and exhibited the overuse of health care services relative to those without chronic diseases ( Table 2 ). The correlations between all of the measures are presented in Multimedia Appendix 2 .

a GAD-7: Generalized Anxiety Disorder Assessment-7.

b CSS-12: Cyberchondria Severity Scale-12.

c COPE: Coping Orientation to Problems Experienced Inventory.

g P <.001.

Measurement Models

Tables 3 - 5 present the performance of the measurement models for the 3 coping strategies. The values of rho_C and rho_A were above 0.7, indicating acceptable construct reliability. All 3 constructs had Cronbach α values exceeding the cutoff of 0.7, indicating adequate reliability. Table 2 presents the models’ convergent validity. All the bootstrapped item loadings exceeded 0.3 and were significant at <.05 for the problem- and avoidant-focused models. However, for cyberchondria and the Brief-COPE, none of the average variance extracted values were above 0.5, indicating unsatisfactory model convergent validity.

a AVE: average variance extracted.

b GAD-7: Generalized Anxiety Disorder-7.

d HC: health care.

b GAD-7: Generalized Anxiety Disorder.

Structural Models

The structural model analysis involved estimating path coefficients for the conceptual model. We performed PLS-SEM on the research model 3 times to estimate path coefficients for the models with different coping strategies. We found that H1 was supported. A significant and positive relationship was observed between a high level of infodemic exposure and increased overuse of health care services (coefficient=0.212, 95% CI 0.151-0.271). In addition, the overuse of health care services was correlated with more severe cyberchondria and higher anxiety levels in all the 3 models, supporting H2 and H3. The effect of the overuse of health care services on cyberchondria was larger than its effect on anxiety. All these relationships were statistically significant ( Tables 3 - 5 ).

Moderating Effects

In our moderation analyses ( Figure 2 and Tables 6 and 7 ), we found that emotion- and avoidant-focused coping strategies significantly moderated the relationship between the overuse of health care services and cyberchondria and that between the overuse of health care services and anxiety, respectively, supporting H5 and H6. For the problem-based model (H4), the moderating effect was not significant for the relationship between the overuse of health care services and cyberchondria (coefficient=0.002, 95% CI −0.011 to 0.006), indicating that H4.1 was not supported. Compared with the direct effects on the relationship between the overuse of health care services and cyberchondria or anxiety, a strong ability to cope with difficulties can effectively mitigate the negative effects of the infodemic-driven overuse of health care services on cyberchondria and anxiety.

a HC: health care.

b GAD: Generalized Anxiety Disorder Assessment.

b CS: coping strategy.

c GAD: Generalized Anxiety Disorder Assessment.

Principal Findings

We performed a series of PLS-SEM analyses to examine the relationships between the infodemic-driven overuse of health care services and cyberchondria and anxiety and determine the moderating effects of 3 types of coping strategies on these relationships. We observed that the individuals who were exposed to an overload of COVID-19–related information were more likely to seek and use extra and unnecessary health care services during the pandemic. Such behavior may lead to a considerable wastage of health resources that are particularly limited during a public health crisis. Although some studies have indicated that during the COVID-19 pandemic individuals with increasing mental health symptoms rarely used mental health services [ 33 - 35 ], we found that the overuse of health care services may contribute to higher levels of depression and cyberchondria during a pandemic. This finding has never been reported before. However, we did not differentiate between the types of health care services, either physical or mental, that the individuals overused during the pandemic. This limitation may affect the implications of our findings for policy making purposes.

Comparisons With Previous Studies

We observed that enhanced coping strategies can mitigate the adverse effects of overusing health care on depression and cyberchondria. Studies have confirmed the association between pandemics and depression, have identified several sources of depression [ 6 , 7 , 10 , 36 , 37 ], and have determined the relationship between depression and cyberchondria [ 38 ]. However, few studies have investigated the relationship between depression or cyberchondria and the infodemic-driven overuse of health care services. Our findings demonstrate that the adverse effects of the pandemic are diverse and require the investigation of individuals’ health from multiple perspectives (ie, infodemic in health communication, the use of health care in health service research, and depression in psychiatry). These effects might not be immediately apparent, but they are all linked to each other and collectively cause harm. Thus, policy makers should develop a comprehensive and cost-effective strategy to address the potential adverse effects of pandemics on people’s health and well-being and better prepare for the next public health crisis.

This study offers new insights into the role of coping strategies in mediating the relationship between health care overuse and depression or cyberchondria during the COVID-19 pandemic. Overall, individuals with strong coping abilities were more likely to report lower levels of depression or cyberchondria than those with weak coping abilities. However, the moderating effects of different coping strategies varied slightly. We discovered that problem-focused coping strategies resulted in lower levels of depression and cyberchondria than avoidant-focused coping strategies. Additionally, emotion-focused coping strategies led to lower levels of depression than the other 2 types of coping strategies. These findings partially align with previous studies. For instance, Li [ 39 ] demonstrated that using both problem-focused and emotion-focused coping strategies was beneficial for psychological well-being. However, previous studies have reported mixed findings. For example, AlHadi et al [ 40 ] indicated that emotion-focused coping strategies were associated with increased depression, anxiety, and sleep disorders in the Saudi Arabian population. Few studies have examined the effect of avoidant-focused coping strategies. In this study, we found that respondents who reported living with chronic diseases exhibited a higher ability to use avoidant-focused coping. This finding is partially consistent with a previous study that found a positive relationship between avoidance-focused coping strategies and mental health in women with heart disease [ 41 ]. Individuals with medical conditions are more likely to adopt avoidant coping strategies. Firouzbakht et al [ 42 ] explained that avoidance is an effective strategy for handling short-term stress and is more likely to be adopted by certain patient groups.

We found that individuals who favor emotion-focused coping strategies to overcome difficulties are able to effectively mitigate the adverse effects of excessive health care use on depression and cyberchondria relative to those who opt for the other 2 coping strategies. This finding is not entirely surprising or unexpected. It is, in fact, quite reasonable when one considers that scholars and researchers in the field have previously indicated that people have a tendency to adopt emotion-focused strategies, especially when they find themselves in situations that are uncontrollable or unpredictable, such as the ongoing global pandemic [ 43 ]. Some studies have found that age can have a significant impact on an individual’s coping strategy preferences. For instance, younger adults were more likely to use emotion-focused coping strategies during the acute phase of the SARS outbreak, whereas older adults used this particular strategy several months after the outbreak had initially occurred [ 44 ]. This suggests that the coping strategies adopted by individuals can vary greatly depending on their age and the stage of the crisis they are experiencing. However, in the context of this study, we did not observe any significant differences in the coping strategy preferences of the different age groups. This could be due to a variety of factors, but a possible explanation is that our model incorporated the COVID-19 infodemic. In this context, it is understandable that providing emotional support might be more important than providing real solutions. This is particularly true in the current digital age, where the internet offers unlimited information sources for people to explore, which can often lead to information overload and increased anxiety. Therefore, emotion-focused coping strategies could be more beneficial in helping individuals navigate the sea of information and manage their emotional responses effectively.

In this study, we used self-developed items to measure the infodemic and overuse of health care services. While this approach allowed us to collect data that were directly related to the research questions, it may have introduced some potential issues. First, self-developed items may have less validity and reliability than standardized questionnaires. This could affect the accuracy of measurements and the validity of findings. Second, using self-developed items may limit comparability with other studies that use standardized questionnaires. Standardized questionnaires allow for easy comparison across studies and populations. The lack of a common metric may make it challenging to compare the findings of this study to other studies or to aggregate them in future meta-analyses. Finally, self-developed items may be more susceptible to response bias. They may not have considered factors like social desirability bias or acquiescence bias as standardized questionnaires do. This could have skewed the responses and affected the accuracy of the findings. Despite these limitations, the study’s findings provide valuable insights and pave the way for future research in this area.

Main Contributions of This Study

The importance of preparedness, prevention, and emergency response to infodemiology is highly encouraged by the WHO [ 45 ]. This study makes a significant contribution by exploring and empirically evaluating the relationship between the infodemic, the overuse of health care services, cyberchondria, and anxiety in the context of the COVID-19 pandemic. It provides empirical evidence supporting the assertion that a high level of infodemic can lead to the increased overuse of health care services, resulting in more severe cyberchondria and heightened anxiety levels. This finding adds a new dimension to our understanding of the psychological impacts of the infodemic, especially in the context of a global public health crisis. Additionally, this study highlights that adopting appropriate coping strategies can potentially reduce the severity of cyberchondria and anxiety, even among people facing high levels of the infodemic and the overuse of health care services.

Future Research

The study’s findings emphasize the importance of coping strategies in reducing the negative effects of the infodemic and the excessive use of health care. Future research could focus on developing and testing interventions to improve coping skills, such as cognitive-behavioral, mindfulness-based, or psychoeducational approaches. Additionally, other factors like social support, personality traits, or health literacy may moderate the relationship between infodemic, health care overuse, cyberchondria, and anxiety. Future research could further explore these variables. This study’s findings may not apply to all populations, so future research could investigate these relationships in different groups, including those with pre-existing mental health conditions, health care professionals, or diverse cultural contexts. By pursuing these future directions, researchers could build on this study’s findings, thereby enhancing our understanding of the psychological impact of infodemic and developing effective interventions.

Limitations

This study has several limitations that need to be addressed. A primary limitation is that the data were cross-sectional and self-reporting, which can introduce several biases. Social desirability bias may occur when respondents provide answers they believe are socially acceptable rather than truthful. Recall bias may also be present, as the respondents were asked to recall experiences from months or even a year ago. The data are also prone to response bias, as respondents may agree or disagree with statements regardless of their content. These biases may have affected the accuracy of the findings. In the future, we will try to collect data at multiple time points to reduce the biases and identify changes over time. Second, the data used in this analysis were obtained from a web-based survey, which excluded individuals who are not familiar with web-based surveys or do not have access to the internet. This could have resulted in selection bias. Additionally, due to the nature of the web-based survey, the demographic information of our sample was highly skewed. The majority of the respondents were young and highly educated and were frequent internet users who may have experienced more infodemic effects than older and less educated individuals. This may have affected the reliability of our findings. A quota sampling method could be used in future studies to improve the representativeness of the sample. Third, the study was conducted in China; thus, it is important to consider the unique context of China when interpreting the results. It is necessary to conduct further research in different cultural and regional contexts to determine the generalizability of the results. Finally, the evaluation of health care service overuse and strength of the infodemic relied on 2 self-developed items, which may have affected the measurement properties and limited the reliability of our findings. The development of standardized questionnaires to measure the infodemic and the overuse of health care services during a pandemic would be a valuable contribution to future research in this field.

Conclusions

This study is the first to demonstrate a significant correlation between the infodemic-driven overuse of health care services and high levels of depression and cyberchondria in the Chinese population during the COVID-19 pandemic. We find that 3 types of coping strategies can effectively mitigate the adverse effects of infodemic-driven health care overuse on depression and cyberchondria. Among them, emotion-focused coping strategies have stronger moderating effects than the other 2 types of coping strategies. These findings provide empirical evidence that can guide policy makers in developing strategies to reduce cyberchondria, provide accurate information about public health crises, and promote adaptive coping strategies to effectively manage future public health crises.

Data Availability

The data sets generated and analyzed during this study are available from the corresponding author on reasonable request.

Authors' Contributions

RHX contributed to developing the study concept and design, data analysis and interpretation, software, writing the original draft, and review and editing. CC contributed to data collection, software, and review and editing. Both authors approved the submitted version.

Conflicts of Interest

None declared.

English-translated questionnaire.

Correlations between measures.

• Joseph AM, Fernandez V, Kritzman S, Eaddy I, Cook OM, Lambros S, et al. COVID-19 misinformation on social media: a scoping review. Cureus. 2022;14(4):e24601. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Farsi D, Martinez-Menchaca HR, Ahmed M, Farsi N. Social media and health care (Part II): narrative review of social media use by patients. J Med Internet Res. 2022;24(1):e30379. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Health topic - Infodemic. World Health Organization. 2023. URL: https://www.who.int/health-topics/infodemic#tab=tab_1 [accessed 2023-05-14]
• Gogol M, Siebenhofer A. [Choosing wisely—against overuse in healthcare systems—activities in Germany and Austria in geriatric medicine]. Wien Med Wochenschr. 2016;166(5-6):155-160. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Morgan DJ, Leppin AL, Smith CD, Korenstein D. A practical framework for understanding and reducing medical overuse: conceptualizing overuse through the patient-clinician interaction. J Hosp Med. 2017;12(5):346-351. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Alnazly E, Khraisat OM, Al-Bashaireh AM, Bryant CL. Anxiety, depression, stress, fear and social support during COVID-19 pandemic among Jordanian healthcare workers. PLoS One. 2021;16(3):e0247679. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Choi EPH, Hui BPH, Wan EYF. Depression and anxiety in Hong Kong during COVID-19. Int J Environ Res Public Health. 2020;17(10):3740. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Tomasoni D, Bai F, Castoldi R, Barbanotti D, Falcinella C, Mulè G, et al. Anxiety and depression symptoms after virological clearance of COVID-19: a cross-sectional study in Milan, Italy. J Med Virol. 2021;93(2):1175-1179. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Tran HTT, Nguyen MH, Pham TTM, Kim GB, Nguyen HT, Nguyen NM, et al. Predictors of eHealth literacy and its associations with preventive behaviors, fear of COVID-19, anxiety, and depression among undergraduate nursing students: a cross-sectional survey. Int J Environ Res Public Health. 2022;19(7):3766. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Bareeqa SB, Ahmed SI, Samar SS, Yasin W, Zehra S, Monese GM, et al. Prevalence of depression, anxiety and stress in China during COVID-19 pandemic: a systematic review with meta-analysis. Int J Psychiatry Med. 2021;56(4):210-227. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Starcevic V, Berle D. Cyberchondria: towards a better understanding of excessive health-related internet use. Expert Rev Neurother. 2013;13(2):205-213. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Smith AC, Thomas E, Snoswell CL, Haydon H, Mehrotra A, Clemensen J, et al. Telehealth for global emergencies: implications for coronavirus disease 2019 (COVID-19). J Telemed Telecare. 2020;26(5):309-313. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Gallotti R, Valle F, Castaldo N, Sacco P, De Domenico M. Assessing the risks of 'infodemics' in response to COVID-19 epidemics. Nat Hum Behav. 2020;4(12):1285-1293. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Yang F. Coping strategies, cyberbullying behaviors, and depression among Chinese netizens during the COVID-19 pandemic: a web-based nationwide survey. J Affect Disord. 2021;281:138-144. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Fluharty M, Bu F, Steptoe A, Fancourt D. Coping strategies and mental health trajectories during the first 21 weeks of COVID-19 lockdown in the United Kingdom. Soc Sci Med. 2021;279:113958. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Shigeto A, Laxman DJ, Landy JF, Scheier LM. Typologies of coping in young adults in the context of the COVID-19 pandemic. J Gen Psychol. 2021;148(3):272-304. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Hang CN, Yu PD, Chen S, Tan CW, Chen G. MEGA: Machine Learning-Enhanced Graph Analytics for infodemic risk management. IEEE J Biomed Health Inform. 2023;27(12):6100-6111. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Lazarus RS. Coping theory and research: past, present, and future. Psychosom Med. 1993;55(3):234-247. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Wechsler B. Coping and coping strategies: a behavioural view. Appl Anim Behav Sci. 1995;43(2):123-134. [ FREE Full text ] [ CrossRef ]
• Hair JF, Hair J, Hult GTM, Ringle CM, Sarstedt M. A Primer on Partial Least Squares Structural Equation Modeling (PLS-SEM). Thousand Oaks, CA. SAGE; 2022.
• McElroy E, Kearney M, Touhey J, Evans J, Cooke Y, Shevlin M. The CSS-12: development and validation of a short-form version of the cyberchondria severity scale. Cyberpsychol Behav Soc Netw. 2019;22(5):330-335. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Peng XQ, Chen Y, Zhang YC, Liu F, He HY, Luo T, et al. The status and influencing factors of cyberchondria during the COVID-19 epidemic. a cross-sectional study in Nanyang City of China. Front Psychol. 2021;12:712703. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-1097. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Sun J, Liang K, Chi X, Chen S. Psychometric properties of the Generalized Anxiety Disorder Scale-7 Item (GAD-7) in a large sample of Chinese Adolescents. Healthcare (Basel). 2021;9(12):1709. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Carver CS. You want to measure coping but your protocol's too long: consider the brief COPE. Int J Behav Med. 1997;4(1):92-100. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Poulus D, Coulter TJ, Trotter MG, Polman R. Stress and coping in Esports and the influence of mental toughness. Front Psychol. 2020;11:628. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Wang AWT, Cheng CP, Chang CS, Chen DR, Chen ST, Shieh V, et al. Does the factor structure of the brief COPE fit different types of traumatic events? Eur J Psychol Assess. 2018;34(3):162-173. [ FREE Full text ] [ CrossRef ]
• Brown TA. Confirmatory Factor Analysis for Applied Research, Second Edition. New York, NY. Guilford Publications; 2015.
• Nunnally JC. Psychometric Theory, 3rd Edition. New York, NY. Tata McGraw-Hill Education; 1994.
• Hair JF, Sarstedt M, Pieper TM, Ringle CM. The use of partial least squares structural equation modeling in strategic management research: a review of past practices and recommendations for future applications. Long Range Plann. 2012;45(5-6):320-340. [ FREE Full text ] [ CrossRef ]
• Streukens S, Leroi-Werelds S. Bootstrapping and PLS-SEM: a step-by-step guide to get more out of your bootstrap results. Eur Manag J. 2016;34(6):618-632. [ FREE Full text ] [ CrossRef ]
• Hair JF, Hult GTM, Ringle CM, Sarstedt M, Danks NP, Ray S. Partial Least Squares Structural Equation Modeling (PLS-SEM) Using R: A Workbook. Cham, Switzerland. Springer International Publishing; 2021.
• Liberman JN, Bhattacharjee S, Rui P, Ruetsch C, Rothman B, Kulkarni A, et al. Impact of the COVID-19 pandemic on healthcare resource utilization in individuals with major depressive disorder. Health Serv Res Manag Epidemiol. 2022;9:23333928221111864. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Saunders R, Buckman JEJ, Leibowitz J, Cape J, Pilling S. Trends in depression and anxiety symptom severity among mental health service attendees during the COVID-19 pandemic. J Affect Disord. 2021;289:105-109. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Lee J, Jeong HJ, Kim S. Stress, anxiety, and depression among undergraduate students during the COVID-19 pandemic and their use of mental health services. Innov High Educ. 2021;46(5):519-538. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Luceño-Moreno L, Talavera-Velasco B, García-Albuerne Y, Martín-García J. Symptoms of posttraumatic stress, anxiety, depression, levels of resilience and burnout in Spanish health personnel during the COVID-19 pandemic. Int J Environ Res Public Health. 2020;17(15):5514. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Chen J, Liu X, Wang D, Jin Y, He M, Ma Y, et al. Risk factors for depression and anxiety in healthcare workers deployed during the COVID-19 outbreak in China. Soc Psychiatry Psychiatr Epidemiol. 2021;56(1):47-55. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Jungmann SM, Witthöft M. Health anxiety, cyberchondria, and coping in the current COVID-19 pandemic: which factors are related to coronavirus anxiety? J Anxiety Disord. 2020;73:102239. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Li Q. Psychosocial and coping responses toward 2019 coronavirus diseases (COVID-19): a cross-sectional study within the Chinese general population. QJM. 2020;113(10):731-738. [ FREE Full text ] [ CrossRef ] [ Medline ]
• AlHadi AN, Alarabi MA, AlMansoor KM. Mental health and its association with coping strategies and intolerance of uncertainty during the COVID-19 pandemic among the general population in Saudi Arabia: cross-sectional study. BMC Psychiatry. 2021;21(1):382. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Sidhu A, Arora AK. A study of mental health and coping among women with coronary heart disease and women without coronary heart disease. Int J Adv Res Dev. 2017;2(6):1-3. [ FREE Full text ]
• Firouzbakht M, Rahmani N, Nia HS, Omidvar S. Coping strategies and depression during the COVID-19 pandemic in pregnant women: a cross sectional study. BMC Psychiatry. 2022;22(1):153. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Chew QH, Wei KC, Vasoo S, Chua HC, Sim K. Narrative synthesis of psychological and coping responses towards emerging infectious disease outbreaks in the general population: practical considerations for the COVID-19 pandemic. Singapore Med J. 2020;61(7):350-356. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Yeung DYL, Fung HH. Age differences in coping and emotional responses toward SARS: a longitudinal study of Hong Kong Chinese. Aging Ment Health. 2007;11(5):579-587. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Wilhelm E, Ballalai I, Belanger ME, Benjamin P, Bertrand-Ferrandis C, Bezbaruah S, et al. Measuring the burden of infodemics: summary of the methods and results of the Fifth WHO Infodemic Management Conference. JMIR Infodemiology. 2023;3:e44207. [ FREE Full text ] [ CrossRef ] [ Medline ]

Abbreviations

Edited by G Eysenbach, T de Azevedo Cardoso; submitted 05.10.23; peer-reviewed by K Wang, J Chen, CN Hang, E Vashishtha, D Liu; comments to author 06.11.23; revised version received 14.11.23; accepted 22.03.24; published 09.04.24.

©Richard Huan Xu, Caiyun Chen. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 09.04.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.