The aim of this pilot study was to explore which lifestyle interventions Dutch GPs and PNs carry out in primary care, which barriers and facilitators can be identified and what main topic are with respect to attitudes towards health promotion activities.
GPs and PNs said that they advice and counsel their patients or refer them to other disciplines. They said that they perceive health promotion activities as part of their job. However, there were several topic areas identified as barriers to deliver health promotion activities. These barriers are related to the patient, the GP and the practice, attitudes, health promotion programs and the healthcare system. Six different and provisional types of GPs were identified, reflecting the main topics that are related to six different attitudes to health promotion activities. Topics brought up by PNs that are related to attitudes were practically unanimous and positive.
The main topic areas as barriers in this study are consistent with results of other studies. Most cited barriers mentioned in the literature are: lack of time [11, 28, 33], lack of confidence in providing advice and effectiveness of interventions [6, 22, 33], lack of reimbursements [11, 19, 28] and lack of patient compliance or motivation [11, 21, 22]. The lack of skills to discuss lifestyle is a major experienced barrier in the literature [28, 34]. Participants in our pilot study only reported a lack of discussion skills regarding alcohol intake and specific diets. Another interesting finding is the fact that Lambe  recommends a national program in his study, due to the inequity of access. However, GPs and PNs in this study state the opposite; they prefer programs in their own practice instead of national programs outside their practice. The themes regarding attitudes that we identified in this study correspond with the existing literature. A study by Lambe  concluded that GPs think their practice is an ideal setting to deal with lifestyle behaviour and Douglas  described most GPs think health promotion is an important part of their job. However, not all studies have found positive attitudes among GPs. Jacobsen  concluded that GPs are frustrated due to the excessive expectations on the part of health policymakers. This was also a topic in our study, GPs said that they did not experience optimal support of the government either. Lawlor  stated that GPs are sceptical because they doubt their ability to be effective and mentioned that social, cultural and environmental factors are the most important determinants of population health. This vision corresponds with the vision of the GP type ‘ignorer’, one of six types identified in this pilot study.
Although our pilot study is small and explorative, we found a variation of topic areas. We categorized these different themes in types of GPs, but this categorisation is not stringent. Since this is a explorative pilot study, other types can be added to this categorisation as well. In the literature different types of GPs were also described. For instance Bucks  who identified five different clusters of GPs, varying from the GPs who is traditional in his/ her approach but at the same time speculative in taking risks, to the GP who is doctor centred in approach, but who is not prepared to take risks with patients health, preferring caution and prevention. Laws  describes four different roles of GPs (‘outside of professional role’, ‘the gatekeeper’, ‘the informer’ and ‘helper’) and how they influence the implementation of lifestyle risk factors. There are similarities with our findings, for instance the first role corresponds with the role ‘ignorer’ and the third one with ‘adviser’. However, in our study we found a wider range of different attitudes.
In this pilot study the topics brought up by PNs were more the same, which has also been found in some other studies. Steptoe  for example concluded that the majority of the GPs and PNs endorsed the statement that PNs are the most appropriate people to carry out health promotion.
This study has certain limitations. We used purposive sampling to find GPs and PNs, but we did not find GPs in solo practices who were willing to participate. Not only because the number of solo practices is declining, but also because of non-response and lack of time, we could not spend more time on finding solo practices. Therefore, only GPs in healthcare centres and general practices were interviewed.
Also, selection bias could have resulted from a non-response. It may be that GPs and PNs who participated in this study are more engaged in addressing lifestyle issues than participants who did not participate. The response rates among Dutch GPs in studies is generally low, probably because of the extension of their tasks, limited time to participate in studies and ‘research tiredness’ . However, low response rates in GPs is not typically Dutch, Templeton, Creavin and Kaner also concluded it is becoming difficult to encourage GPs to participate in studies [38–40].
Due to the limited time of the GPs it was not only difficult to find general practices, but also to conduct in depth interviews of 60 minutes. Therefore we conducted interviews of 30 minutes. However, we did find a great variety in answers. No new themes were identified in the last three interviews so we assume that saturation was reached or almost reached. Yet, socially desirable answers or recall bias with respect to attitudes and barriers and facilitators is still possible.
Implication for future research and clinical practice
In this study we highlighted 41 barriers mentioned by GPs and PNs with respect to health promoting activities in general practices. Future studies will be necessary to explore how (national) health promoting programs could be optimally implemented in general practices. Moreover, more studies are needed to assess the role of the GP umbrella organizations with respect to the development, dissemination and implementation of lifestyle interventions, because GPs and PNs stated they can advocate and spread proven effective health promotion programs in general practices on a continuous base. Furthermore, this was a small explorative pilot study. More in depth interviews are necessary to provide more insight in the different types of attitudes of GPs and PNs.
It is difficult to find solutions for the identified barriers in this study. Investing in collaboration between different disciplines in general practice and addressing the advocating role that umbrella GP organisations can have to promote lifestyle interventions could be strategies to increase health promotion activities. Next to this, a consistent national health policy to promote healthy behaviours is necessary. Furthermore, in this study enthusiasm of PNs to carry out lifestyle interventions was identified as a facilitator. The role and position of PNs should be further explored to gain the most benefit from them.