Beyond the consultation room: Proposals to approach health promotion in primary care according to health‐care users, key community informants and primary care centre workers

Abstract Background Primary health care (PHC) is the ideal setting to provide integrated services centred on the person and to implement health promotion (HP) activities. Objective To identify proposals to approach HP in the context of primary care according to health‐care users aged 45‐75 years, key community informants and primary care centre (PCC) workers. Methods Descriptive‐interpretive qualitative research with 276 participants from 14 PCC of seven Spanish regions. A theoretical sampling was used for selection. A total of 25 discussion groups, two triangular groups and 30 semi‐structured interviews were carried out. A thematic interpretive contents analysis was carried out. Results Participants consider that HP is not solely a matter for the health sector and they emphasize intersectoral collaboration. They believe that it is important to strengthen community initiatives and to create a healthy social environment that encourages greater responsibility and participation of health‐care users in decisions regarding their own health and better management of public services and resources. HP, care in the community and demedicalization should be priorities for PHC. Participants propose organizational changes in the PCC to improve HP. PCC workers are aware that HP falls within the scope of their responsibilities and propose to increase their training, motivation, competences and knowledge of the social environment. Informants emphasize that HP should be person‐centred approach and empathic communication. HP activities should be appealing, ludic and of proven effectiveness. Conclusions According to a socio‐ecological and intersectoral model, PHC services must get actively involved in HP together with community and through outreach interventions.


| BACKGROUND
Health promotion is a complex process that involves the interaction of strategies such as health education, implementation of healthy policies and community actions. In addition, HP is closely related with the principles and development of PHC. Indeed, the essential characteristics of PHC (accessibility, follow-up and continuity) and its presence in the community 6,7 constitute the ideal context to offer integrated and person-centred services and to implement HP activities that encourage changes towards more healthy behaviours. However, the incorporation of HP interventions in the daily practice of PCC workers presents barriers such as heavy workload, lack of time and skills, low motivation, uncertainty about effectiveness and the prevailing biomedical paradigm at the microlevel (health professionals) and macrolevel (policies, universities, institutions). 8,9 On the other hand, health-care users also present intrapersonal, interpersonal, social and environmental conditioning factors which influence their determination to put into practice the recommendation of PHC professionals. 10 Health promotion involves complex interventions. Complexity results from the number of interacting components; the amount and difficulty of behaviours required by those delivering or receiving the intervention; the number of groups or organizational levels targeted by the intervention; the number and variability of outcomes; and the degree of flexibility of the intervention. 11,12 The main directives for the design, implementation, and evaluation of this type of interventions were developed by the Medical Research Council (MRC) 11,[13][14][15] in a mixed-method approach with five sequential phases: (i) definition of the theoretical foundation; (ii) construction of a model; (iii) development of a pilot study; (iv) completion of the definitive trial; and (v) long-term implementation.
The qualitative study presented in this manuscript corresponds to the results of the second phase of the EIRA Project, which follows the UK MRC framework. The objective of the EIRA study was to carry out and evaluate a complex, multirisk intervention designed for PHC patients aged 45-75 years, with the objective of developing health-promoting behaviours that improve the patients' quality of life and prevent the most frequent chronic diseases and their potential complications. 16 strengthen community initiatives and to create a healthy social environment that encourages greater responsibility and participation of health-care users in decisions regarding their own health and better management of public services and resources.
HP, care in the community and demedicalization should be priorities for PHC.
Participants propose organizational changes in the PCC to improve HP. PCC workers are aware that HP falls within the scope of their responsibilities and propose to increase their training, motivation, competences and knowledge of the social environment.
Informants emphasize that HP should be person-centred approach and empathic communication. HP activities should be appealing, ludic and of proven effectiveness.
Conclusions: According to a socio-ecological and intersectoral model, PHC services must get actively involved in HP together with community and through outreach interventions.

K E Y W O R D S
health promotion, lifestyle, primary health care, primary prevention, qualitative research For the design of complex interventions that drive HP activities, the co-operation between health-care users and health-care professionals is considered crucial. In-depth knowledge of the context where the interventions will take place of the experiences and perceptions of the population target and of the professionals that will implement HP is also essential. Taking into account the discourses of all stakeholders can be instrumental in increasing the motivation for participating in the study and can contribute strategies to facilitate recruitment and also the adherence of health-care professionals and health-care users. It can also enhance acceptability, sustainability and adaptation of the intervention to each context. In addition, cultural sensitivity and social significance of the intervention for the target population increase the probability of positive changes and of translation of the results into real life.
Although some studies have analysed the factors that influence the implementation of HP activities from the perspective of healthcare users and PCC workers, 8,10 few have incorporated the point of view of key community informants. Moreover, most studies include the approach to a single behaviour, whereas this study focuses on the people that need to improve more than one health-promoting behaviours.
The objective of this study was to identify proposals to approach HP in the context of primary care according to health-care users, key community informants and PCC workers in seven Spanish regions.
Specifically, we aim to identify proposals to promote positive changes in behaviour related to nutrition, physical activity, smoking, mental health and cardiovascular risk.

| Design
Descriptive-interpretive qualitative research to identify proposals to approach HP taking into account the perspectives and experiences in the daily lives of health-care users, key community informants and PCC workers.

| Study population
The study population were as follows: (i) health-care users from 45 to 75 years of age from participant PCC (target population of the EIRA study); (ii) key informants with in-depth knowledge of the community context (community workers and health workers with a managerial role or working directly in the community); and (iii) workers from participating PCC (professionals based in the PCC, including social workers and administrative staff).

| Sample design and participant selection strategy
Sample design was intentional, reasoned and theoretical. 17 We aimed at discursive representativeness to achieve maximum richness of information and in-depth understanding of the phenomenon. Table 1

| Data collection techniques
Individual and group conversational techniques were used 18 : eleven discussion groups and two triangular groups 19 with health-care users; 30 semi-structured interviews with key community informants (15 health workers and 15 non-health workers); and 14 discussion groups with PCC workers. Table 2 shows the characteristics of the 276 participants. The analysis of the information started simultaneously with the interviews; data saturation was obtained and it was consequently decided to cancel discussion groups with health-care users in

Andalusia.
The techniques were based on a set of questions of topics with common elements on how to improve the approach to HP, with some minor adaptations according to the type of informant (Annex 1). The design of the topic guide was based on a review of the literature, the experience of the research team and the objectives of the study; a pilot was carried out before the study was conducted. Individual interviews only had one interviewer; they took place in a setting accessible for the informants and had a duration of 45-60 minutes.
The discussion groups took place in the health centre with one moderator and one observer and lasted between 90 and 120 minutes.
After obtaining informed consent from the participants, the interviews were recorded in audio or audio and video with the exception of the group of women from the Maghreb, which did not consent to the recording and notes were taken. The field work was carried out by interviewers of each region, who followed the manual that

| Analysis of the information
All recordings were transcribed literally; the data that identified informants were anonymized. The transcriptions were carried out by experts and reviewed by the interviewers. 20 A thematic interpretive contents analysis was carried out. 18 (Table 3). These quotations were translated by a professional scientific translator and later reviewed by the research team to verify that the meaning of the original discourse was maintained.

| Rigour and quality criteria
We adhered to the following rigour criteria suggested by various authors 22 : description of context, of participants and of the research process; methodological adequacy; triangulation of analysis; and reflexivity of the research team.

| RESULTS
Participants' recommendations to approach HP can be classified according to a socio-ecological model of the following factors (Table 3).

| Public policy
According to key community informants and PCC workers, HP is not just a matter for the health sector. It requires public policies and an integral approach at all levels of society. Indeed, intersectorial collaboration is essential. They mention the following examples of public policies for HP: urbanism in cities (green areas, facilities…); policies that reduce fats in food; avoidance of misleading food advertising; and promotion of active lifestyles (at home, at work, commuting). In addition, they consider the work-life balance essential to be able to carry out HP activities making use of community facilities. PCC workers suggest to provide specific training in HP during undergraduate studies.

| Community factors
All informants' groups refer to the importance of encouraging community action and of creating a healthy social environment to (i) inspire health-care users to take more responsibility and to actively participate in decisions regarding their own health and (ii) to improve the management of public services and resources. They propose mapping community assets available to health-care users and PCC workers to maximize their potential. According to key community informants and PCC workers, awareness by health-care professionals about these resources, health assets and social prescription would contribute to a more active life and enhance social cohesion.
In addition, key community informants and PCC workers emphasize the need to train health-care users with knowledge of HP for community outreach, as opposed of only providing information to people attending the PCC. They also consider that HP needs to start from childhood, and they propose working in schools with the involvement of the parents. Furthermore, they emphasize the importance of working with companies to introduce HP in the workplace. They suggest strengthening community health councils to include the different social groups, the sectors with an impact on health and the professionals of the health-care services. PCC workers believe that it is crucial to develop alliances with local mass media for the dissemination of health promotion, available activities and community networks. And support, support, policies that support change, not only from the health services… but for politicians to come up with policies that encourage and not hamper. Every social class has to … interdepartmental projects are very interesting… (PCC workers, Basque Country, ID1WBC)

Community factors
We want more activities in our neighbourhood, more associations, more things. To fill in any way that space that remains empty, to fill it with something different and creative, that keeps you well, that the brain then can develop its capacities… (Health-care users, Basque Country, ID11UBC) One of our alliances or collision with the work in the health centres, the social workers, I believe that we are here as promotion agents in and out of the centres. And then, we have a network, we establish a network that it's something that already existed and we try to give it a different twist from those in charge of the programmes within the centres. In fact, it's the same thing as smoking, it depends on the stage they are in, if they are in the precontemplative stage, you cannot do anything, you will have to wait to the next time they come, until the moment she says: "Ok, I will try it," but of course it's useless, sometimes. You must know whom to give advice to. If that person is not receptive it's kind of dumb, you should wait until. (PCC workers, Castilla-Leon, ID1WCL) I think I need more training in promotion, because there is some on diet and exercise but either I have not been able or didn't feel like attending, but I would need it on diet because sometimes they ask me about products I don't know anything about and then I have to look in google. ( Nursing has a critical role in health promotion. Previously during the awareness stage and we should adapt our organisation so that we could effectively reach the young and take advantage of those occasions in which they come for any other issue to provide another type of intervention (Key informant, Aragon, ID1KAR) The approach to the person must be interdisciplinary and many of these unilateral programmes, then we have to treat people and make them aware that they own their health and that they have the option and the public system can provide help to keep their health. (PCC workers, Andalusia, ID2WAND) Motivation is important and that they understand it, very important, but that they have another life. The intervention could be the same but with different language or with… with different conditioning factors. It's not the same to explain a diet to somebody that always eats at work, stressed about the children and this and that … I don't know, that is moonlighting with a person that regularly shops at her local butcher, older and you think… But if you put the 2 together, I'm almost sure that the younger will get bored (Key informant, Basque Country, ID3KBC) The council organises many health promoting activities, you know? Also for exercising, you know? Besides, they socialise a lot. I some of the patients that I have referred to these Wednesday walks for example, where they meet by the metro station… And really, those that I referred are delighted, because they socialise, in addition, and that creates a motivation to go. On their own they don't make up their minds but if they can go with a group then… (PCC workers, Catalonia, ID13WCAT) The professionals of the PCC say things naturally…. every day you should go for a walk. Even if it's nothing but you really are making the effort to move a bit, with people a bit old. The simple fact that the nurse monitors you and tells you… a short fifteen-minute walk…(Key informant, Aragon, ID5KAR) Yes to the psychologist. That many people sometimes old people in particular they feel lonely and go to the doctor because you go there and you see them almost every time you go, and it's a way to enter for her to get a consultation so that they listen to her. (Health-care users, Aragon, ID12UAR) For the retired people, mornings are better than afternoons; for those that work… a bit later. But well, let's say that 6 is quite a good time. From 6 to 8… Let's say, between 6 and 9 in the evening. At those times they can…(Key informant, Basque Country, ID2KBC)

Structure format of activities
Flexible times, in the right place where you can do it and a wide range of people to come (Health-care users, Castilla-Leon, ID1UCL) Between these and those contents we should insert, see… active participation so that … for it to be… not only participative in relation to knowledge because now I explain this and then that … but for it to have a fun element, easy to assimilate, and not a boring activity (Key informant, Basque Country, ID1KBC) Less than forty-five minutes, after forty-five minutes people start to …lose concentration start to think about their shopping list, what they are going to do next… yes. Also, for the health professional, ok? An intervention over forty-five minutes needs much more effort and preparation. (

| Primary care centre workers
Despite the difficulties of integrating HP in their daily clinical practice, PCC workers are aware that it falls within the scope of their responsibilities and propose to increase their training (Table 4)

| Relationship primary care centre workershealth-care users
The interaction between PCC workers and public generated a large number of comments amongst health-care users. All informants' groups mention as an improvement a personal, empathic relationship between professionals and health-care users. The ability to "put yourself in the other person's shoes" would enhance trust and generate a greater inclination to change towards healthier behaviours.
Health-care users explain that a relationship of trust is created with continuity of care with the same professional. They emphasize the follow-up and learning together to compromise and to prioritize the behaviours that need to be modified. Changing all behaviours simultaneously is not a feasible objective. Moreover, they advocate a holistic approach that takes into account the specific needs of each individual. Many PCC workers explain that these aspects are already integrated within their daily practice, whereas health-care users mention them in the context of items to improve.
All groups claim that they need strategies to translate theory into practice and to avoid getting stuck in the advice phase. They agree about the need to empower patients to motivate them to change.
In relation to change in behaviours to improve the relationship professional health-care users, the three participants' groups have suggested the following items to health-care professionals: 1) recommend feasible objectives; 2) emphasize pros and cons of not changing; 3) carry out an active, close follow-up and positive reinforcement, acknowledge small achievements; 4) try to understand the reasons behind refusing to modify behaviours. Health-care users underscore that banning and reprimands do not benefit change.

| People
PCC workers emphasize that people should invest time in activities that promote healthy behaviours. They highlight that within a quieter, more relaxed lifestyle there is more room for self-care. Key community informants agree and maintain that it is crucial to make an effort to be happier, to motivate the population towards individual and social changes, in particular in relation to a better work-life balance. Key community informants and PCC workers refer to improving self-esteem and individual willpower and to strengthen the role of the family to support the individual who is attempting to change.

| Health promotion activities
The discourses of the participants identify several elements to take into account about the design, development and evaluation of HP activities.
T A B L E 4 Training needed to implement health promotion interventions according to primary care centre workers Practical training in health promotion (in-depth understanding and updating) Evidence on effectiveness of health promotion recommendations Motivational interview (how to encourage change in undecided people, empowerment, etc.) Communication skills (empathy, good interaction, feeling supported, clear, simple and adapted information) Patient-centred care Community health: methodology, tools, evaluation and participation strategies Awareness of existing community resources and how to use them Learn marketing strategies to succeed with messages and advice Training in multiculturality Healthy diet in people from other cultures Healthy diet in people with few resources/ during financial hardship Advanced training in physical activity (practical and personalized) Approach to mental health and emotional well-being issues Work in multidisciplinary teams Use and applicability of information and communication technologies (ICTs)

| Reference framework
In relation to the reference framework of the intervention, participants would like to include individual, group and community elements, with an emphasis on the individual and the community. On the other hand, key community informants and PCC workers underscore the importance of a participative design that allows sharing and exchanging ideas. They emphasize the participation of social representatives of the area, the role of social services and of community leaders. They point out that it is important to avoid prominence, fragmentation and duplication. They consider that people feel more engaged when they participate in the decisions; it also implies a more consistent attitude with regard to learning and the implementation of what has been learned and practiced. They also underscore the relevance to start from an in-depth knowledge of the community, the identification of individual and collective interests, expectations and needs, reaching out to the population that does not attend PHC services and working with cultural and socio-economic awareness.
They also mention the relevance of having clear, evidence-based objectives that take into account their own and others' successful experiences.

| Contents/components of the intervention
The three participants' groups emphasize fostering interpersonal and social relationships in all interventions to motivate and facilitate the success of the programme. They evaluate positively sharing experiences and needs during HP activities. Health-care users would like a space to talk about their personal situation, to let off steam, to learn to accept difficulties through the example of other sufferers and to support one another.
Health-care users and PCC workers put forward specific proposals to tackle the intervention components of the EIRA study (Table 5). In connection with mental health, they propose to work with the strengths of the people, encourage art and creativity, investigate how to live with a more positive attitude, and strategies towards negative thoughts, worries and problem resolution. They explain that before suggesting changes in habits, it is important to assess mental health, because mental health disorders significantly hinder these changes. They claim that currently, some health-care professionals approach mental health problems with psychopharmacological drugs and they propose demedicalization and encouragement of social cohesion amongst other options. They consider that it is important to include psychologists in the interventions.
With regard to nutrition, they underscore the implementation of motivation strategies for people undertaking restrictive diets and the need to combine foods to achieve a nutritionally healthy diet. They suggest developing healthy diet workshops that bypass extreme body ideals, discuss social obsession with weight and creating programmes of low-cost healthy diets. To promote smoking cessation, they suggest personalized care and group activities due to the potential of the group as a support unit. In relation to physical activity, they recommend to encourage walking. Further than the benefits of walking, they need to take into account the activity most appropriate for that particular person, cultural, economic and health conditions, as well as the frequency, duration and location of the activity, and how to prevent injuries. They consider that practicing physical activities in group is much more beneficial because it also strengthens interaction and increases self-esteem and social cohesion.

| Structure format of health promotion activities
All participants' groups explain that HP activities must be appealing, creative, ludic, participative, assimilable and practical and must include motivational elements, use a direct and simple language and develop in small groups.
Key community informants highlight the importance of a good design and that they should be structured but flexible. They also suggest programming the activities on the basis of small, feasible changes.
PCC workers add that the activities must be effective, safe, focused on health, with short-and long-term results and should result from the coordination of a multidisciplinary team. They also emphasize an active and close follow-up within the framework of continuity in primary care.

| Evaluation
Key community informants and PCC workers agree that monitoring and evaluating the results of all activities are essential. They believe that planning a critical evaluation of objectives is crucial towards improvement. In addition, PCC workers indicate that the evaluation must include not only the process (i.e. if this person has received any advice) but also health outcomes.

| Comparisons with existing literature
The HP suggestions obtained in this study belong to the socio-  Workshop on how to interpret food labelling resources to better her own health. 24,25 In our study, participants explain that coordination amongst biopsychosocial and community resources is essential to promote the well-being of health-care users. 24,25 The salutogenic gaze, health assets, network collaborations (intersectoral and community participation), equity and sustainability are the basic ingredients of community health. 26 As the community approach should be an essential element of PHC, all these elements should be part of daily practice. However, in this study, PCC workers talk about citizen participation in the approach to HP from PHC, whereas key community informants reach further and refer to a joint construction and leadership of the community.
The health-care users of this study convey the difficulties of translating theory into practice with regard to behavioural change. In relation to HP intervention, health-care users claim a holistic approach based on their characteristics and needs, and not only focused on health problems. 27 Moreover, the person-centred approach model implies that the person is an active agent of her changes and her life and that the role of the professional is not managerial but based on unconditional acceptance, empathy and authenticity. 28,29 Achieving HP in a patient-centred context requires reflection on how to best support optimal health and care through reflection on the patient's history. 30 In addition, the motivational interview is an effective strategy to promote behavioural changes centred on the person. In fact,

| Strengths and limitations of the study
A strength of this study are the recommendations for HP from a polyhedric gaze that includes the perspectives of health-care users, key community informants and PCC workers. This participative strategy is essential for the design and implementation of an acceptable, adequate, feasible complex strategy and for the integration within other programmes in terms of location, schedule and duration. This article corresponds to the phase 1 or modelling phase of the MRC framework, and the results have been used to design a multirisk intervention with the goal to improve HP. 33,34 Despite the proposals of participants on public policies and structural and institutional aspects, the design of the intervention has taken into account the results more feasibly modifiable in the context of PHC and the involvement of community resources. Even though the design included a theoretical sampling, participant workers in health centres that volunteered to take part in the EIRA project, which suggests a particular interest for HP. While the point of view of this collective might not be transferable to other more sceptical professionals with regard to HP, we consider that their recommendations are very rich given their interest and reflexivity with regard to the phenomenon under study. There appears to be an overlap between key community informants and PCC work- Although caution is needed before transferring these results to other settings, the similarity with other studies suggests its applicability.
Scheduled meetings and a researcher's manual guaranteed uniformity of techniques as implemented by different interviewers in each community.
It was difficult to capture the views of the immigrant population and those from the most disadvantaged socio-economic levels of society, who are in fact more vulnerable and least engaged in HP activities.
However, we tried to collect their discourse and opinions through key community informants. Although the analysis of perspectives according to gender and age was not an objective of the current investigation, we consider that further analyses taking into account this stratification would provide valuable information.
A current challenge is to generate evidence on strategies to improve the training and skills of PCC workers to broaden their capacity to detect resources, customs and cultural and environmental elements in the communities. A future challenge will involve in-depth development and generation of evidence on the theoretical basis of HP, health assets, salutogenesis and evaluation of the interventions to facilitate the success of public health measures.

| CONCLUSIONS
This study provides suggestions for the design, development and evaluation of HP activities. It is essential to approach HP from a socioecological, intersectoral model that encourages greater responsibility and participation of health-care users in decisions regarding their own health and for a better management of public services and resources.
PHC services must get actively involved in HP together with the community and through outreach interventions.