Challenges and strategies for conducting research in primary health care practice: an integrative review

Despite global efforts toward strengthening primary health care (PHC) in the last 40 years, providing accessible and good quality patient-centered health care is still a challenge to most countries. Recently, the report Operational Framework for Primary Health Care (2020) released by the World Health Organization reinforced the principles of the Astana Declaration highlighting 14 levers that must be simultaneously pulled to promote PHC across the world [1].

One of those 14 “operational levers” describes the importance of conducting research that is meaningful for PHC: “Research and knowledge management, including dissemination of lessons learned, as well as the use of knowledge to accelerate the scale-up of successful strategies to strengthen PHC” [1]. Although conducting research that meets these premises is not simple, primary care practice-based research (PC-PBR) has become an important vehicle for the development of science in the real world, because of its external validity to other PHC settings and contexts, making knowledge translation easier to put evidence into professional practice [2].

PC-PBR occurs in the context of patient health care in the community, according to Dolor et al. (2015), resulting in the research questions being primarily generated by the health services to respond to the needs of their territory [3]. PHC is responsible for serving as the first point of contact for patients, through which all health issues should be addressed. It serves as an ideal setting for conducting practice-based research, encompassing the implementation of innovations and studies aimed at enhancing the quality of care for various health conditions. These conditions span across diverse areas, including mental health [4] and chronic kidney disease [5]. Furthermore, it is also pertinent in the context of public health emergencies, such as the COVID-19 pandemic [6].

One solution to foster this type of research is creating practice-based research networks (PBRNs). Their aim is to bring healthcare professionals, researchers, health managers, and academic institutions together, facilitating partnerships, and providing structure and technical support to healthcare professionals to carry out research projects that are developed and conducted in PHC settings to tackle important aspects of PHC [7, 8]. They also help on the job of acquiring funding, capacity building, organizing the necessary logistics to put a research project in place and all sorts of tasks from study design to publication [3, 9]. In this way, PBRNs seek to promote a culture of scientific research in an environment originally dedicated to health care [10] and to answer relevant questions about the local health needs of PHC services. According to Bodenheimer et al. (2005), PBRNs are increasingly seen as institutions that can simultaneously conduct research efficiently and leverage changes in practice [11], serving as laboratories for approaching important challenges to PHC.

However, a preview study [9] developed in Canada described some lessons learned to engage PBRLNs present aspects related to the need for continuity in ethics, regular team meetings, enhancing levels of engagement with stakeholders, the need for structural support and recognizing differences in data sharing across provinces.

Even though the literature on PC-PBR is growing, “How to implement a PBRN and how to scale PC-PBR?” and “How can a healthcare service become a setting for knowledge and innovation production?” are two questions still unanswered. Moreover, scenarios with incipient PHC could benefit from evidence-oriented policies and practice-oriented research. To answer these two questions, available information from places that already run PC-PBR projects needs to be systematized around the challenges, obstacles and solutions found by other researchers. Aiming to help researchers from low- and middle-income countries that are willing to produce research in primary care, we performed an integrative review identifying the challenges and strategies for carrying out PC-PBR.

An integrative literature review was performed based on the methodology proposed by Whittemore & Knafl (2005) [12] that includes (a) identification of the problem, (b) literature search, (c) evaluation, (d) analysis and (e) presentation of results. Differently from a systematic review, the broader focus of an integrative review enables the inclusion of studies using different methodologies (qualitative, quantitative and mixed) in the analysis and supplies the methodological rigor necessary for a broader understanding of one specific phenomenon [13, 14].

A total of 440 publications were identified in the databases. After excluding duplicate studies (n=120) and those that did not answer the guiding question (n=283), 37 studies were read in their entirety. Out of these, 11 were excluded as they did not meet the eligibility criteria. The final sample consisted of 26 studies (Fig. 1), with the majority being published in the past two decades and conducted in high-income countries (HICs), primarily in the United States of America (n=13). Furthermore, a significant proportion of these studies were case studies focused on the medical profession (Table 2).

During the data analysis, six overarching themes and 15 subthemes related to the challenges of carrying out PC-PBR emerged. Among these challenges, difficulties regarding research planning were noteworthy, with issues ranging from excessive bureaucracy to challenges in planning and developing a research project. The Engagement of health professionals in research was recognized as one theme encompassing four different subthemes: lack of training and experience in scientific writing; difficulties with foreign languages; previous negative research experiences; and fears of negative impacts on the healthcare team, patients and productivity. Challenges regarding knowledge translation detail the difficulties in applying the knowledge acquired from one article to a change in daily work. Infrastructure issues are related to the location of the health services and how dispersed they can be in one area, the lack of technological tools and the little access to funding resources to sponsor more robust and long-term projects. Finally, a weak relationship between universities and health services can lead to little – or even no – collaboration between research institutes and PHC practices. The lack of international partnerships is finally presented as one main challenge for low- and middle-income countries (LMICs) since such collaborations could be helpful in building capacity for young research centers to address pressing issues in contexts where PHC is still very incipient (Table 3).

The strategies listed in the articles included in this review were organized according to the challenges described in the previous section. The following were highlighted: suggestions related to creating a research agenda adapted to each reality; training strategies to develop research skills; sharing the results with all stakeholders involved, from participants to health managers and decision-makers; and the importance of creating networks for practice-based research (Table 4).

The challenges and strategies for the implementation of PC-PBR indicate operational, structural, and political issues. One of the key aspects learned about planning a PC-PBR study is to identify and include all stakeholders (patients, employees, doctors and administration) in the development phase of the project, allowing for discussions about the study design and its implementation phases. This approach must become an integral part of the study, being comprehensive to addressing barriers to participation, obtain data, analyze and interpret the results and, finally, discuss its findings and implications. Additionally, planning data collection that demands little effort from health professionals can strengthen the study’s realization and the involvement of everyone.

In this context, it is important to emphasize that all challenges are even more pronounced in LMICs. In this regard, efforts are being made towards decolonization [40], encouraging research that validates the context and perspectives of local thinkers, thereby expanding the discussion to generate and incorporate evidence into real scenarios that value the knowledge of communities, healthcare professionals, policymakers, and researchers in LMICs. Therefore, the present study aimed to synthesize the challenges and strategies that underlie this discussion, but a gap was identified in terms of the production of this discussion in LMICs.

To address the issue of limited international collaborations in LMICs, it is crucial to explore targeted implications and strategies to surmount this constraint. Some viable strategies involve providing training and education in cultural sensitivity, thereby enhancing the efficacy of these partnerships. While international collaboration typically prioritizes partnerships with high-income countries, LMICs can also explore collaborations with other LMICs. Sharing knowledge, best practices and resources with neighboring countries facing similar challenges can result in mutually advantageous outcomes.

PC-PBR only happens if the professionals who are directly involved in patient care and health service management are integrated as part of the team of researchers, not just as the subjects of the research [8, 36]. Although it is a great challenge, training healthcare professionals to conduct research in primary care is fundamental for the success of these projects [23, 24].

Alternative research approaches, such as implementation research, have advanced and grown as new strategies to reduce the gap between research and practice, mainly because they systematically approach the factors that contribute to this gap, understanding the context and identifying barriers and solutions for delivering sustainable and effective health care [41]. Thus, to make progress in overcoming these structural barriers it is important to understand the essential pieces of the research process, without which a project will likely die prematurely. One of these elements is the minimal infrastructure needed for PC-PBR research projects to be long-lasting and sustainable [9, 23].

The studies under analysis point out that the most promising way for this to happen is through collaboration between primary care services, universities, and research institutes. In addition, these collaborations can provide training in research skills for health professionals, creating an environment conducive to exchanging experiences, ideas, and questions about the practice. All these suggestions will help to create a research agenda oriented toward solving real issues related to taking care of patients in primary care, which is the main objective of conducting PC-PBR [8].

The distance between universities and primary care settings is recurrently cited. This issue reinforces the idea that there is a place where knowledge is produced (universities and academia) that is different from the places where health care occurs. In other words, primary care is seen as a place where scientific evidence produced by academia is put into practice.

Conducting scientific research within primary care practices is innovative and can create ruptures and conflicts when it affects the way the job is done or when it takes people out of their comfort zones. By placing health professionals—and at times, patients—as agents of research production, PC-PBR can change the way new knowledge is produced. If knowledge is traditionally produced in academia and then taken as a truth by the place where patient care occurs, PC-PBR can not only generate new knowledge to change professional practice but also bring new evidence to change the way academia works, guiding new research that is better aligned with reality [34].

In some countries, a more horizontal construction of new evidence and knowledge translation can be seen between academia and healthcare practice. In Australia, for example, PBR protocols are designed to build a sustainable collaboration between a PBRN and an Advanced Center of Research and Translation in Health to build a research platform for planning, conducting and translating research evidence to improve care across the healthcare spectrum [42].

Aligned with the need for partnership between universities and practices, international collaborations are also an opportunity to guide professionals in places where universities and research institutes are not yet established. Cases such as Australia and New Zealand, where two PBR networks were established to encourage research in the area of osteopathy, show that PBRN has the potential to facilitate the access of professional researchers and clinics that are interested in collaborating with clinical tests and, thus, offer the scientific community an opportunity to conduct research with different methodologies in diverse contexts [42].

Regarding the difficulties in engaging health professionals in PC-PBR, some examples listed in the articles were little experience in scientific writing, difficulties reading articles in foreign languages, limited self-trust and lack of training to start and conduct studies. Thus, studies recommend that universities and research institutes organize training courses to develop research skills and exchange experiences to determine shared research priorities [8].

Although essential, the development of research skills is not enough for professionals to engage with and incorporate studies into their places of practice. For PC-PBR projects to advance, leadership is necessary to influence policymakers and managers and advocate for studies to be directly connected with the practice where health care happens.

The majority of the selected studies highlighted the medical category in the discussion about PBR. However, it is important to expand the professional composition of PC-PBR beyond and consider other categories to organize more participative and multidisciplinary studies. All health professionals must be invited to interact and collaborate with scientific activities and implement new projects. The inclusion of all health professionals, including community health workers, nursing assistants, and dental hygienists, who are commonly found in LMICs, can improve the development of research projects that will better take into consideration the patients’ and the territory’s needs [8].

Implementing PC-PBR goes beyond research production, since the results of the studies produced by researchers, health professionals, users and managers, in addition to the lessons learned, are shared with the health service where the study was held, bringing greater transparency to the entire process and motivating more health professionals to actively participate in future research projects [38].

The challenges for implementing PBR are similar in the contexts analyzed, showing that turning one place that was originally designed for delivering primary care into a place of knowledge production is not a trivial task. The benefits depicted in the studies show that transforming the traditional methods of knowledge production and translation through PC-PBR can generate a virtuous cycle, providing criticism and reflection about the practice and generating innovations and new knowledge to improve healthcare and patients’ health and well-being.

Additionally, the found strategies point to the need for lasting and systemic actions involving health managers, decision-makers, academics, different types of health professionals and patients, aiming to transform PHC practice in the long term. Despite being more the exception than the rule, PC-PBR has the potential to transform a PHC system that is still under development into an innovative, socially accountable, more comprehensive, accessible, and patient-centered healthcare approach. Furthermore, recognizing the transformative potential of PC-PBR, it becomes imperative to explore strategies for scaling these practices and approaches, ultimately having a broader and more profound impact on the entire primary healthcare system.