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Process evaluations of primary care interventions addressing chronic disease: a systematic review
  1. Hueiming Liu1,2,3,
  2. Alim Mohammed4,
  3. Janani Shanthosh2,3,
  4. Madeline News2,3,
  5. Tracey-Lea Laba2,3,5,
  6. Maree L Hackett1,2,3,
  7. David Peiris2,3,
  8. Stephen Jan1,2,3
  1. 1University of Sydney, Sydney, New South Wales, Australia
  2. 2The George Institute for Global Health, Sydney, NSW, Australia
  3. 3University of New South Wales, Sydney, NSW, Australia
  4. 4The George Institute for Global Health, Hyderabad, India
  5. 5Menzies Centre for Health Policy, University of Sydney, Sydney, New South Wales, Australia
  1. Correspondence to Dr Hueiming Liu; hliu{at}


Objective Process evaluations (PEs) alongside randomised controlled trials of complex interventions are valuable because they address questions of for whom, how and why interventions had an impact. We synthesised the methods used in PEs of primary care interventions, and their main findings on implementation barriers and facilitators.

Design Systematic review using the UK Medical Research Council guidance for PE as a guide.

Data sources Academic databases (MEDLINE, SCOPUS, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, EMBASE and Global Health) were searched from 1998 until June 2018.

Eligibility criteria We included PE alongside randomised controlled trials of primary care interventions which aimed to improve outcomes for patients with non-communicable diseases.

Data extraction and synthesis Two independent reviewers screened and conducted the data extraction and synthesis, with a third reviewer checking a sample for quality assurance.

Results 69 studies were included. There was an overall lack of consistency in how PEs were conducted and reported. The main weakness is that only 30 studies were underpinned by a clear intervention theory often facilitated by the use of existing theoretical frameworks. The main strengths were robust sampling strategies, and the triangulation of qualitative and quantitative data to understand an intervention’s mechanisms. Findings were synthesised into three key themes: (1) a fundamental mismatch between what the intervention was designed to achieve and local needs; (2) the required roles and responsibilities of key actors were often not clearly understood; and (3) the health system context—factors such as governance, financing structures and workforce—if unanticipated could adversely impact implementation.

Conclusion Greater consistency is needed in the reporting and the methods of PEs, in particular greater use of theoretical frameworks to inform intervention theory. More emphasis on formative research in designing interventions is needed to align the intervention with the needs of local stakeholders, and to minimise unanticipated consequences due to context-specific barriers.

PROSPERO registration number CRD42016035572.

  • process evaluations
  • systematic review
  • non-communicable disease
  • qualitative research
  • primary care

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  • Contributors HL and SJ conceived the idea for a systematic review of process evaluations. DP, SJ, TL and MH provided guidance to HL in the development of the protocol. AM, JS and MN assisted with the selection of papers, data extraction and analysis. TL assisted with the adjudication of the papers. HL drafted the manuscript, and all authors contributed to the revisions of the manuscript and approved the final manuscript.

  • Funding MLH was supported by an NHMRC Career Development Fellowship Level 2(APP1141328). SJ is a recipient of an NHMRC Principal Research Fellowship (2017-21). TL was supported by a NHMR ECF (Sidney Sax) APP 1110230. HL was supported by a NHMRC post graduate scholarship (APP1114897).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement This systematic review selected published papers through database searches.

  • Author note This systematic review forms part of HL’s PhD thesis and is not externally funded or commissioned.

  • Patient consent for publication Not required.

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