# Factors for the integration of prevention in primary care: an overview of reviews

Estelle Clet, Pierre Leblanc, Francois Alla, Christine Cohidon

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Estelle Clet, Pierre Leblanc, Francois Alla, Christine Cohidon. Factors for the integration of prevention in primary care: an overview of reviews. BJGP Open, 2024, 10.3399/bjgpo.2023.0141. hal-04617579

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# Factors for the integration of prevention in primary care: an overview of reviews

Estelle Clet, Pierre Leblanc, Francois Alla, Christine Cohidon

<figure><img src="image_1.png" /></figure>

## To cite this version:

Estelle Clet, Pierre Leblanc, Francois Alla, Christine Cohidon. Factors for the integration of prevention in primary care: an overview of reviews. BJGP Open, 2024, Online ahead of print. 10.3399/bjgpo.2023.0141. hal-04617579

HAL Id: hal-04617579

https://hal.science/hal-04617579v1

Submitted on 19 Jun 2024

HAL is a multi-disciplinary open access archive for the deposit and dissemination of scientific research documents, whether they are published or not. The documents may come from teaching and research institutions in France or abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est destinée au dépôt et à la diffusion de documents scientifiques de niveau recherche, publiés ou non, émanant des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés.

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BJGP OPEN

# Factors for the integration of prevention in primary care: an overview of reviews

Clet, Estelle; Leblanc, Pierre; Alla, François; Cohidon, Christine

DOI: https://doi.org/10.3399/BJGPO.2023.0141

To access the most recent version of this article, please click the DOI URL in the line above.

Received 31 July 2023

Revised 30 October 2023

Accepted 31 October 2023

© 2024 The Author(s). This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License (http://creativecommons.org/licenses/by/4.0/). Published by BJGP Open. For editorial process and policies, see: https://bjgpopen.org/authors/bjgp-open-editorial-process-and-policies

When citing this article please include the DOI provided above.

## Author Accepted Manuscript

This is an 'author accepted manuscript': a manuscript that has been accepted for publication in BJGP Open, but which has not yet undergone subediting, typesetting, or correction. Errors discovered and corrected during this process may materially alter the content of this manuscript, and the latest published version (the Version of Record) should be used in preference to any preceding versions
# Factors for the integration of prevention in primary care: an overview of reviews

Clet, Estelle; Leblanc, Pierre; Alla, François; Cohidon, Christine

DOI: https://doi.org/10.3399/BJGPO.2023.0141

To access the most recent version of this article, please click the DOI URL in the line above.

Received 31 July 2023

Revised 30 October 2023

Accepted 31 October 2023

© 2024 The Author(s). This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License (http://creativecommons.org/licenses/by/4.0/). Published by BJGP Open. For editorial process and policies, see: https://bjgpopen.org/authors/bjgp-open-editorial-process-and-policies

When citing this article please include the DOI provided above.

## Author Accepted Manuscript

This is an 'author accepted manuscript': a manuscript that has been accepted for publication in BJGP Open, but which has not yet undergone subediting, typesetting, or correction. Errors discovered and corrected during this process may materially alter the content of this manuscript, and the latest published version (the Version of Record) should be used in preference to any preceding versions
**Title:**

Factors for the integration of prevention in primary care: an overview of reviews

**Authors:**

Estelle Clet<sup>1,2,3</sup>, PharmD, ORCID iD: 0000-0002-4767-5967

Pierre Leblanc<sup>4,5</sup> MD, ORCID iD: 0000-0001-9779-2806

and François Alla<sup>1,2,3*</sup> MD, PhD, ORCID iD: 0000-0002-5793-7190

and Christine Cohido<sup>6*</sup> MD, PhD, ORCID iD: 0000-0003-2343-500X

**Corresponding author:**

Estelle Clet, 1 rue Jean Burguet, 33000 Bordeaux, France, estelle.clet@chu-bordeaux.fr, University Hospital of Bordeaux and University of Bordeaux

**Registration:**

The protocol of this overview of reviews has been registered on PROPERO (CRD42022359738).

**Word count of main text:**

2500 words

**Number of tables:**

0 table

**Number of figures:**

2 figures

**Number of supplementary material:**

4 supplementary materials

<footnote n="1"><sup>1</sup>University Hospital Centre Bordeaux Division of Public Health, Prevention department, Bordeaux, Nouvelle-Aquitaine, FR 33000</footnote>

<footnote n="2"><sup>2</sup>University of Bordeaux, INSERM, BPH, U1219, I-prev/PHARES, CIC 1401, Bordeaux, Aquitaine, FR 33000</footnote>

<footnote n="3"><sup>3</sup>Institute of Public Health Epidemiology and Development, Prevention research chair
Bordeaux, Aquitaine, FR 33000</footnote>

<footnote n="4"><sup>4</sup>Quality and Population Health Department, Civil Hospices of Lyon, Lyon, France</footnote>

<footnote n="5"><sup>5</sup>Research On Healthcare Performance (RESHAPE), Claude Bernard Lyon 1 University, INSERM U1290, Lyon, France</footnote>

<footnote n="6"><sup>6</sup>Department of family medicine, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Switzerland</footnote>

<footnote>* FA and CC contributed equally to the manuscript</footnote>
**Title:**

Factors for the integration of prevention in primary care: an overview of reviews

**Authors:**

Estelle Clet<sup>1,2,3</sup>, PharmD, ORCID iD: 0000-0002-4767-5967

Pierre Leblanc<sup>4,5</sup> MD, ORCID iD: 0000-0001-9779-2806

and François Alla<sup>1,2,3*</sup> MD, PhD, ORCID iD: 0000-0002-5793-7190

and Christine Cohido<sup>6*</sup> MD, PhD, ORCID iD: 0000-0003-2343-500X

**Corresponding author:**

Estelle Clet, 1 rue Jean Burguet, 33000 Bordeaux, France, estelle.clet@chu-bordeaux.fr, University Hospital of Bordeaux and University of Bordeaux

**Registration:**

The protocol of this overview of reviews has been registered on PROPERO (CRD42022359738).

**Word count of main text:**

2500 words

**Number of tables:**

0 table

**Number of figures:**

2 figures

**Number of supplementary material:**

4 supplementary materials

<footnote n="1"><sup>1</sup>University Hospital Centre Bordeaux Division of Public Health, Prevention department, Bordeaux, Nouvelle-Aquitaine, FR 33000</footnote>

<footnote n="2"><sup>2</sup>University of Bordeaux, INSERM, BPH, U1219, I-prev/PHARES, CIC 1401, Bordeaux, Aquitaine, FR 33000</footnote>

<footnote n="3"><sup>3</sup>Institute of Public Health Epidemiology and Development, Prevention research chair
Bordeaux, Aquitaine, FR 33000</footnote>

<footnote n="4"><sup>4</sup>Quality and Population Health Department, Civil Hospices of Lyon, Lyon, France</footnote>

<footnote n="5"><sup>5</sup>Research On Healthcare Performance (RESHAPE), Claude Bernard Lyon 1 University, INSERM U1290, Lyon, France</footnote>

<footnote n="6"><sup>6</sup>Department of family medicine, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Switzerland</footnote>

<footnote>* FA and CC contributed equally to the manuscript</footnote>
**Abstract**

**Background**

The global burden of non-communicable diseases is increasing and the need for prevention is huge. Policies have yet to produce results and prevention indicators remain low. Primary care (PC) represents an opportunity to optimise the practice of prevention, but GPs are coming up against barriers that are holding back their prevention practices.

**Aim**

The aim of this overview of reviews is to identify the barriers and facilitators for the implementation of routine prevention practices in PC.

**Design and setting**

This study is an international overview of reviews focusing on the integration of prevention in PC settings.

**Method**

The search was conducted on July 2022 in MEDLINE, EMBASE, Web of Science and the Cochrane Database of Systematic Reviews. Included reviews are: systematic reviews or scoping reviews adopting a systematic approach.

**Results**

The 35 reviews included identify multiple barriers and facilitators related to the integration of prevention in PC. These factors are very heterogeneous as regards their source (the patient, the professional and the health system) and their level of action (individual, organisational or contextual). The results show the need to organise PC at the professional level (e.g. in training), at the local level (e.g. partnerships) and at the political level (e.g. funding model).

**Conclusion**

The factors influencing the integration of prevention in PC are multiple and act at different levels (individual, organisational and health system level). Organisation factors play a major role and seem to be a means of overcoming the difficulties encountered by healthcare professionals in developing preventive practices.

**Keywords**

Prevention, primary health care, organisation

**How this fits in:**

Many factors influence the practice of prevention in primary care. Many of these have already been identified, but the organisational aspect has so far been little explored in this context. In view of the current changes and structuring of primary care in many countries, the results of this overview of reviews could help health professionals and health authorities to integrate prevention into these structural changes.

**List of abbreviations:**

OECD: Organisation for Economic Co-operation and Development

HPs: Healthcare Professionals

PC: Primary care

WHO: World Health Organisation
**Abstract**

**Background**

The global burden of non-communicable diseases is increasing and the need for prevention is huge. Policies have yet to produce results and prevention indicators remain low. Primary care (PC) represents an opportunity to optimise the practice of prevention, but GPs are coming up against barriers that are holding back their prevention practices.

**Aim**

The aim of this overview of reviews is to identify the barriers and facilitators for the implementation of routine prevention practices in PC.

**Design and setting**

This study is an international overview of reviews focusing on the integration of prevention in PC settings.

**Method**

The search was conducted on July 2022 in MEDLINE, EMBASE, Web of Science and the Cochrane Database of Systematic Reviews. Included reviews are: systematic reviews or scoping reviews adopting a systematic approach.

**Results**

The 35 reviews included identify multiple barriers and facilitators related to the integration of prevention in PC. These factors are very heterogeneous as regards their source (the patient, the professional and the health system) and their level of action (individual, organisational or contextual). The results show the need to organise PC at the professional level (e.g. in training), at the local level (e.g. partnerships) and at the political level (e.g. funding model).

**Conclusion**

The factors influencing the integration of prevention in PC are multiple and act at different levels (individual, organisational and health system level). Organisation factors play a major role and seem to be a means of overcoming the difficulties encountered by healthcare professionals in developing preventive practices.

**Keywords**

Prevention, primary health care, organisation

**How this fits in:**

Many factors influence the practice of prevention in primary care. Many of these have already been identified, but the organisational aspect has so far been little explored in this context. In view of the current changes and structuring of primary care in many countries, the results of this overview of reviews could help health professionals and health authorities to integrate prevention into these structural changes.

**List of abbreviations:**

OECD: Organisation for Economic Co-operation and Development

HPs: Healthcare Professionals

PC: Primary care

WHO: World Health Organisation
## Introduction

Non-communicable diseases (e.g. cardiovascular diseases, diabetes, chronic respiratory diseases) are responsible for 74% of deaths worldwide ¹. These deaths are partly preventable through a reduction in behavioural risk factors such as tobacco and alcohol consumption, diet and physical activity¹. To act on these risk factors, primary care (PC) providers are indispensable. They have regular contact with a large number of users and can encourage early attention to health². Prevention and health promotion services are also an integral part of the PC mission, as defined by the World Health Organisation (WHO) at the international conference on PC in Alma Ata in 1978³.

Accordingly, prevention in PC is the subject of several health policy strategies in various countries⁴,⁵. However, these policies have yet to produce significant results in the field and prevention indicators remain low. In 2019, almost 60% of adults in OECD countries were overweight or obese ⁶. PC professionals, particularly GPs, are aware of the value of prevention and are motivated to promote this approach ⁷⁻¹⁰. However, they face many obstacles that prevent them from systematising prevention approaches ¹¹,¹², making the health outcomes still very heterogeneous. For example, worldwide, 59% of women have a diagnosis of hypertension; of these 47% are treated, and only 23% have controlled hypertension ¹³.

To improve the integration of prevention into the practices of PC professionals, it is necessary to describe in detail the context in which they operate. Many factors (barriers and facilitators) have already been identified in other settings ¹⁴ or with a focus on behavioural change ¹⁵. The organisational aspect appears to be an important lever in PC professionals to integrate prevention into their practices¹⁴. However, to the best of our knowledge, no systematic synthesis has yet focused on the organisation aspect of prevention practice in PC. This
## Introduction

Non-communicable diseases (e.g. cardiovascular diseases, diabetes, chronic respiratory diseases) are responsible for 74% of deaths worldwide ¹. These deaths are partly preventable through a reduction in behavioural risk factors such as tobacco and alcohol consumption, diet and physical activity¹. To act on these risk factors, primary care (PC) providers are indispensable. They have regular contact with a large number of users and can encourage early attention to health². Prevention and health promotion services are also an integral part of the PC mission, as defined by the World Health Organisation (WHO) at the international conference on PC in Alma Ata in 1978³.

Accordingly, prevention in PC is the subject of several health policy strategies in various countries⁴,⁵. However, these policies have yet to produce significant results in the field and prevention indicators remain low. In 2019, almost 60% of adults in OECD countries were overweight or obese ⁶. PC professionals, particularly GPs, are aware of the value of prevention and are motivated to promote this approach ⁷⁻¹⁰. However, they face many obstacles that prevent them from systematising prevention approaches ¹¹,¹², making the health outcomes still very heterogeneous. For example, worldwide, 59% of women have a diagnosis of hypertension; of these 47% are treated, and only 23% have controlled hypertension ¹³.

To improve the integration of prevention into the practices of PC professionals, it is necessary to describe in detail the context in which they operate. Many factors (barriers and facilitators) have already been identified in other settings ¹⁴ or with a focus on behavioural change ¹⁵. The organisational aspect appears to be an important lever in PC professionals to integrate prevention into their practices¹⁴. However, to the best of our knowledge, no systematic synthesis has yet focused on the organisation aspect of prevention practice in PC. This
approach makes it possible to produce an overall view of the factors influencing the practice
of prevention in the CPs. The aim of this overview of reviews is therefore to identify the
barriers and facilitators for the implementation of prevention practice in PC.

## Methods

This review is an overview of reviews. It is a systematic review of systematic reviews, i.e. it
includes any kind of literature review with a rigorous methodology to achieve a single
synthesis of a specific topic ¹⁶. This overview of reviews was conducted in accordance with the
recommendations of the PRISMA statement¹⁷ and the mixed methods systematic reviews¹⁸.

## Data searches

The search equation was developed with a librarian from the University of Bordeaux and
includes the keywords "prevention", "primary care", "barriers" OR " facilitators" and their
synonyms. The search was conducted on 05 July 2022 in MEDLINE, EMBASE, Web of Science
and the Cochrane Database of Systematic Reviews (Supplementary Box 1). No date or location
restrictions were applied. Only articles published in English were included. The data was
managed on the Covidence platform.

## Study selection

This study focuses on the integration of prevention of risk factors in the routine practices of
PC providers. Two types of preventive intervention were included: (i) primary prevention
interventions which aim to reduce the incidence of chronic conditions in the general
population (e.g. vaccination); (ii) secondary prevention which aims to detect chronic
conditions early in a population sample with risk factors (e.g. screening). Reviews addressing
approach makes it possible to produce an overall view of the factors influencing the practice
of prevention in the CPs. The aim of this overview of reviews is therefore to identify the
barriers and facilitators for the implementation of prevention practice in PC.

## Methods

This review is an overview of reviews. It is a systematic review of systematic reviews, i.e. it
includes any kind of literature review with a rigorous methodology to achieve a single
synthesis of a specific topic ¹⁶. This overview of reviews was conducted in accordance with the
recommendations of the PRISMA statement¹⁷ and the mixed methods systematic reviews¹⁸.

## Data searches

The search equation was developed with a librarian from the University of Bordeaux and
includes the keywords "prevention", "primary care", "barriers" OR " facilitators" and their
synonyms. The search was conducted on 05 July 2022 in MEDLINE, EMBASE, Web of Science
and the Cochrane Database of Systematic Reviews (Supplementary Box 1). No date or location
restrictions were applied. Only articles published in English were included. The data was
managed on the Covidence platform.

## Study selection

This study focuses on the integration of prevention of risk factors in the routine practices of
PC providers. Two types of preventive intervention were included: (i) primary prevention
interventions which aim to reduce the incidence of chronic conditions in the general
population (e.g. vaccination); (ii) secondary prevention which aims to detect chronic
conditions early in a population sample with risk factors (e.g. screening). Reviews addressing
only tertiary and quaternary prevention have been excluded. We have also included articles
on prevention in general without a specific theme.

In this overview of reviews, the PC setting follows the WHO definition¹⁹. Therefore, reviews
dealing with emergency departments or hospitals have not been included. As concerns the
targeted population, all patients in PC were included (adults and elderly people) excluding
children and adolescents as well as specific communities (e.g. migrants, disabled people) due
to their particular care pathways. We have included systematic reviews as well as scoping
reviews with a systematic approach. Qualitative and quantitative reviews are both included.
All inclusion and exclusion criteria are presented in the *Supplementary Table 1*.

Titles and abstracts were independently and blindly reviewed by two reviewers. Conflicting
abstracts were resolved by reading the full text. Eligible full texts were read independently by
two reviewers to be included in the final study. Conflicts were resolved through discussion or
by the involvement of a third reviewer if no consensus could be reached.

**Data extraction**

A data extraction form was designed specifically for this study. It contained the following
information: identification of the review (title, authors and date), objectives, prevention
theme, search and analysis method, number of primary articles included, outcomes (barriers
and facilitators) and the risk of bias assessment. Data extraction was carried out by two
reviewers.

**Quality assessment**

For all reviews included in the study, a reviewer assessed the methodological quality using the
ROBIS tool²⁰. A quality score is assigned as follows: high risk of bias, low risk of bias and unclear
risk of bias.
only tertiary and quaternary prevention have been excluded. We have also included articles
on prevention in general without a specific theme.

In this overview of reviews, the PC setting follows the WHO definition¹⁹. Therefore, reviews
dealing with emergency departments or hospitals have not been included. As concerns the
targeted population, all patients in PC were included (adults and elderly people) excluding
children and adolescents as well as specific communities (e.g. migrants, disabled people) due
to their particular care pathways. We have included systematic reviews as well as scoping
reviews with a systematic approach. Qualitative and quantitative reviews are both included.
All inclusion and exclusion criteria are presented in the *Supplementary Table 1*.

Titles and abstracts were independently and blindly reviewed by two reviewers. Conflicting
abstracts were resolved by reading the full text. Eligible full texts were read independently by
two reviewers to be included in the final study. Conflicts were resolved through discussion or
by the involvement of a third reviewer if no consensus could be reached.

**Data extraction**

A data extraction form was designed specifically for this study. It contained the following
information: identification of the review (title, authors and date), objectives, prevention
theme, search and analysis method, number of primary articles included, outcomes (barriers
and facilitators) and the risk of bias assessment. Data extraction was carried out by two
reviewers.

**Quality assessment**

For all reviews included in the study, a reviewer assessed the methodological quality using the
ROBIS tool²⁰. A quality score is assigned as follows: high risk of bias, low risk of bias and unclear
risk of bias.
## Data synthesis and analysis

The data synthesis followed a convergent integrated approach¹⁸. The first step was to translate the quantitative data into qualitative data by means of a textual description. Then the two types of data were put together.

The assembled data were then analysed using a thematic approach, coding the results in an analysis grid. This analysis grid (Figure 1) was designed using different sources. The first was the "consolidated framework assessing PC organisation and performance" by N. Senn et al.²¹. This is a framework describing the organisation of PC from a very global point of view integrating dynamic interactions. With this objective in mind, it was adapted to prevention, one of the themes of PC. Thus 3 contextual factors (health system, socio-cultural context and political and legal context), 2 domains (delivery of PC services and organisation and structure of PC practices) and 1 connecting construct (accessibility) were enlisted from this framework for the analysis grid. To this, 3 additional domains were added: users, health professionals (HPs) and preventive intervention. They were added inductively based on the data obtained in the overview of reviews that were included. This grid includes aspects related to the intervention, actors, functioning and context of prevention in PC.

## Results

### Search results

The search strategy allowed us to identify 420 records of which 44 were duplicates. 376 records were thus examined of which 285 were identified as irrelevant. 91 full texts were assessed for eligibility after which 35 articles were included (Figure 2).

### Characteristics of included reviews
## Data synthesis and analysis

The data synthesis followed a convergent integrated approach¹⁸. The first step was to translate the quantitative data into qualitative data by means of a textual description. Then the two types of data were put together.

The assembled data were then analysed using a thematic approach, coding the results in an analysis grid. This analysis grid (Figure 1) was designed using different sources. The first was the "consolidated framework assessing PC organisation and performance" by N. Senn et al.²¹. This is a framework describing the organisation of PC from a very global point of view integrating dynamic interactions. With this objective in mind, it was adapted to prevention, one of the themes of PC. Thus 3 contextual factors (health system, socio-cultural context and political and legal context), 2 domains (delivery of PC services and organisation and structure of PC practices) and 1 connecting construct (accessibility) were enlisted from this framework for the analysis grid. To this, 3 additional domains were added: users, health professionals (HPs) and preventive intervention. They were added inductively based on the data obtained in the overview of reviews that were included. This grid includes aspects related to the intervention, actors, functioning and context of prevention in PC.

## Results

### Search results

The search strategy allowed us to identify 420 records of which 44 were duplicates. 376 records were thus examined of which 285 were identified as irrelevant. 91 full texts were assessed for eligibility after which 35 articles were included (Figure 2).

### Characteristics of included reviews
The prevention topics are various, some reviews dealing with a specific theme and four review deal with prevention from a general point of view. The reviews included are described in *Supplementary Table 2*. The analysis methods of the included reviews are mostly qualitative (n=33), two reviews have a mixed analysis method (qualitative and quantitative). Following the risk of bias assessment, 22 reviews were classified as having a low risk of bias, 3 a high risk of bias and 10 with an unclear risk of bias.

## Main findings

A large number of barriers and facilitators were identified. These factors are very heterogeneous with regard to their source (the patient, the professional or the health system) and their level of action (individual, organisational or contextual). All the results and some examples are shown in *Supplementary Table 3*.

## Individual

### Health professionals

This topic concerns all individual factors related to HPs working in PC. Lack of time ²²⁻⁴⁰ is the most cited constraint (n=19). Receiving appropriate and relevant prevention training ²²,26,31,34,36,40,41 is the factor positively associated with prevention practice cited in the most reviews (n=7).

### Users

Regarding this topic, related to users, the most frequently found barrier is lack of education and knowledge on the part of patients on the subject of prevention (n=4). While, the facilitator most frequently cited (n=4) are the support of family and friends in the patient's entourage ³⁴,⁴⁰,⁴²,⁴³.
The prevention topics are various, some reviews dealing with a specific theme and four review deal with prevention from a general point of view. The reviews included are described in *Supplementary Table 2*. The analysis methods of the included reviews are mostly qualitative (n=33), two reviews have a mixed analysis method (qualitative and quantitative). Following the risk of bias assessment, 22 reviews were classified as having a low risk of bias, 3 a high risk of bias and 10 with an unclear risk of bias.

## Main findings

A large number of barriers and facilitators were identified. These factors are very heterogeneous with regard to their source (the patient, the professional or the health system) and their level of action (individual, organisational or contextual). All the results and some examples are shown in *Supplementary Table 3*.

## Individual

### Health professionals

This topic concerns all individual factors related to HPs working in PC. Lack of time ²²⁻⁴⁰ is the most cited constraint (n=19). Receiving appropriate and relevant prevention training ²²,26,31,34,36,40,41 is the factor positively associated with prevention practice cited in the most reviews (n=7).

### Users

Regarding this topic, related to users, the most frequently found barrier is lack of education and knowledge on the part of patients on the subject of prevention (n=4). While, the facilitator most frequently cited (n=4) are the support of family and friends in the patient's entourage ³⁴,⁴⁰,⁴²,⁴³.
## Organisational

### Organisation and structure of PC practices

This topic concerns organisation and environmental characteristics that may influence PC. These are the material and human resources that a PC provider requires to develop prevention in his or her practice and the ways in which they would be organised²¹.

There are several elements related to the organisation and structure of PC that can influence the practice of prevention by HPs. For example, the most cited barrier (n=5) is the lack of equipment available for professionals to develop prevention in their practices²⁴,²⁶,³¹,³⁹,⁴¹. The mobilisation of an information system is the most frequent facilitator mentioned in the literature (n=3) to develop prevention in PC³⁹,⁴⁰,⁴⁴.

### Delivery of PC services

This is defined as the process by which HPs deliver PC services to patients and the population ²¹. Providing recommendations and advice to patients²⁵,³⁰,⁴¹,⁴⁵,⁴⁶ is the main facilitator in this area (n=5). The fact that certain prevention themes are given less priority than other health problems²²,²⁹,³⁶ is a significant barrier to the development of prevention in PC.

### Prevention intervention

This topic is defined by all of the factors that relate to a prevention intervention, i.e. the development or the components of the intervention, the tools used for or the implementation of the intervention. Lack of information materials for patients ³⁶,⁴⁰ hinder the development of prevention in PC. On the contrary, a low-cost intervention ²⁴, integrated into routine activities ²⁴,⁴⁷, in a systematic way ⁴¹ which is simple to implement ²⁴ and adapted to the needs of the
## Organisational

### Organisation and structure of PC practices

This topic concerns organisation and environmental characteristics that may influence PC. These are the material and human resources that a PC provider requires to develop prevention in his or her practice and the ways in which they would be organised²¹.

There are several elements related to the organisation and structure of PC that can influence the practice of prevention by HPs. For example, the most cited barrier (n=5) is the lack of equipment available for professionals to develop prevention in their practices²⁴,²⁶,³¹,³⁹,⁴¹. The mobilisation of an information system is the most frequent facilitator mentioned in the literature (n=3) to develop prevention in PC³⁹,⁴⁰,⁴⁴.

### Delivery of PC services

This is defined as the process by which HPs deliver PC services to patients and the population ²¹. Providing recommendations and advice to patients²⁵,³⁰,⁴¹,⁴⁵,⁴⁶ is the main facilitator in this area (n=5). The fact that certain prevention themes are given less priority than other health problems²²,²⁹,³⁶ is a significant barrier to the development of prevention in PC.

### Prevention intervention

This topic is defined by all of the factors that relate to a prevention intervention, i.e. the development or the components of the intervention, the tools used for or the implementation of the intervention. Lack of information materials for patients ³⁶,⁴⁰ hinder the development of prevention in PC. On the contrary, a low-cost intervention ²⁴, integrated into routine activities ²⁴,⁴⁷, in a systematic way ⁴¹ which is simple to implement ²⁴ and adapted to the needs of the
patients as well as to the reality of the services<sup>24</sup> will favour the development of prevention
in PC.

Accessibility

Accessibility is defined as the possibility of recieving care when and where it is needed <sup>21</sup>.
There are four types of accessibility: time accessibility<sup>25,31,34-37,40,41,48,49</sup>, geographical
accessibility<sup>41,43,44</sup>, accessibility of providers<sup>33,40,41,44,50</sup> and financial accessibility<sup>22,32,39-41,44,47,49,51</sup>.

The two most common barriers found (n=4) are the lack of time for patients<sup>25,31,48,49</sup> and the
lack of economic support for patients<sup>22,32,40,49</sup>. Conversely, offering time slots outside office
hours is the most frequent (n=2) facilitator for accessibility in the development of prevention
in PC<sup>41,48</sup>.

Contextual

Socio-cultural context

This theme is defined by N. Senn et al. as “the social status, education levels, self-confidence,
behavioural context, culture and tradition”²¹.

There are two socio-cultural contexts, that of the patient and that of the HPs. Both have an
impact on prevention in the PC system. The patient's socio-cultural background is the most
frequently cited (n=6).

Political and legal context

The political and legal context defined by N. Senn et al. as “a country’s political system, its
legislative and regulatory setting”²¹.
patients as well as to the reality of the services<sup>24</sup> will favour the development of prevention
in PC.

Accessibility

Accessibility is defined as the possibility of recieving care when and where it is needed <sup>21</sup>.
There are four types of accessibility: time accessibility<sup>25,31,34-37,40,41,48,49</sup>, geographical
accessibility<sup>41,43,44</sup>, accessibility of providers<sup>33,40,41,44,50</sup> and financial accessibility<sup>22,32,39-41,44,47,49,51</sup>.

The two most common barriers found (n=4) are the lack of time for patients<sup>25,31,48,49</sup> and the
lack of economic support for patients<sup>22,32,40,49</sup>. Conversely, offering time slots outside office
hours is the most frequent (n=2) facilitator for accessibility in the development of prevention
in PC<sup>41,48</sup>.

Contextual

Socio-cultural context

This theme is defined by N. Senn et al. as “the social status, education levels, self-confidence,
behavioural context, culture and tradition”<sup>21</sup>.

There are two socio-cultural contexts, that of the patient and that of the HPs. Both have an
impact on prevention in the PC system. The patient's socio-cultural background is the most
frequently cited (n=6).

Political and legal context

The political and legal context defined by N. Senn et al. as “a country’s political system, its
legislative and regulatory setting”<sup>21</sup>.
The unclear definition of the role of professionals<sup>28,38</sup> is an example of political barriers to the development of prevention in PC. The use of legislation in the context of behavioural change<sup>40</sup>, as is the case for tobacco, and the institutional promotion of prevention campaigns and messages<sup>34</sup> are favourable for the development of prevention in PC.

## Discussion

### Summary

The factors acting on the integration of prevention in PC are numerous and varied. They can be classified in eight themes according to their area of action. These themes are related to the individual, organisational and contextual level of the healthcare system (Supplementary Table 3).

### Comparison with existing literature

The results show that the implementation of prevention in PC goes far beyond the fact that patients are not sufficiently informed and professionals are not sufficiently trained. There are clearly factors linked to changes in the behaviour of patients and professionals<sup>15</sup> and in their experiences and their emotions, but many other dimensions of the PC system, its organisation, its accessibility, the context and the interactions within it must also be taken into account. The multiplicity of factors involved and the dynamic relationships between them resonates with similar findings pertaining to other types of changes in the PC setting<sup>52</sup>. PC must therefore be considered as a set of elements of differing natures operating at various levels, as depicted by the three-level framework: microsystem (clinical level), mesosystem (organisational level) and macrosystem (health system level)<sup>53</sup>.
The unclear definition of the role of professionals<sup>28,38</sup> is an example of political barriers to the development of prevention in PC. The use of legislation in the context of behavioural change<sup>40</sup>, as is the case for tobacco, and the institutional promotion of prevention campaigns and messages<sup>34</sup> are favourable for the development of prevention in PC.

## Discussion

### Summary

The factors acting on the integration of prevention in PC are numerous and varied. They can be classified in eight themes according to their area of action. These themes are related to the individual, organisational and contextual level of the healthcare system (Supplementary Table 3).

### Comparison with existing literature

The results show that the implementation of prevention in PC goes far beyond the fact that patients are not sufficiently informed and professionals are not sufficiently trained. There are clearly factors linked to changes in the behaviour of patients and professionals<sup>15</sup> and in their experiences and their emotions, but many other dimensions of the PC system, its organisation, its accessibility, the context and the interactions within it must also be taken into account. The multiplicity of factors involved and the dynamic relationships between them resonates with similar findings pertaining to other types of changes in the PC setting<sup>52</sup>. PC must therefore be considered as a set of elements of differing natures operating at various levels, as depicted by the three-level framework: microsystem (clinical level), mesosystem (organisational level) and macrosystem (health system level)<sup>53</sup>.
Some of the factors identified in the literature can be modified, while others cannot (e.g. patients' physio-pathological status, patient's social norms). The factors that can be modified are mainly related to the organisation in nature (e.g. providing more training for HPs, improving coordination between HPs, making suitable infrastructure available, developing a shared information system, etc.). Accordingly, a study found that the way in which office practices are organised is a predictor of better performance in terms of prevention⁵⁴. Thus, the development of prevention in PC cannot be conceived independently of a solid underlying organisation.

Many countries are currently reorganising their PC systems. This is the case in the United Kingdom, France and Canada, with the development of coordinated practice structures, the aim of which is to coordinate a multidisciplinary team of HPs in the same area around a common health project⁵⁵⁻⁵⁷. In France, for example, these coordinated exercise structures have a mandatory prevention mission⁵⁷. These organisation changes may provide an opportunity to work on integrating prevention into HP practices.

## Implication for research and/or practice

If more prevention is to be integrated into CPs, all levels of the healthcare system must be involved in developing prevention interventions. Given the number and diversity of factors identified in this overview of reviews, it is essential to consider several strategies.

One of the major conditions for the development of prevention is the development of healthcare organisations. It would appear that these structures could remove barriers to the coordination and accessibility of HPs. A study shows that joint management of patients in primary care by several healthcare professionals improves the quality of care and reduces organisational constraints⁵⁸. Thus, it is not necessary to create a specific prevention system,
Some of the factors identified in the literature can be modified, while others cannot (e.g. patients' physio-pathological status, patient's social norms). The factors that can be modified are mainly related to the organisation in nature (e.g. providing more training for HPs, improving coordination between HPs, making suitable infrastructure available, developing a shared information system, etc.). Accordingly, a study found that the way in which office practices are organised is a predictor of better performance in terms of prevention⁵⁴. Thus, the development of prevention in PC cannot be conceived independently of a solid underlying organisation.

Many countries are currently reorganising their PC systems. This is the case in the United Kingdom, France and Canada, with the development of coordinated practice structures, the aim of which is to coordinate a multidisciplinary team of HPs in the same area around a common health project⁵⁵⁻⁵⁷. In France, for example, these coordinated exercise structures have a mandatory prevention mission⁵⁷. These organisation changes may provide an opportunity to work on integrating prevention into HP practices.

### Implication for research and/or practice

If more prevention is to be integrated into CPs, all levels of the healthcare system must be involved in developing prevention interventions. Given the number and diversity of factors identified in this overview of reviews, it is essential to consider several strategies.

One of the major conditions for the development of prevention is the development of healthcare organisations. It would appear that these structures could remove barriers to the coordination and accessibility of HPs. A study shows that joint management of patients in primary care by several healthcare professionals improves the quality of care and reduces organisational constraints⁵⁸. Thus, it is not necessary to create a specific prevention system,
but rather to reflect on how the CP system could take into account all the dimensions of
prevention.

## Strengths and limitations

The reviews included in this overview of reviews are very heterogeneous in terms of their
subject matter and the methods of analysis used and some of the reviews were assessed as
having a high risk of bias. Also, this overview of reviews does not allow us to conclude whether
certain factors are specific to certain themes (e.g. cancer screening) or to certain professionals
in particular (e.g. general practitioners, nurses) nor the extent to which they influence each
other. However, the objective here was to have an overall view of the factors influencing the
routine practice of prevention.

## Conclusion

Multiple factors influence the integration of prevention practices within PC, operating at
distinct levels: the individual, organisational and health system levels. The organisation aspect
of these factors is significant and integrating the practice of prevention within existing
healthcare organisations seems to be a way of removing certain barriers.
but rather to reflect on how the CP system could take into account all the dimensions of
prevention.

## Strengths and limitations

The reviews included in this overview of reviews are very heterogeneous in terms of their
subject matter and the methods of analysis used and some of the reviews were assessed as
having a high risk of bias. Also, this overview of reviews does not allow us to conclude whether
certain factors are specific to certain themes (e.g. cancer screening) or to certain professionals
in particular (e.g. general practitioners, nurses) nor the extent to which they influence each
other. However, the objective here was to have an overall view of the factors influencing the
routine practice of prevention.

## Conclusion

Multiple factors influence the integration of prevention practices within PC, operating at
distinct levels: the individual, organisational and health system levels. The organisation aspect
of these factors is significant and integrating the practice of prevention within existing
healthcare organisations seems to be a way of removing certain barriers.
**Acknowledgments**

The authors wish to thank Frederique Flamerie, the librarian at the University of Bordeaux for her help in conducting the systematic literature search.

**Primary funding source:**

PREVA'NA (Prévention et actions en Région Nouvelle-Aquitaine), Région Nouvelle-Aquitaine, 2021.

**Conflict of Interest**

None declared
**Acknowledgments**

The authors wish to thank Frederique Flamerie, the librarian at the University of Bordeaux for her help in conducting the systematic literature search.

**Primary funding source:**

PREVA'NA (Prévention et actions en Région Nouvelle-Aquitaine), Région Nouvelle-Aquitaine, 2021.

**Conflict of Interest**

None declared
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References

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3. Declaration of Alma-Ata International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 September 1978. *Development*. 2004;47(2):159-161.
doi:10.1057/palgrave.development.1100047

4. Australian Government Department of Health and Aged Care. Australia's Primary Health Care 10 Year Plan 2022–2032.; 2022. https://www.health.gov.au/resources/publications/australias-primary-health-care-10-year-plan-2022-2032?language=en. Accessed March 9, 2023.

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10. Cohidon C, Imhof F, Bovy L, et al. Patients' and General Practitioners' Views About Preventive Care in Family Medicine in Switzerland: A Cross-sectional Study. *J Prev Med Public Health Yebang Uihakhoe Chi*. 2019;52(5):323-332. doi:10.3961/jpmph.19.184

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doi:10.1007/s11121-020-01087-6

15. Mather M, Pettigrew LM, 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.* 2022;11:180. doi:10.1186/s13643-022-02030-2

16. Aromataris E, Fernandez R, Godfrey CM, et al. Summarizing systematic reviews: methodological development, conduct and reporting of an umbrella review approach. *JBI Evid Implement.* 2015;13(3):132. doi:10.1097/XEB.0000000000000055

17. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. *BMJ*. 2021;372:n71. doi:10.1136/bmj.n71

18. Stern C, Lizarondo L, Carrier J, et al. Methodological guidance for the conduct of mixed methods systematic reviews. *JBI Evid Synth*. 2020;18(10):2108-2118. doi:10.11124/JBISRIR-D-19-00169

19. World Health Organization. *The World Health Report 2008 : Primary Health Care Now More than Ever*. World Health Organization; 2008. https://apps.who.int/iris/handle/10665/43949. Accessed December 5, 2022.

20. Whiting P, Savović J, Higgins JPT, et al. ROBIS: A new tool to assess risk of bias in systematic reviews was developed. *J Clin Epidemiol.* 2016;69:225-234. doi:10.1016/j.jclinepi.2015.06.005

21. Senn N, Breton M, Ebert ST, et al. Assessing primary care organization and performance: Literature synthesis and proposition of a consolidated framework. *Health Policy*. Published online 2021:8.

22. Carter C, Harnett JE, Krass I, Gelissen IC. A review of primary healthcare practitioners' views about nutrition: implications for medical education. *Int J Med Educ.* 2022;13:124-137.
doi:10.5116/ijme.6271.3aa2

23. Deehan A, Marshall EJ, Strang J. Tackling alcohol misuse: opportunities and obstacles in primary care. *Br J Gen Pract J R Coll Gen Pract.* 1998;48(436):1779-1782.

24. de Oliveira N, Peduzzi M, Agreli H, Matsumoto K. Implementation of evidence-based nutritional management in primary health care settings: a systematic scoping review. *Aust J Prim Health.* 2021;28. doi:10.1071/PY20280

25. Eisner D, Zoller M, Rosemann T, et al. Screening and prevention in Swiss primary care: a systematic review. *Int J Gen Med.* 2011;4:853-870. doi:10.2147/IJGM.S26562

26. Fee JA, McGrady FP, Rosendahl C, Hart ND. Dermoscopy Use in Primary Care: A Scoping Review. *Dermatol Pract Concept*. Published online April 30, 2019:98-104. doi:10.5826/dpc.0902a04

27. Hall L, Thorneloe R, Rodriguez-Lopez R, et al. Delivering brief physical activity interventions in primary care: a systematic review. *Br J Gen Pract J R Coll Gen Pract.* 2022;72(716).
doi:10.3399/BJGP.2021.0312
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36. Neale EP, Middleton J, Lambert K. Barriers and enablers to detection and management of chronic kidney disease in primary healthcare: a systematic review. *BMC Nephrol*. 2020;21(1):83.
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37. Somerville M, Ball L, Sierra-Silvestre E, Williams LT. Understanding the knowledge, attitudes and practices of providing and receiving nutrition care for prediabetes: an integrative review. *Aust J Prim Health*. 2019;25(4):289-302. doi:10.1071/PY19082

38. van Dillen SME, Hiddink GJ. To what extent do primary care practice nurses act as case managers lifestyle counselling regarding weight management? A systematic review. *BMC Fam Pract*. 2014;15:197. doi:10.1186/s12875-014-0197-2

39. Vedel I, Puts MTE, Monette M, et al. 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.
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28. Henderson J, Koehne K, Verrall C, et al. How is Primary Health Care conceptualised in nursing in Australia? A review of the literature. *Health Soc Care Community*. 2014;22(4):337-351.
doi:10.1111/hsc.12064

29. Ju I, Banks E, Calabria B, 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. doi:10.1136/bmjopen-2017-021137

30. Kay E, Vascott D, Hocking A, et al. A review of approaches for dental practice teams for promoting oral health. *Community Dent Oral Epidemiol*. 2016;44(4):313-330.
doi:10.1111/cdoe.12220

31. Loescher LJ, Stratton D, Slebodnik M, Goodman H. Systematic review of advanced practice nurses' skin cancer detection knowledge and attitudes, clinical skin examination, lesion detection, and training. *J Am Assoc Nurse Pract*. 2018;30(1):43-58.
doi:10.1097/JXX.0000000000000004

32. McConville A, Hooven K. Factors influencing the implementation of falls prevention practice in primary care. *J Am Assoc Nurse Pract*. 2020;33(2):108-116. doi:10.1097/JXX.0000000000000360

33. Mishra K, Atkins DE, Gutierrez B, et al. Screening for adverse childhood experiences in preventive medicine settings: a scoping review. *J Public Health*. Published online May 22, 2021.
doi:10.1007/s10389-021-01548-4

34. Moreno-Peral P, Conejo-Cerón S, Fernández A, et al. Primary care patients' perspectives of barriers and enablers of primary prevention and health promotion-a meta-ethnographic synthesis. *PloS One*. 2015;10(5):e0125004. doi:10.1371/journal.pone.0125004

35. Najmi M, Brown AE, Harrington SR, et al. A systematic review and synthesis of qualitative and quantitative studies evaluating provider, patient, and health care system-related barriers to diagnostic skin cancer examinations. *Arch Dermatol Res*. 2022;314(4):329-340.
doi:10.1007/s00403-021-02224-z

36. Neale EP, Middleton J, Lambert K. Barriers and enablers to detection and management of chronic kidney disease in primary healthcare: a systematic review. *BMC Nephrol*. 2020;21(1):83.
doi:10.1186/s12882-020-01731-x

37. Somerville M, Ball L, Sierra-Silvestre E, Williams LT. Understanding the knowledge, attitudes and practices of providing and receiving nutrition care for prediabetes: an integrative review. *Aust J Prim Health*. 2019;25(4):289-302. doi:10.1071/PY19082

38. van Dillen SME, Hiddink GJ. To what extent do primary care practice nurses act as case managers lifestyle counselling regarding weight management? A systematic review. *BMC Fam Pract*. 2014;15:197. doi:10.1186/s12875-014-0197-2

39. Vedel I, Puts MTE, Monette M, et al. 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.
doi:10.1016/j.jgo.2010.11.003

40. Wändell PE, de Waard AKM, Holzmann MJ, et al. Barriers and facilitators among health professionals in primary care to prevention of cardiometabolic diseases: A systematic review. *Fam Pract*. 2018;35(4):383-398. doi:10.1093/fampra/cmx137
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48. de Waard AKM, Wändell PE, Holzmann MJ, et al. Barriers and facilitators to participation in a health check for cardiometabolic diseases in primary care: A systematic review. *Eur J Prev Cardiol*. 2018;25(12):1326-1340. doi:10.1177/2047487318780751

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42. Atkins L, Stefanidou C, Chadborn T, et al. Influences on NHS Health Check behaviours: a systematic review. *BMC Public Health*. 2020;20(1):1359. doi:10.1186/s12889-020-09365-2

43. Murray J, Craigs CL, Hill KM, et al. A systematic review of patient reported factors associated with uptake and completion of cardiovascular lifestyle behaviour change. *BMC Cardiovasc Disord*. 2012;12(1):120. doi:10.1186/1471-2261-12-120

44. Dennis S, Williams A, Taggart J, et al. Which providers can bridge the health literacy gap in lifestyle risk factor modification education: a systematic review and narrative synthesis. *BMC Fam Pract*. 2012;13:44. doi:10.1186/1471-2296-13-44

45. Holden DJ, Jonas DE, Porterfield DS, et al. Systematic Review: Enhancing the Use and Quality of Colorectal Cancer Screening. *Ann Intern Med*. 2010;152(10):668-676. doi:10.7326/0003-4819-152-10-201005180-00239

46. Prusaczyk A, Żuk P, Guzek M, et al. An overview of factors influencing cancer screening uptake in primary healthcare institutions. *Fam Med Prim Care Rev*. 2022;24(1):71-77.
doi:10.5114/fmpcr.2022.113019

47. Nelson HD, Cantor A, Wagner J, et al. Achieving Health Equity in Preventive Services: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop. *Ann Intern Med*. 2020;172(4):258-271. doi:10.7326/M19-3199

48. de Waard AKM, Wändell PE, Holzmann MJ, et al. Barriers and facilitators to participation in a health check for cardiometabolic diseases in primary care: A systematic review. *Eur J Prev Cardiol*. 2018;25(12):1326-1340. doi:10.1177/2047487318780751

49. Godbee K, Gunn J, Lautenschlager NT, et al. Implementing dementia risk reduction in primary care: a preliminary conceptual model based on a scoping review of practitioners' views. *Prim Health Care Res Dev*. 2019;20:e140. doi:10.1017/S1463423619000744

50. de Lusignan S, Mold F, Sheikh A, et al. Patients' online access to their electronic health records and linked online services: a systematic interpretative review. *BMJ Open*. 2014;4(9):e006021.
doi:10.1136/bmjopen-2014-006021

51. Yonel Z, Cerullo E, Kröger AT, Gray LJ. Use of dental practices for the identification of adults with undiagnosed type 2 diabetes mellitus or non-diabetic hyperglycaemia: a systematic review.
*Diabet Med J Br Diabet Assoc*. 2020;37(9):1443-1453. doi:10.1111/dme.14324

52. Lau R, Stevenson F, Ong BN, et al. Achieving change in primary care--causes of the evidence to practice gap: systematic reviews of reviews. *Implement Sci IS*. 2016;11:40. doi:10.1186/s13012-016-0396-4

53. Legido-Quigley H, McKee M, Nolte E, Glinos IA. Assuring the Quality of Health Care in European Union.; 2008:241. http://www.euro.who.int/_data/assets/pdf_file/0007/98233/E91397.pdf.
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58. Norful AA, Swords K, Marichal M, et al. Nurse practitioner-physician comanagement of primary care patients: The promise of a new delivery care model to improve quality of care. Health Care Manage Rev. 2019;44(3):235-245. doi:10.1097/HMR.0000000000000161
54. Dahrouge S, Hogg WE, Russell G, et al. Impact of remuneration and organizational factors on completing preventive manoeuvres in primary care practices. CMAJ. 2012;184(2):E135-E143. doi:10.1503/cmaj.110407

55. Gouvernement du Québec. Centres intégrés de santé et de services sociaux (CISSS) et centres intégrés universitaires de santé et de services sociaux (CIUSSS). Published 2023. https://www.quebec.ca/sante/systeme-et-services-de-sante/organisation-des-services/cisss-et-ciusss. Accessed July 28, 2023.

56. NHS England. What are integrated care systems? https://www.england.nhs.uk/integratedcare/what-is-integrated-care/. Accessed July 28, 2023.

57. Ministère de la santé et de la prévention. Les communautés professionnelles territoriales de santé (CPTS). Published July 28, 2023. https://sante.gouv.fr/systeme-de-sante/structures-de-soins/les-communautes-professionnelles-territoriales-de-sante-cpts/. Accessed July 28, 2023.

58. Norful AA, Swords K, Marichal M, et al. Nurse practitioner-physician comanagement of primary care patients: The promise of a new delivery care model to improve quality of care. Health Care Manage Rev. 2019;44(3):235-245. doi:10.1097/HMR.0000000000000161
<figure><img src="image_3.png" /><figcaption>Figure 1: Analysis grid</figcaption></figure>

<figure><img src="image_4.png" /><figcaption>Figure 2: Flow diagram</figcaption></figure>
<figure><img src="image_3.png" /><figcaption>Figure 1: Analysis grid</figcaption></figure>

<figure><img src="image_4.png" /><figcaption>Figure 2: Flow diagram</figcaption></figure>