Identifying patients with psychosocial problems in general practice: a scoping review protocol.

INTRODUCTION: Psychosocial problems (PSPs) are common issues associated with negative health outcomes. Since general practitioners are the first point of contact for any health-related concern, understanding their options to recognise patients with PSPs plays an important role as it is essential for early intervention and can prevent serious conditions. The objective of our scoping review is to map published evidence on the usage of instruments to identify patients with PSPs in general practice. METHODS AND ANALYSIS: We will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist and the Joanna Briggs Institute Reviewer's Manual on scoping reviews. A systematic search of four electronic databases (Medline (Ovid), Web of Science Core Collection, PsycInfo, Cochrane Library) will be conducted for quantitative and qualitative studies published in English, Spanish, French and German. Main study characteristics as well as information on identification instruments will be extracted and visualised in structured tables to map the available evidence. The protocol has been registered with Open Science Framework, https://osfio/c2m6z. ETHICS AND DISSEMINATION: This study does not require ethical approval as we will not collect personal data. Dissemination will consist of publications, presentations and other knowledge translation activities. © Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Our review addresses a topic of great public health importance, as early and structured identification of patients with psychosocial problems (PSPs) in general practice can improve patient health, the work of primary care professionals and the healthcare system.

This will be the first scoping review to analyse which instruments general practitioners use to identify patients with PSPs.

The search strategy includes four electronic databases with peer-reviewed literature and is based on tailored search strings which have been iteratively refined in order to retrieve as many relevant published studies as possible.

A limitation of our scoping review will be that a quality and risk of bias assessment of the included studies will not be performed.

Background

Since general practitioners (GPs) are the first point of contact for people with any health-related concern, patients visit their GP not only for medical reasons but also for psychosocial problems (PSPs).1–3 This issue was started to be studied decades ago4–6 and a vast body of research has investigated the significance of PSPs in health. People with PSPs are vulnerable to negative health outcomes, comorbidities and show a generally poorer health status.7 PSPs affect immunologic and inflammatory processes8–10 and are associated with an increased risk of illness, delayed recovery, chronic disease progression, compromised quality of life and mortality rates.7 11–13 Individuals who are socially isolated are at risk of premature mortality, comparable to well-documented risk factors, such as smoking and obesity.14–18 Certain work factor combinations increase health impairments.19–21 PSPs are related to several conditions, such as cardiovascular diseases, diabetes, infectious diseases and psychiatric disorders.17 22–27

Studies show that at least one-third of patients in general practices report suffering from PSPs. GPs in Germany are consulted by patients with PSPs at least three times a week.3 28 29 Major problems identified were family problems, caregiving tasks, violence-related issues, isolation, financial problems, employment problems, problems with physical functioning and legal problems.3 4 6 30–38 The International Classification of Primary Care, second edition (ICPC-2) includes a section that captures the most common social problems encountered in the primary care context39 which we include in our understanding of PSPs as we intend to focus on these kinds of problems that do not yet meet the criteria for a psychological or psychiatric diagnosis and for medical treatment. Studies also show that GPs recognise a fifth to a half of patients with relevant PSPs,5 which can lead to inadequate diagnostics, non-specific or no intervention or treatment at all and ineffective use of time.2 4 32 33 35 36 40–48

Although integration of the psychosocial perspective into medicine is widely demanded in research and from official health organisations, a practical approach in the form of a systematic and structured instrument is not part of the recommendations and is therefore worth investigating.1 3 7 44 49–51

Health complaints related to PSPs that are not primarily medical and that do not yet have the status of a disease or disorder are inherently complex and heterogeneous. Providing or referring to a universally valid concept of PSPs is difficult as academic disciplines, as well as organisations outside the academic context and policy-makers use different concepts. Nevertheless, PSPs are a relevant issue in everyday general practice and structured approaches could help provide guidance to GPs and their practice team early in the continuum of care. Early identification of problems will help to better meet patient needs and GPs resources. Against this background, we are particularly interested in instruments that are supportive and practical in daily practice and that capture a broad range of PSPs at once. Existing screening tools (eg, General Health Questionnaire, Somatic and Psychological Health Report Questionnaire)52–54 show an acceptable validity and reliability, but are not regularly used in general practice.

The aim of our scoping review is to comprehensively explore the evidence on instruments that can help GPs and their practice team identify patients with PSPs and thus contribute to the development of a practical approach that incorporates the biopsychosocial perspective in medicine. Bringing the results together will help provide an overview of the evidence and identify knowledge gaps, which will provide direction for further research activities.

Our research question is: What is known about the usage of instruments to identify patients with PSPs in general practice?

To our knowledge, there is no scoping review that addresses the question proposed by this review.

Methods and analysis

The scoping review will be conducted by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist55 and the Joanna Briggs Institute (JBI) Reviewer’s Manual on scoping reviews.56 Due to the various study types, diverse definitions of PSPs, as well as identification instruments, heterogeneity across studies is expected to be high. Therefore, a scoping review was chosen as an appropriate approach.57 58

Eligibility criteria

Studies will be eligible for inclusion if they meet the specified criteria presented in table 1.

Table 1

Inclusion and exclusion criteria for eligible studies

	Inclusion	Exclusion
Population	Adolescent or adult patients in general practices, with PSPs in general or specific social problems (eg, social problems according to ICPC-2, Section Z)39	Patients with disease-specific PSPs related to, for example, cancer, HIV, diabetes, substance use disorder or psychiatric disorders
Concept	Any kind of identification instrument (eg, questionnaire, interview) and reporting formats (eg, self-reported, clinical examination) for PSPs
Context	Studies with samples from developed countries, developing countries and countries in transition Studies conducted in general practice settings
Type of studies	Quantitative study designs (eg, cross-sectional studies, cohort studies, case–control studies), qualitative studies, mixed methods studies	Study protocols Reviews Author replies/comments
Type of publications	Full-text publications according to the EQUATOR Network61 guidelines
Language, time	English French Spanish German No time restrictions	All other languages

**Poverty/financial problem (Z01), Food/water problem (Z02), Housing/neighborhood problem (Z03), Social cultural problem (Z04), Work problem (Z05), Unemployment problem (Z06), Education problem (Z07), Social welfare problem (Z08), Legal problem (Z09), Health care system problem (Z10), Compliance/being ill problem (Z11), Relationship problem with partner (Z12), Partner’s behavior problem (Z13), Partner illness problem (Z14), Loss/death of partner problem (Z15), Relationship problem with child (Z16), Illness problem with child (Z18), Loss/death of child problem (Z19), Relationship problem parent/family (Z20), Behavior problem parent/family (Z21), Illness problem parent/family (Z22), Loss/death parent/family member (Z23), Relationship problem friend (Z24), Assault/harmful event problem (Z25), Fear of a social problem (Z27) and Limited function/disability (Z28).

EQUATOR, enhancing the quality and transparency of health research; ICPC-2, international classification of primary care, second edition; PSPs, psychosocial problems.

Included studies are required (1) to include adolescent or adult patients in general practices and (2) to use any kind of instrument or format to identify patients with PSPs. We take into consideration studies that include PSPs in general as well as studies that focus on specific social problems according to the ICPC-2.39 We will include studies with samples from all countries. Studies will be excluded if the study population consists of patients with PSPs related to specific chronic diseases or conditions (eg, cancer, HIV, diabetes, substance use disorder or psychiatric disorders), as it can be assumed that GPs are more likely to ask about PSPs if they know of an existing disease. In line with the characteristics of a scoping review, this review will consider not only quantitative study designs for inclusion (eg, cohort studies, case–control studies and cross-sectional studies) but also qualitative studies and mixed methods studies. We will include full-text publications in English, Spanish, French and German without time restrictions.

Information sources and search strategy

We developed a search strategy for Medline (Ovid) (see table 1 in the online supplemental file 1) and will adapt this strategy to the databases PsycInfo, the Cochrane Library and the Web of Science Core Collection. We will hand search and screen reference lists of included studies to identify other potential studies that meet the inclusion criteria. We will screen the reference lists of systematic reviews and scoping reviews which examined studies potentially fitting our inclusion criteria for further relevant studies. Search results will be downloaded and imported into the reference management tool EndNote X9. After elimination of duplicates, the remaining references will be uploaded and screened in Rayyan.59

Study selection process

With our research team consisting of a sociologist, a psychologist, a general practitioner, a physician and a methodologist, we follow the multidisciplinary team approach as proposed by Levac et al.60 In the first step of selection process, two reviewers will independently screen titles and abstracts and select studies that meet the inclusion criteria (table 1). This step is followed by full-text screening of these potentially relevant studies. Disagreements will be solved by discussion between the two reviewers until consensus is obtained or a third reviewer will be consulted. The process of study selection will be presented in a PRISMA flow chart, including the results from the search, elimination of duplicates, phases of studies selection, reasons for exclusion after full-text read and final number of included studies. We will provide a list of all potentially relevant studies that were read in full-text form, but excluded from the review and justify the exclusion.

Data extraction process

A data extraction form has been developed specifically for this scoping review (table 2). Data extraction will be piloted on five studies by two independent reviewers and the form modified if necessary. Afterwards, two reviewers will independently extract data from selected studies. Any discussion between the reviewers will be resolved by discussion or a third reviewer will be consulted. If study results are reported in more than one publication, we will summarise the information of both publications. In case of conflicting results, the first full-text publication will be the main data source.

Table 2

Items of data extraction

General information	Study name
	References of the publication(s)
	Objective(s) as stated
	Study design as described
	Years of study execution
	Sample size of included and analysed participants or practices
	Definition of PSPs as described (with reference)
	Components of PSPs examined
	Prevalence of patients with PSPs reported (eg, number of patients per week/month/year or study period)
Population	Age (years)
	Gender
	Ethnicity
	Specific characteristics (eg, geriatric patients, pregnant women)
	Other comorbidities
Context	Country of origin
	General practice setting
Concept	Name of identification instrument with reference
	Type of identification instrument (eg, questionnaire, interview)
	Description of identification instrument
	Type of reporting format (eg, self-reported, clinical examination)
	Identification instrument administered (eg, by physician, nurse, patient, other professionals)
	Time to complete (min)
	Components examined (eg, social factors, environmental factors)
	Identification instrument scored (eg, by physician, nurse, patient)
	Conclusion stated by authors

PSPs, psychosocial problems.

The extraction form contains detailed information on subjects provided in table 2.

A quality and risk of bias assessment of the included studies will not be performed as this is not the aim of a scoping review.56 58

Collating, summarising and reporting data

Our search results will be reported by using a flow diagram to clearly detail the review decision process. We will map the characteristics of the included studies and the evidence found on different identification instruments in a structured tabular form. A clear narrative summary related to the objective of the scoping review will follow. Aggregated findings will provide an overview of the research that has been conducted on the use of instruments to identify patients with PSPs in general practice, highlight knowledge gaps and inform the direction of further research activities.

Patient and public involvement

No patients or public were involved in the development of this protocol.

Ethics and dissemination

As we will synthesise information from publicly available publications and will not collect personal, sensitive or confidential information from participants, ethical approval is not required. Dissemination activities will consist of reporting results of the scoping review by submitting an article for publication to a scientific journal and presenting results at relevant conferences.