The article by López de Castro, et al is a new contribution to the knowledge and analysis of the research situation in primary health care (PHC) in our country. It uses a literature study of the articles in the journal Atención Primaria over the last 10 years. This type of study has the limitation of only analysing research exclusively from publications.
Besides, this study uses data from only one journal which, despite being a reference for the publication of research in PHC in Spain, it is a known fact that certain studies (probably those which the researchers consider more important) are sent for publication to other journals with a higher impact factor. However, these limitations do not detract from the interest value of the data contributed by this study.
Firstly, it confirms that we are in a phase of stagnation as regards the volume of publications, which started approximately 10 years ago, and as been condemned on different occasions.1,2 It is true that in some autonomous communities the situation appears somewhat better (Catalonia, Valencia, Madrid, and Andalusia, together, generate more than 60% of the publications), but even in those it is still very far from what is hoped for and desired as regards the importance of PHC in the in the health system as a whole. We should ask ourselves what is different in these autonomous communities as regards research, but also a more general and important question is, why are we not capable of overcoming this phase of stagnation?
It is true that there are numerous difficulties in carrying out research studies in PHC, many of which have been identified in different studies, such as the recent one by Cevallos, et al,3 which agrees with the majority of the factors identified. The professionals normally claim the lack of incentive, motivation and support by the administration and health managers, as the most important limiting factors. However, we must recognise that the professionals of PHC themselves are, to a large extent, responsible for the current situation since, although recognising the importance of research as a source of evidence in which to base our clinical practice, there does not appear to be sufficient interest to carry out studies directed at answering the relevant questions in PHC in our field.4 In fact, on many occasions, the difficulties, although real, rather than the true barriers, are used as excuses to not carry out these types of activities. If we want to look for solutions and alternatives to overcome this stagnation phase it is essential to identify the true reasons for not carrying out research in PHC, using qualitative methodologies, as suggested by March, et al.5
The data on the topics published confirm the predominance of studies related to the organisation of the services (40%). On the other hand, studies related to psychosocial and behavioural aspects of the population are less frequent (only 19%), particularly as they are key points in family and community medicine (FCM). But, perhaps the result which attracts most attention is the relatively reduced presence of studies related to clinical topics (only 19%). Although this fact has been pointed out earlier, this apparent lack of interest in carrying out research on clinical topics is strange if we take into account that they would be studies with a significant impact potential in PHC clinical practice. It seems as if health professionals from PHC will accept that the other health care fields are those who will specify the health service guidelines, even in our own field.
As regards the study designs used, it is verified that the situation has not changed significantly and that the research carried out continues to consist almost exclusively of descriptive studies (94%). It is still surprising that, despite the fact that FCM is one of the specialities which has most rapidly incorporated the necessities of evidence based medicine (EBM) and most insistent in the need to base clinical practice and recommendations on health interventions on evidence originating from randomised clinical trials, so few experimental studies are carried out in PHC (only 4.3% of the publications). It is true that the professionals in this field are participating more and more in clinical trials, but the majority are studies sponsored by the pharmaceutical industry in the process of developing new drugs (and it participates in only 5% of the clinical trials carried out in our country, despite the fact that PHC is the environment where it ends up prescribing the majority of these drugs) and on many occasions this participation is sought exclusively as a source of patients (often when the hospitals have not been able to include the required number), without any real intellectual contribution to their design. It would be an important achievement if the PHC professionals were included in the groups who design these studies and have an influence in assuring that they are directed towards resolving the questions of major interest to them. It would also be important in assuring that they were capable of designing and carrying out trials which answer the questions which are really relevant to their clinical practice, and with a pragmatic approach which facilitated the applicability of their results.
Lastly, the anecdotal presence (practically the absence) of systematic reviews which summarise the evidence on a topic and may be useful for clinical practice guidelines, is also remarkable, as are qualitative studies which permit a more suitable approach to many of the problems relevant to PHC.
In 2003, the prestigious journal The Lancet, on the subject of its editor attending a WONCA international conference in Canada, where theoretical approaches prevailed but very little quality research in PHC had been presented, published an editorial article, where it was asked if research in PHC was not a lost cause6. We must be capable of showing that this is not so, and that research in PHC is necessary and important, as defended in an article in that same journal one year later7. Despite involving some additional difficulties, research in PHC is preferable to the simple extrapolation of the results of studies carried out in other health care environments.
Research in PHC continues to have the desirable volume, relevance, the quality and the impact. As professionals we normally complain about the problems of developing these types of activities, but we do not make sufficient efforts to resolve them, but we do limit ourselves, on many occasions, to hoping that others will do it and complain if they do not do it. We must earn the prestige of research in PHC by ourselves and not trust that someone else will achieve it without having giving us the credit for it. We must demonstrate to the scientific community that we are capable of approaching, with rigour, the questions that interest us and obtain answers which will contribute to improving the care we provide to our patients.
