Advanced musculoskeletal physiotherapy practice: Informing education curricula

Patients presenting with musculoskeletal disorders in the emergency department: A qualitative study of their experiences when cared by advanced practice physiotherapists in the province of Québec

BACKGROUND

Advanced practice physiotherapy (APP) models of care are promising to alleviate pressure in emergency departments (EDs) where physiotherapists' new roles include being a first-contact practitioner and leading the overall care and management of patients with minor musculoskeletal disorders (MSKDs) to alleviate ED physicians' caseload.

PURPOSE

To explore patients' acceptability, experience, satisfaction, and perception of a new APP-led model of care in the ED.

METHODS

Patients presenting to the ED with a minor MSKD and who agreed to participate in a multicenter, pan-Canadian randomized controlled trial assessing the efficacy and costs of an APP model of care were invited to participate in this qualitative study. Semi-structured interviews were performed to identify themes related to their experiences with this model. Verbatim transcripts were coded and analysed using an inductive thematic analysis.

RESULTS

11 patients participated and three themes were identified: 1- They were satisfied with the care received within the model; 2- They found APPs to have the appropriate skill set to manage MSKDs and to assume medical-delegated tasks; 3- Timely access to care was a key factor in the acceptability of this model and participants believed physiotherapists were appropriate first-contact practitioners. One participant proposed that the APP model of care should also offer follow-up care.

CONCLUSION

Participants had a positive experience of care in this new model. These results support the implementation of APP models of care in EDs as the participants appear receptive to new roles for APPs.

Physiotherapists' Perception of and Readiness to Use, Telerehabilitation for Musculoskeletal Disorders in Malaysia: A Cross-Sectional Study

Introduction: Musculoskeletal ailments exert a significant impact on global populations. To address challenges posed by geographical constraints and financial limitations, physiotherapists have explored and found telerehabilitation to be a viable solution. Despite its proven effectiveness in clinical practice, the integration of telerehabilitation has been sluggish. This cross-sectional survey sought to delve into the perspectives and readiness of physiotherapists in Malaysia regarding telerehabilitation for musculoskeletal disorders. Methods: A customized survey instrument was developed and evaluated for face validity and reliability. The 36-item questionnaire was distributed through the Google Form platform, targeting respondents via social media channels such as Facebook and WhatsApp. Data analysis used descriptive statistics (frequency and percentage). Results: The survey garnered responses from 271 physiotherapists. A majority (76.3%, n = 202) expressed agreement regarding the potential benefits of telerehabilitation in physiotherapy practice. About 77% of the respondents also showcased greater readiness for monitoring client progress through telerehabilitation as opposed to assessment and treatment. Notable benefits identified by respondents included preventing cross-infection (98.5%) and reducing travel time for both clients (94.0%) and physiotherapists (90.6%). Conclusion: The study reveals that physiotherapists in Malaysia exhibit positive attitudes and preparedness for implementing telerehabilitation in managing musculoskeletal conditions.

Developing a core competency and capability framework for advanced practice physiotherapy: A qualitative study

INTRODUCTION

There is an urgent need to develop an international competency and capability framework to support standardization of education and roles in advanced practice physiotherapy (APP). This need arose due to the rapid growth of the APP model of care, implemented out of necessity in the absence of agreement as to the competencies and capabilities or formal education required for the roles. This study explores the views and perceptions of practitioners and key stakeholders on a draft competency and capability framework for advanced practice physiotherapists.

OBJECTIVES

The purpose of this study was to: 1) gather feedback from key stakeholders (advanced practice physiotherapists, researchers, and leaders) on a draft competency and capability framework and 2) use that feedback to revise and improve the draft framework.

DESIGN

Qualitative study using a series of four multi-national online focus groups. Thematic analysis was conducted according to Braun and Clarke.

RESULTS

Sixteen participants from the United Kingdom, Ireland, Canada, Australia, and New Zealand participated in the study. Five themes were generated after data analysis: clinical expert, experienced communicator, strong leader, collaborator, and knowledge creator). A modified competency and capability framework was developed based on feedback from the focus groups and input from subject matter experts (SMEs).

CONCLUSION

This study provides a modified core competency and capability framework comprising 24 competencies grouped under six domains. This study is a step toward international standardization of advanced practice physiotherapy based on a commonly agreed framework for the education and training of advanced practice physiotherapists.

Evaluating the importance of a core competency and capability framework for advanced practice physiotherapy: A cross-sectional survey

INTRODUCTION

The need for a global core competency and capability framework for advanced practice physiotherapy is important due to the rapidly changing nature of health care delivery internationally and the need to standardize advanced practice physiotherapy.

OBJECTIVE

To determine the importance of a proposed international core competency and capability framework for advanced practice physiotherapy.

METHODS

We conducted a cross-sectional online survey of advanced practice physiotherapists across seven countries. The importance of each competency and capability was rated on a five-point agreement Likert scale. Participants were from the United Kingdom, Ireland, Australia, New Zealand, Canada, Switzerland and Argentina.

RESULTS

A total of 99 participants completed the survey, comprising 63% (57/90) females and 33% (30/90) males. Sixty percent, 60% (54/90), had over 20 years of experience. The survey participants represented a diverse geographic distribution, with 25% (23/90) from Australia, 25% (23/90) from Canada, 18% (6/90) from New Zealand, and 18% (6/90) from the United Kingdom. Four percent 4% (4/90) from Ireland, and 4% (4/90) from other countries (Switzerland and Argentina). The survey revealed a strong consensus among participants, with all competencies and capabilities ranked as high and considered important to advanced practice.

CONCLUSION

This study demonstrates a consensus among advanced practice physiotherapists across seven countries on the importance of a proposed competency and capability framework. The findings highlight the need for a global standard in advanced practice physiotherapy, particularly in light of the rapidly changing healthcare landscape.

Identifying competencies in advanced healthcare practice: an umbrella review

The four pillars of advanced healthcare practice (AHCP) are clinical practice, leadership and management, education, and research. It is unclear, however; how competencies of AHCP as defined by individual health professions relate to these pillars. Addressing this knowledge gap will help to facilitate the operationalization of AHCP as a concept and help inform educational curricula. To identify existing competencies across AHCP literature and examine how they relate to the four pillars of a multi-professional AHCP framework. An umbrella review was conducted in accordance with JBI methodology. The electronic search for published and grey literature was completed using CINAHL, Scopus, Medline (OVID), Embase (OVID), ERIC (OVID) and Google. Secondary reviews and research syntheses of master level AHCP programs published after 1990 in either English or French were considered for inclusion and results were analyzed using a directed content analysis. Seventeen publications detailing 620 individual competencies were included. AHCP competencies were described across four professions and 22 countries, with many publications related to nursing and AHCP in the United Kingdom, Canada, and Australia. Many retrieved competencies were found to map to the four pillars of AHCP, although clinical practice and leadership and management pillars were addressed more often. Competencies of AHCP are generally consistent with the four pillars. However, the distribution of competencies is unequal across pillars, professions, and geographical regions, which may provide direction for further research. Doi: 10.17605/OSF.IO/KV2FD Published on March 07, 2023.

Use of the International IFOMPT Cervical Framework to inform clinical reasoning in postgraduate level physiotherapy students: a qualitative study using think aloud methodology

BACKGROUND

Vascular pathologies of the head and neck are rare but can present as musculoskeletal problems. The International Federation of Orthopedic Manipulative Physical Therapists (IFOMPT) Cervical Framework (Framework) aims to assist evidence-based clinical reasoning for safe assessment and management of the cervical spine considering potential for vascular pathology. Clinical reasoning is critical to physiotherapy, and developing high-level clinical reasoning is a priority for postgraduate (post-licensure) educational programs.

OBJECTIVE

To explore the influence of the Framework on clinical reasoning processes in postgraduate physiotherapy students.

METHODS

Qualitative case study design using think aloud methodology and interpretive description, informed by COnsolidated criteria for REporting Qualitative research. Participants were postgraduate musculoskeletal physiotherapy students who learned about the Framework through standardized delivery. Two cervical spine cases explored clinical reasoning processes. Coding and analysis of transcripts were guided by Elstein's diagnostic reasoning components and the Postgraduate Musculoskeletal Physiotherapy Practice model. Data were analyzed using thematic analysis (inductive and deductive) for individuals and then across participants, enabling analysis of key steps in clinical reasoning processes and use of the Framework. Trustworthiness was enhanced with multiple strategies (e.g., second researcher challenged codes).

RESULTS

For all participants (n = 8), the Framework supported clinical reasoning using primarily hypothetico-deductive processes. It informed vascular hypothesis generation in the patient history and testing the vascular hypothesis through patient history questions and selection of physical examination tests, to inform clarity and support for diagnosis and management. Most participant's clinical reasoning processes were characterized by high-level features (e.g., prioritization), however there was a continuum of proficiency. Clinical reasoning processes were informed by deep knowledge of the Framework integrated with a breadth of wider knowledge and supported by a range of personal characteristics (e.g., reflection).

CONCLUSIONS

Findings support use of the Framework as an educational resource in postgraduate physiotherapy programs to inform clinical reasoning processes for safe and effective assessment and management of cervical spine presentations considering potential for vascular pathology. Individualized approaches may be required to support students, owing to a continuum of clinical reasoning proficiency. Future research is required to explore use of the Framework to inform clinical reasoning processes in learners at different levels.

Scoping Review of Curricula and Pedagogical Approaches for Physiotherapist Performed Point of Care Ultrasonography

Purpose

This study collates and maps physiotherapy pre- and post-licensure curricula and pedagogical approaches for point of care ultrasonography (POCUS).

Method

We used a standardized scoping review methodology and reporting framework. A total of 18,217 titles and abstracts, and 1,372 full text citations were screened, with 209 studies classified as physiotherapist performed POCUS.

Results

Of the 209 studies, 15 evaluated pre- and post-licensure curricula and pedagogical approaches. Seventy-two to 98% of pre-licensure programs reported including theoretical knowledge of POCUS and 44-45% reported practical teaching or competency assessment. In post-licensure studies of POCUS, 0-61% of physiotherapists reported training for POCUS. All studies of post-licensure pedagogical approaches included an assessment of theoretical knowledge of POCUS, but only one study included a practical assessment of competency. There was considerable variability in POCUS methods and duration of pedagogical approaches. Except for one study, all pedagogical approaches reported improvement in theoretical knowledge.

Conclusion

Progress in physiotherapy-specific, standardized, competency-based curricula and pedagogical approaches in POCUS has been limited, with minimal research available, and considerable variability both pre- and post-licensure. These findings could be used to advocate for the inclusion of POCUS in pre- and post-licensure physiotherapy curriculum, and suggest a need for clear guidelines from regulatory colleges and licensing bodies, and a common terminology for physiotherapist performed POCUS. Future directions for research include a systematic review of the psychometric properties of physiotherapist performed POCUS within and across anatomical areas, an assessment of value of different forms of training, and an evaluation of the impact of physiotherapist performed POCUS on patient outcomes.

Management of Low Back Pain: Do Physiotherapists Know the Evidence-Based Guidelines?

BACKGROUND

Clinical practice guidelines promote bio-psychosocial management of patients suffering from low back pain (LBP). The objective of this study was to examine the current knowledge, attitudes and beliefs of physiotherapists about a guideline-adherent approach to LBP and to assess the ability of physiotherapists to recognise signs of a specific LBP in a clinical vignette.

METHODS

Physiotherapists were recruited to participate in an online study. They were asked to indicate whether they were familiar with evidence-based guidelines and then to fill in the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS), Back Pain Attitudes Questionnaire (Back-PAQ), Neurophysiology of Pain Questionnaire (NPQ), as well as questions related to two clinical vignettes.

RESULTS

In total, 527 physiotherapists participated in this study. Only 38% reported being familiar with guidelines for the management of LBP. Sixty-three percent of the physiotherapists gave guideline-inconsistent recommendations regarding work. Only half of the physiotherapists recognised the signs of a specific LBP.

CONCLUSIONS

The high proportion of physiotherapists unfamiliar with guidelines and demonstrating attitudes and beliefs not in line with evidence-based management of LBP is concerning. It is crucial to develop efficient strategies to enhance knowledge of guidelines among physiotherapists and increase their implementation in clinical practice.

A proposed framework for point of care musculoskeletal ultrasound and ultrasound image-guided interventions by physiotherapists: scope of practice, education and governance

BACKGROUND

The use of point of care ultrasound (PoCUS) in the management of musculoskeletal (MSK) disorders is a diverse area of PoCUS practice. Its use by clinicians, such as physiotherapists, can occur across a wide range of roles and care pathway configurations; however, professional, educational and regulatory uncertainties can leave clinicians, managers and patients at risk.

MAIN BODY

A PoCUS framework approach (previously applied to support PoCUS consolidation and expansion) is used to frame these proposals. Central to this is the defining of (clinical and sonographic) scope of practice (ScoP). A number of indicative ScoPs are described to both (i) illustrate application of the principles and (ii) provide templates for ScoP derivations for individual services or clinicians. Image-guided MSK interventions are increasingly an aspect of MSK physiotherapy PoCUS. Given the utility of physiotherapists drawing upon their imaging to fully inform the selection (and performance) of such techniques, we present a rationale for competency in undertaking sonographic differentials as a pre-cursor to performing ultrasound image-guided MSK interventions. Alignment of ScoP with the relevant education and formal competency assessments are a cornerstone of the PoCUS framework approach; as such, key aspects of MSK PoCUS education and competency assessment are outlined. Strategies for addressing such requirements in healthcare settings where formal provision is not accessible, are also presented. Governance considerations are aligned with the regulatory environment, including those pertaining to professional guidance and insurance considerations. In addition, generic quality assurance elements are emphasised, as core aspects of high-quality service provision. Whilst the paper clarifies the situation for MSK physiotherapists using PoCUS in the UK, prompts are provided to support other professional groups working in MSK services in the United Kingdom (UK) and MSK physiotherapists/physical therapists in other countries-to facilitate their application of the principles.

CONCLUSION

Acknowledging the breadth of MSK physiotherapy PoCUS practice, this paper draws upon a framework approach to provide integrated ScoP, education/competency and governance solutions, along with mechanisms for other professions working with MSK PoCUS-and physiotherapists/physical therapists outside of the UK-to consolidate and expand their practice.

Exploration of mentor and mentee perspectives of a mentored clinical practice programme to improve patient outcomes in musculoskeletal physiotherapy

Background

A recent randomised controlled trial has demonstrated the impact on practice of an educational programme for clinicians. Mentored clinical practice in musculoskeletal physiotherapy resulted in clinically significant improvements in both physiotherapist performance and patient outcomes. The objectives of this study were to explore mentor and mentee perceptions of a mentored clinical practice programme, in order to identify key factors in the process to improve patient outcomes.

Methods

Employing a case study design of a mentoring programme that led to improved patient outcomes, mentored clinical practice was explored from multiple perspectives using a grounded theory strategy of enquiry to derive a theory of mentored clinical practice grounded in the views of the participants. Semi-structured interviews with a purposive sample of mentors and mentees were employed along with qualitative observations of mentored clinical practice. Data analysis and collection were concurrent, with analysis an iterative process deriving inductive analytical categories from the data through constant comparison.

Findings

Highly informative themes of how the complex interaction between mentor, mentee, patient and environment worked successfully were identified from the data. The mentors’ knowledge, additional perspectives, critical analysis and facilitatory style were enabling factors, as were mentees’ motivation, openness to criticism and commitment to reflect on practice. Themes around potential threats to the mentees’ development were also identified. Overloading or contradictory feedback and lack of relationship with mentees were barriers that mentors could bring; fear, defensiveness, routine working, people-pleasing and lack of experience were potential mentee barriers. A model emerges from the data demonstrating how these themes interact, providing guidance to mentors and mentees to optimise the effectiveness of mentored clinical practice.

Conclusion

This study provides a sound basis for future mentored clinical practice, producing a model from key themes from a case study where impact on clinician performance and patient outcomes are established.

Development of a multinational, multidisciplinary competency framework for physiotherapy training in pessary management: an E-Delphi study

INTRODUCTION AND HYPOTHESIS

Vaginal support pessaries are intravaginal devices designed to relieve symptoms of pelvic organ prolapse, but they can cause serious medical complications if not managed well. Physiotherapists are well placed to manage pessaries, but there are no guidelines on the training required for competency in pessary management (PM).

METHODS

A scoping review of current literature on PM training was conducted to develop draft competency standards, which were reviewed by a multidisciplinary focus group. Using e-Delphi methodology, a multidisciplinary and multinational expert panel then refined the standards. Three rounds of e-Delphi online surveys were conducted, with individual participant feedback and one videoconference to discuss items that did not reach consensus. Consensus was set at 80% agreement and stability measured using kappa coefficient.

RESULTS

Pessary training competency standards, developed by 29 experts, covered three key domains including: (1) prerequisite knowledge and understanding; (2) entrustable professional activities; (3) pessary-specific standards under ten key roles. Consensus was reached on all 73 (100%) competency standards and stability demonstrated for 95.9% of standards. There was no attrition of expert panel participants through the e-Delphi rounds.

CONCLUSIONS

This e-Delphi study provides the first, robust recommendations on training standards for physiotherapists in PM. These competency standards will provide clinicians with a self-assessment tool, and educators and training institutions with a benchmark in training for PM, which should improve options and reduce risk for women with prolapse being managed with a pessary.

Development of real world learning opportunities in community exercise prescription for healthcare professional programmes - 'Physio Hub'

BACKGROUND

Given the challenge of chronic lifestyle diseases, the shift in healthcare focus to primary care and recognised importance of a preventive approach to health, including exercise prescription, the embedding of related learning in healthcare professional programmes is critical.

METHODS

In response to these contemporary demands, a complex curriculum development project was undertaken at University College Dublin, employing a four dimensional curriculum framework for the development of health professional curricula, that focused on (1) future orientation of healthcare practices (the why?), (2) defining capabilities of graduates (the what?), (3) teaching, learning and assessment (the how?) and (4) organisation/institution delivery (the where)? The process was informed by latest exercise, health promotion, educational and health policy literature, alongside engagement with multiple internal university and external community stakeholders.

RESULTS

Having sufficient clinical education opportunity for translating exercise theory into practice was identified as a key need (the Why?). Development of strategies for health promotion and design and delivery of evidence based exercise programmes with inter-professional and inter-sectoral network building were some of the graduate capabilities identified as being critically important. (the what?) The resultant UCD Physio Hub model of clinical education combines 'on campus' and 'community outreach' activity to facilitate inter-sectoral 'real world' experiential student learning in health promotion and exercise prescription for both healthy and clinical populations. Underpinned by social constructivist educational theory, students are encouraged to be creative and to collaborate in responding to identified health needs of specific community groups by designing and delivering community services. (the how?) In developing new student learning opportunities to enhance curriculum, a supportive organisational culture and context was critical with UCD having excellent exercise infrastructure and the Physio Hub project aligning with a community engagement ethos articulated in the university's strategy. (the where?) CONCLUSION: This paper provides an overview of Physio Hub, its services, educational practices and translational research ethos, all of which are combined to deliver a rich exercise and health promotion learning experience. Although developed for physiotherapy in this instance, the curriculum process and resultant education model could be applied across medical and other health professional programmes and to facilitate interdisciplinary learning.

An analysis of advanced and specialist posts in diagnostic radiography: Do job descriptions describe advanced practice?

INTRODUCTION

Underpinned by a multi professional advanced clinical practice (ACP) framework, role consistency in practice level and education has been advocated across allied health professions. However little research has evaluated ACP expectations in radiography. This study identified the capability requirements of advanced and specialist diagnostic radiographers and mapped these to home country advanced practice frameworks and the Society and College of Radiographers (SCoR) Education and Career Framework.

METHODS

A consecutive sample of UK job advertisements was collected over six months and analysed for role focus, professional and clinical responsibilities, reporting or procedural expectations and knowledge and experience. Qualitative content analysis was used to scrutinise capabilities during role mapping.

RESULTS

A total of 42 job descriptions were analysed across UK Trusts and Health Boards, with 31 roles (73.8%) containing the terms advanced or specialist. Half of the advertised roles expected proficiency in reporting (n = 21; 50%). Responsibilities mapped to the practice outcomes of the SCoR framework in 31 roles (n = 31/42; 73.8%). The English documents (n = 40/42; 95.2%) evaluated against the multi professional framework identified significantly (χ2 = 14.6; p < 0.01) fewer capabilities (n = 13/40; 32.5%). Clinical practice was reflected broadly in textual behavioural descriptors however, leadership, education and research responsibilities were internal and operational in nature.

CONCLUSION

This analysis of diagnostic radiographer job descriptions has demonstrated that many posts advertised as 'advanced' differ from advanced practice roles defined by the multi professional ACP framework, although they meet professional body standards.

IMPLICATIONS FOR PRACTICE

Utilisation of diagnostic radiographers as 'true' advanced clinical practitioners remains intermittent. Greater consistency in job descriptions is required to strengthen radiography advanced practice and support radiographer development.

Effects on health and process outcomes of physiotherapist-led orthopaedic triage for patients with musculoskeletal disorders: a systematic review of comparative studies

BACKGROUND

Physiotherapist-led (PT-led) orthopaedic triage is an evolving model of care for patients with musculoskeletal disorders. Objectives for this study were to establish the current evidence body on the impact of PT-led orthopaedic triage on health, quality, and service outcomes for patients referred for orthopaedic consultation, compared with standard (orthopaedic surgeon) care.

METHODS

Medline, EMBASE, Scopus and CINAHL were searched from inception until 7 May 2018; search updated 24 April 2020. Search terms (including derivatives) included physiotherapy, advanced/extended scope, musculoskeletal/orthopaedic, triage. The search was framed as Population = patients referred for orthopaedic consultation; Intervention = PT-led orthopaedic triage; Comparison = standard care; Outcomes = health, quality and process outcomes. Only randomised controlled trials (RCTs) and prospective comparative cohort studies were eligible for inclusion. Screening, study selection, data extraction, and assessment of methodological quality were performed independently by reviewer pairs. Quality was scored with the Downs and Black checklist. Certainty of evidence was determined using GRADE. PROSPERO registration number CRD42017070950.

RESULTS

We included two RCTs and eleven cohort studies (n = 1357 participants) of variable methodological quality (range 14-23 of possible 28). Certainty of evidence was low to moderate. There was no difference between PT-led orthopaedic triage and standard care for patient-reported outcomes (two RCTs). Perceived quality of care with PT-led orthopaedic triage was higher (two RCTs, four cohort studies) or equal (one cohort study) compared with standard care. PT-led orthopaedic triage had higher surgery conversion rates (one RCT, three cohort studies) (55-91% vs 22-38%), lower (two RCTs) or equal rate (two cohort studies) of referral for investigations, shorter waiting times (one RCT, one cohort study), and lower costs (one RCT). Furthermore, there was high agreement between physiotherapists' and orthopaedic surgeons' treatment approach (eight cohort studies), referral for investigation (five cohort studies), and diagnosis (nine cohort studies). Study limitations were the low number of RCTs, and variable methodological quality.

CONCLUSIONS

Evidence of low to moderate certainty suggests that PT-led orthopaedic triage leads to similar diagnostic decisions as standard care, has a higher conversion-to-surgery rate, reduces waiting times, is cost effective and valued by patients, and that health outcomes are equivalent.

[Impact of models of care integrating direct access to physiotherapy in primary care and emergency care contexts in patients with musculoskeletal disorders: A narrative review]

BACKGROUND

Musculoskeletal disorders are increasing in prevalence, principally due to sedentary behaviors. Strong evidence supports an early need for first-line treatment including physiotherapy. New and innovative models in primary and emergency care have been drawn up and put the physiotherapist's skills to work in early and first-line management of patients with musculoskeletal disorders. The objectives of this review were to identify and describe studies assessing models of care integrating direct access to physiotherapy in primary care and in emergency care for patients with musculoskeletal disorders and to provide perspectives on the application of these two models in France.

METHODS

A literature review was carried out including studies extracted from four scientific databases: PubMed, CINAHL, Embase, and PEDro. The selected articles had to address the clinical effectiveness or efficiency of these models for the provision of care in primary or in emergency care. A narrative literature review method was used. The synthesis deals with the qualitative analysis of the included studies.

RESULTS

Thirty-nine studies were included in this review: 19 on assessment of the direct access to physiotherapy model in primary care and 20 on the direct access to physiotherapy model in emergency departments as concerns patients with musculoskeletal disorders. The studies showed that the different models incorporating direct access to physiotherapy in primary or in emergency care provided better outcomes in terms of quality and access to care while maintaning a similar degree of safety. However, the methodology of the studies included was estimated as being of heterogeneous quality.

CONCLUSION

The studies dealing with the new models for provision of care integrating direct access to physiotherapy in primary care or emergency care impart two lessons: (1) they are not designed to replace the physician; (2) collaboration between different health professionals aimed at improving patients' access to efficient care is to be encouraged. It would be worthwhile to focus upon dissemination factors that would enhance the efficiency of these innovative models in other countries, as in France.