Applying a modified Prochaska's model of readiness to change for general practitioners on depressive disorders in CME programmes: validation of tool

Longitudinal Comparison of Continuing Medical Education Learning Objectives and Intent-to-Change Statements of Participants

INTRODUCTION

Successful completion of continuing medical education (CME) activities is often required for ongoing physician board certification, licensure, and hospital privileges. CME activities are designed to address professional knowledge or practice gaps. The authors examined participants' "intent to change" after CME activities to evaluate whether CME activity content was suitably linked with the stated learning objectives.

METHODS

The authors performed a retrospective mixed-methods thematic content analysis of written and electronic records from American Association of Neurological Surgeons-sponsored CME activities. Data from 2011 through 2016 were analyzed using a quantitative, deductive content analysis approach. Data were examined for each year separately as well as longitudinally over the six consecutive years. Intent-to-change data that did not align with meeting objectives were analyzed inductively using a qualitative content analysis approach to explore potential unintended learning themes.

RESULTS

The authors examined 85 American Association of Neurological Surgeons CME activities (424 CME objectives). The objectives were compared with 1950 intent-to-change statements. Thematic patterns of recurrent intent-to-change statements that matched with CME objectives included topics of resident education, complication avoidance, clinical best practices and evidence, new innovations, and novel surgical techniques. Just over a third of intent-to-change statements (37.3%) were not related to any meeting objective. Approximately a quarter of these unmatched statements led to new learning objectives in subsequent years.

CONCLUSIONS

An examination of CME learning objectives and participant intent-to-change statements provides information for examination of both meeting planner and learner attitudes for future CME activity planning.

Readiness to change for interprofessional collaboration in healthcare: Development and validation of a theory-based instrument

This paper presents a study that aimed to develop and validate a theory-based instrument for the assessment of readiness to change for interprofessional collaboration in healthcare (IPC-TTM). The instrument was developed in the Persian language and tested in the Iranian context. Healthcare professionals from medical and nursing professions participated in the assessment of validity and reliability of the instrument. We conducted this psychometric study in two phases: First, the questionnaire was developed based on the transtheoretical model (TTM) through literature review and expert panel. Then, in the validation phase, we held three modified Delphi rounds to assess the content and face validity of the questionnaire. We used confirmatory factor analysis (CFA) to evaluate the fit of the questionnaire as applied to modified TTM. Reliability of the final instrument was tested by assessing the test-retest reliability of instrument items with Kappa coefficient. We also calculated the intraclass correlation coefficient (ICC) and Cronbach's alpha to assess the test-retest reliability and internal consistency of the instrument sub-scales. The initial item pool consisted of 30 items and three sub-scales (Attitude, Intention, and Action). The content validity of the questionnaire was confirmed with 17 items. Based on the CFA results two additional items were deleted to increase the fit of the model. The final instrument was confirmed with 15 items and three sub-scales. Reliability assessment on the 15-item instrument showed an acceptable test-retest reliability of the instrument items. ICC values for the Attitude, Intention, and Action sub-scales of the instrument were calculated as 0.82, 0.73, and 0.71, respectively. Moreover, Cronbach's alpha for the Attitude, Intention, and Action sub-scales were 0.85, 0.73, and 0.77, respectively. This study offers a new theory-based instrument to measure readiness to change for interprofessional collaboration in healthcare in the Iranian context. The questionnaire can be used for 'needs assessment' in developing tailored educational interventions and self-assessments in interprofessional education studies.

The Mini-International Neuropsychiatric Interview is useful and well accepted as part of the clinical assessment for depression and anxiety in primary care: a mixed-methods study

BACKGROUND

Psychiatric complaints are common among primary care patients, with depression and anxiety being the most frequent. Diagnosis of anxiety and depression can be difficult, potentially leading to over- as well as under-diagnosis. The diagnostic process can be facilitated by incorporating structured interviews as part of the assessment. One such instrument, the Mini-International Neuropsychiatric Interview (MINI), has been established and accepted in psychiatric care. The purpose of this study was to explore the experiences and perceptions of the paper-and-pen version of MINI version 6.0 among patients and staff in primary care centers in Sweden.

METHODS

The MINI was introduced at three primary care centers and was conducted by either therapists or general practitioners. Patients presented with symptoms that could suggest depression or anxiety disorders. The duration of the interview was recorded. The experiences and perceptions of 125 patients and their interviewers were collected using a structured questionnaire. Global satisfaction was measured with a visual-analog scale (0-100). Semi-structured interviews were conducted with 24 patients and three therapists, and focus groups were held with 17 general practitioners. Qualitative content analysis was used for the interviews and focus groups. The findings across the groups were triangulated with results from the questionnaires.

RESULTS

The median global satisfaction with the MINI was 80 for patients and 86 for interviewers. General practitioners appreciated that the MINI identified comorbidities, as one-third of the patients had at least two psychiatric diagnoses. The MINI helped general practitioners attain a more accurate diagnosis. Patients appreciated that the MINI helped them recognize and verbalize their problems and did not find it intrusive. Patients and interviewers had mixed experiences with the yes-no format of the MINI, and the risk of subjective interpretations was acknowledged. Patients, general practitioners and therapists stated that the MINI contributed to appropriate treatment. The MINI assessment lasted 26 min on average (range 12 to 60 min).

CONCLUSIONS

The paper-and-pen version of the MINI could be useful in primary care as part of the clinical assessment of patients with problems suggestive of depression or anxiety disorders. The MINI was well accepted by patients, general practitioners and therapists.

Effectiveness of an interprofessional education model based on the transtheoretical model of behaviour change to improve interprofessional collaboration

This study aimed to assess the effectiveness of an interprofessional education model (IPE) based on the transtheoretical model to improve the participants' interprofessional collaborative practice. The study was conducted in Iran using a controlled before-and-after study design. The participants (n = 91) were the residents of emergency medicine and nurses of the emergency units from two teaching hospitals affiliated to Iran University of Medical Sciences. The participants in the intervention group (n = 40) were 22 residents and 18 nurses. The control group (n = 51) consisted of 20 residents and 31 nurses. The participants were classified based on their stage of readiness to change. The interventions were two-day workshops for each stage (i.e., attitude and intention). We used the Interprofessional Collaborator Assessment Rubric (ICAR) to assess the effectiveness of the developed model. The interprofessional collaboration of the participants in the intervention and control groups was assessed at four time points before and after the intervention in the real emergency unit environment. Student's t-test and repeated measures analysis of variance (RM-ANOVA) were used to analyse the data. We used partial eta-squared (η²) for effect size calculations. The mean values of ICAR scores in the intervention and control groups were 95.63 ± 19.14 and 89.19 ± 16.11 before the intervention. The mean values of ICAR scores at 3 months after the intervention were 99.82 ± 22.32 and 88.29 ± 16.87 in the intervention and control groups, respectively. After 6 months, the mean values of ICAR scores of the intervention and control groups were 98.6 ± 23.40 and 87.98 ± 16.01, respectively. The results showed that the intervention had a medium educational effect size (partial η² = 0.06) on performance of the participants. Our results showed that an IPE model that is tailored to the learners' stage of readiness to change improves interprofessional collaboration in the participants. The developed model could be applied for improving interprofessional collaborative performance in other IPE programmes.

Are They Complying? Physicians' Knowledge, Attitudes, and Readiness to Change Regarding Low Back Pain Treatment Guideline Adherence

STUDY DESIGN

Cross-sectional survey of 145 primary care practitioners (PCPs).

OBJECTIVE

To examine low back pain (LBP) guideline knowledge, readiness to implement (RTI) these guidelines, and LBP attitudes and beliefs among Israeli PCPs and determine whether physician age, guideline familiarity, and medical specialty affect these variables.

SUMMARY OF BACKGROUND DATA

LBP is a common condition managed primarily by PCPs. Little is known, however, about physician's LBP knowledge, attitudes, and beliefs and how these factors (knowledge, A&B) influence their practice behavior. Knowledge, attitudes, and beliefs of PCPs have been shown to influence the course of their patients' LBP, and guidelines were devised in an attempt to improve the effectiveness and quality of LBP care. Research worldwide and in Israel has shown that LBP guideline implementation is not yet optimal.

METHODS

Participants completed a questionnaire. Variables were measured using a translated, validated version of the Health Care Providers' Pain and Impairment Relationship Scale; demographic and professional characteristics were analyzed for correlation with the outcome variables.

RESULTS

The likelihood of PCPs having nonguideline-consistent attitudes and beliefs (A&B) was greater among those older than 50 years (P < 0.05). Family medicine specialists (family practitioners [FPs]) were more likely to have a high level of guideline knowledge as compared to nonfamily medicine specialists (general practitioners (83.8 vs. 61.9, respectively; P < 0.001). Differences between FPs and general practitioners were also observed for the mean Health Care Providers' Pain and Impairment Relationship Scale score (34.6 vs. 41.1, respectively, P = 0.00), indicating a higher consistency of attitudes and beliefs with guidelines among FPs. No significant association was found between PCPs' knowledge level and RTI the guidelines.

CONCLUSION

The present study showed that PCPs, especially FPs, had high levels of LBP guideline knowledge, although RTI was limited. The need for greater exposure to and understanding of the importance of implementation of LBP guidelines is essential for future guideline adherence.

LEVEL OF EVIDENCE

3.

Development of a Tool to Stage Households' Readiness to Change Dietary Behaviours in Kerala, India

Dietary interventions and existing health behaviour theories are centred on individuals; therefore, none of the available tools are applicable to households for changing dietary behaviour. The objective of this pilot study was to develop a practical tool that could be administered by community volunteers to stage households in rural Kerala based on readiness to change dietary behaviour. Such a staging tool, comprising a questionnaire and its algorithm, focusing five dietary components (fruits, vegetables, salt, sugar and oil) and households (rather than individuals), was finalised through three consecutive pilot validation sessions, conducted over a four-month period. Each revised version was tested with a total of 80 households (n = 30, 35 and 15 respectively in the three sessions). The tool and its comparator, Motivational Interviewing (MI), assessed the stage-of-change for a household pertaining to their: 1) fruit and vegetable consumption behaviour; 2) salt, sugar and oil consumption behaviour; 3) overall readiness to change. The level of agreement between the two was tested using Kappa statistics to assess concurrent validity. A value of 0.7 or above was considered as good agreement. The final version was found to have good face and content validity, and also a high level of agreement with MI (87%; weighted kappa statistic: 0.85). Internal consistency testing was performed using Cronbach’s Alpha, with a value between 0.80 and 0.90 considered to be good. The instrument had good correlation between the items in each section (Cronbach’s Alpha: 0.84 (fruit and vegetables), 0.85 (salt, sugar and oil) and 0.83 (Overall)). Pre-contemplation was the most difficult stage to identify; for which efficacy and perceived cooperation at the household level were important. To the best of our knowledge, this is the first staging tool for households. This tool represents a new concept in community-based dietary interventions. The tool can be easily administered by lay community workers and can therefore be used in large population-based studies. A more robust validation process with a larger sample is needed before it can be widely used.

Conceptual model for dietary behaviour change at household level: a 'best-fit' qualitative study using primary data

Background

Interventions having a strong theoretical basis are more efficacious, providing a strong argument for incorporating theory into intervention planning. The objective of this study was to develop a conceptual model to facilitate the planning of dietary intervention strategies at the household level in rural Kerala.

Methods

Three focus group discussions and 17 individual interviews were conducted among men and women, aged between 23 and 75 years. An interview guide facilitated the process to understand: 1) feasibility and acceptability of a proposed dietary behaviour change intervention; 2) beliefs about foods, particularly fruits and vegetables; 3) decision-making in households with reference to food choices and access; and 4) to gain insights into the kind of intervention strategies that may be practical at community and household level. The data were analysed using a modified form of qualitative framework analysis, which combined both deductive and inductive reasoning. A priori themes were identified from relevant behaviour change theories using construct definitions, and used to index the meaning units identified from the primary qualitative data. In addition, new themes emerging from the data were included. The associations between the themes were mapped into four main factors and its components, which contributed to construction of the conceptual model.

Results

Thirteen of the a priori themes from three behaviour change theories (Trans-theoretical model, Health Belief model and Theory of Planned Behaviour) were confirmed or slightly modified, while four new themes emerged from the data. The conceptual model had four main factors and its components: impact factors (decisional balance, risk perception, attitude); change processes (action-oriented, cognitive); background factors (personal modifiers, societal norms); and overarching factors (accessibility, perceived needs and preferences), built around a three-stage change spiral (pre-contemplation, intention, action). Decisional balance was the strongest in terms of impacting the process of behaviour change, while household efficacy and perceived household cooperation were identified as ‘markers’ for stages-of-change at the household level.

Conclusions

This type of framework analysis made it possible to develop a conceptual model that could facilitate the design of intervention strategies to aid a household-level dietary behaviour change process.

A tailored educational intervention improves doctor's performance in managing depression: a randomized controlled trial

RATIONAL AND OBJECTIVES

To assess the effects of a tailored and activating educational intervention, based on a three-stage modified Prochaska model of readiness-to-change, on the performance of general physicians in primary care (GPs) regarding management of depressive disorders.

METHODS

Parallel group, randomized control trial. Primary hypothesis was that performance would improve by 20 percentage units in the intervention arm. The setting was primary care in southern Tehran. The participants were 192 GPs stratified on stage of readiness-to-change, sex, age and work experience. The intervention was a 2-day interactive workshop for a small group of GPs' at a higher stage of readiness-to-change ('intention') and a 2-day interactive large group meeting for those with lower propensity to change ('attitude') at the pre-assessment. GPs in the control arm participated in a standard educational programme on the same topic. The main outcome measures were validated tools to assess GPs' performance by unannounced standardized patients, regarding diagnosis and treatment of depressive disorders. The assessments were made 2 months before and 2 months after the intervention.

RESULTS

GPs in the intervention arm significantly improved their overall mean scores for performance regarding both diagnosis, with an intervention effect of 14 percentage units (P = 0.007), and treatment and referral, with an intervention effect of 20 percentage units (P < 0.0001). The largest improvement after the intervention appeared in the small group: 30 percentage units for diagnosis (P = 0.027) and 29 percentage units for treatment and referral (P < 0.0001).

CONCLUSIONS

Activating learning methods, tailored according to the participants' readiness to change, improved clinical performance of GPs in continuing medical education and can be recommended for continuing professional development.

Effects on knowledge and attitudes of using stages of change to train general practitioners on management of depression: a randomized controlled study

OBJECTIVE

To assess the impact on knowledge and attitudes of a tailored educational intervention on depression using a modified version of the Prochaska stages of change model, compared with standard continuing medical education, for general practitioners (GPs) in primary care in Iran.

METHOD

Using a randomized controlled trial, a total of 192 GPs were evenly randomized to intervention or control arm. The topic for the educational intervention was depressive disorders. The participants were divided in to small and large groups, depending on their initial stage of change. The GPs' knowledge and skills regarding management of depressive disorders were assessed through a questionnaire with 7 multiple choice questions, 11 Likert statements, 3 case vignettes, and 1 essay question. Attitudes toward management of depressive disorders were also assessed. Both questionnaires were validated.

RESULTS

There was a significant improvement in knowledge mean scores regarding multiple choice and Likert questions (intervention effect 6%; P = 0.002), as well as for the case vignettes and essay question (intervention effect 12%; P = 0.011) in the intervention arm, in comparison with the control arm. There were significant changes in mean attitude scores in both study arms, but no difference between them.

CONCLUSIONS

A theoretical model of medical learning and behavioural change can be used to devise educational formats that suit different stages of learning. Such tailored educational formats can improve GPs' knowledge and skills regarding management of depressive disorders.