Assessing the transtheoretical model of change constructs for physicians counseling smokers

How to persuade more primary care professionals to adopt a valued smoking cessation referral aid: a cross-sectional study of facilitators and barriers

BACKGROUND

To study the factors associated with the intention of primary care professionals (PCPs) to use or not use a referral aid (RA) for selecting an evidence-based smoking cessation intervention (EBSCI).

METHODS

Participants (n = 85) were recruited from June to September 2020 to complete an online questionnaire based on the I-Change Model to assess the factors associated with the adoption of RA. The differences between PCPs with (n = 37) and without (n = 48) the intention to adopt in terms of demographics, motivational factors, and post-motivational factors were subsequently assessed. Correlation and logistic regression analyses were conducted to investigate the factors associated with the intention to adopt.

RESULTS

Both groups indicated that they highly appreciated the RA. However, PCPs without the intention to adopt expressed a more negative attitude towards the RA, experienced less social support, showed low self-efficacy, and encountered barriers such as lack of time and skills. The factors most strongly associated with the intention to adopt were advantages, disadvantages, self-efficacy, less barriers, working in a solo practice and age.

CONCLUSIONS

The adoption of RA can be facilitated in two ways. The first one is by increasing the added value of the tool through a second round of co-creation focusing on the adoptability of the RA in practice. The second approach is by communicating the added value of referring to EBSCIS and thereby using the RA by implementing it in smoking cessation training for PCPs, which could also help to improve the attitude, social support, self-efficacy, and perceived skills in terms of RA usage among PCPs.

IMPACT

This study is the first work in the Netherlands to investigate the willingness of PCPs to actively refer patients to other EBSCIs in addition to providing face-to-face counseling themselves.

TRIAL REGISTRATION

The study was registered at the Netherlands Trial Register (NL7020, https://www.trialregister.nl/trial/7020 ).

Assessment of the Efficiency of Tobacco Cessation Counseling in Primary Care

Clinical Practice Guidelines for Treating Tobacco Use and Dependence advocate for using counseling targeted at tobacco users’ motivation to quit during each office visit. We evaluate tobacco use screening and counseling interventions delivered during routine periodic health examinations by 44 adult primary care physicians practicing in 22 clinics of a large health system in southeast Michigan. 484 office visits were audio-recorded and transcribed. For this study, current tobacco users ( N = 91) were identified using pre-visit surveys and audio-recordings. Transcripts were coded for the delivery of tobacco-related counseling interventions. The extent to which counseling interventions were used and/or targeted to the patients’ readiness to quit was the main outcome measure. The majority of tobacco users ( n = 77) had their tobacco use status assessed, and most received some sort of tobacco-related counseling ( n = 74). However, only 15% received the recommended counseling targeted to their readiness to quit. On the other hand, 19% received less counseling than recommended given their readiness to quit, 7% received only nonindicated counseling, and 59% received nonindicated counseling in addition to indicated counseling. Results illustrate physicians’ commitment to cessation counseling and also identify potential opportunities to improve the efficiency of tobacco-related counseling in primary care.

Implementation of smoking cessation guidelines in the emergency department: a qualitative study of staff perceptions

Background

The US Public Health Service smoking cessation practice guideline specifically recommends that physicians and nurses strongly advise their patients who use tobacco to quit, but the best approach for attaining this goal in the emergency department (ED) remains unknown. The aim of this study was to characterize emergency physicians’ (EPs) and nurses’ (ENs) perceptions of cessation counseling and to identify barriers and facilitators to implementation of the 5 A’s framework (Ask-Advise-Assess-Assist-Arrange) in the ED.

Methods

We conducted semi-structured, face-to-face interviews of 11 EPs and 19 ENs following a pre-post implementation trial of smoking cessation guidelines in two study EDs. We used purposeful sampling to target EPs and ENs with different attitudes toward cessation counseling, based on their responses to a written survey (Decisional Balance Questionnaire). Conventional content analysis was used to inductively characterize the issues raised by study participants and to construct a coding structure, which was then applied to study transcripts.

Results

The main findings of this study converged upon three overarching domains: 1) reactions to the intervention; 2) perceptions of patients’ receptivity to cessation counseling; and 3) perspectives on ED cessation counseling and preventive care. ED staff expressed ambivalence toward the implementation of smoking cessation guidelines. Both ENs and EPs agreed that the delivery of smoking cessation counseling is important, but that it is not always practical in the ED on account of time constraints, the competing demands of acute care, and resistance from patients. Participants also called attention to the need for improved role clarity and teamwork when implementing the 5 A’s in the ED.

Conclusions

There are numerous challenges to the implementation of smoking cessation guidelines in the ED. ENs are generally willing to take the lead in offering brief cessation counseling, but their efforts need to be reinforced by EPs. ED systems need to address workflow, teamwork, and practice policies that facilitate prescription of smoking cessation medication, referral for cessation counseling, and follow-up in primary care. The results of this qualitative evaluation can be used to guide the design of future ED intervention studies.

Trial registration

ClinicalTrials.gov registration number NCT00756704

Tobacco training in clinical social work graduate programs

The leading cause of preventable death, in the most vulnerable segments of society, whom social workers often counsel, is cigarette smoking. The purpose of this study was to assess tobacco smoking cessation training in clinical social work programs. A valid 21-item questionnaire was sent to the entire population of 189 clinical graduate social work programs identified by the Council on Social Work Education. A three-wave mailing process was used to maximize the return rate. Directors from 112 clinical social work programs returned completed questionnaires (61 percent). The majority (91 percent) of directors reported having never thought about offering formal smoking cessation training, and only nine of the programs (8 percent) currently provided formal smoking cessation education. The three leading barriers to offering smoking cessation education were as follows: not a priority (60 percent), not enough time (55 percent), and not required by the accrediting body (41 percent). These findings indicate that clinical social work students are not receiving standardized smoking cessation education to assist in improving the well-being of their clients. The national accrediting body for graduate clinical social work programs should consider implementing guidelines for smoking cessation training in the curriculums.

Health care professionals' beliefs about using wiki-based reminders to promote best practices in trauma care

Background

Wikis are knowledge translation tools that could help health professionals implement best practices in acute care. Little is known about the factors influencing professionals’ use of wikis.

Objectives

To identify and compare the beliefs of emergency physicians (EPs) and allied health professionals (AHPs) about using a wiki-based reminder that promotes evidence-based care for traumatic brain injuries.

Methods

Drawing on the theory of planned behavior, we conducted semistructured interviews to elicit EPs’ and AHPs’ beliefs about using a wiki-based reminder. Previous studies suggested a sample of 25 EPs and 25 AHPs. We purposefully selected participants from three trauma centers in Quebec, Canada, to obtain a representative sample. Using univariate analyses, we assessed whether our participants’ gender, age, and level of experience were similar to those of all eligible individuals. Participants viewed a video showing a clinician using a wiki-based reminder, and we interviewed participants about their behavioral, control, and normative beliefs—that is, what they saw as advantages, disadvantages, barriers, and facilitators to their use of a reminder, and how they felt important referents would perceive their use of a reminder. Two reviewers independently analyzed the content of the interview transcripts. We considered the 75% most frequently mentioned beliefs as salient. We retained some less frequently mentioned beliefs as well.

Results

Of 66 eligible EPs and 444 eligible AHPs, we invited 55 EPs and 39 AHPs to participate, and 25 EPs and 25 AHPs (15 nurses, 7 respiratory therapists, and 3 pharmacists) accepted. Participating AHPs had more experience than eligible AHPs (mean 14 vs 11 years; P = .04). We noted no other significant differences. Among EPs, the most frequently reported advantage of using a wiki-based reminder was that it refreshes the memory (n = 14); among AHPs, it was that it provides rapid access to protocols (n = 16). Only 2 EPs mentioned a disadvantage (the wiki added stress). The most frequently reported favorable referent was nurses for EPs (n = 16) and EPs for AHPs (n = 19). The most frequently reported unfavorable referents were people resistant to standardized care for EPs (n = 8) and people less comfortable with computers for AHPs (n = 11). The most frequent facilitator for EPs was ease of use (n = 19); for AHPs, it was having a bedside computer (n = 20). EPs’ most frequently reported barrier was irregularly updated wiki-based reminders (n = 18); AHPs’ was undetermined legal responsibility (n = 10).

Conclusions

We identified EPs’ and AHPs’ salient beliefs about using a wiki-based reminder. We will draw on these beliefs to construct a questionnaire to measure the importance of these determinants to EPs’ and AHPs’ intention to use a wiki-based reminder promoting evidence-based care for traumatic brain injuries.

Exploring primary care providers' interest in using patient navigators to assist in the delivery of tobacco cessation treatment to low income, ethnic/racial minority patients

We examined attitudes and practices regarding tobacco cessation interventions of primary care physicians serving low income, minority patients living in urban areas with a high smoking prevalence. We also explored barriers and facilitators to physicians providing smoking cessation counseling to determine the need for and interest in deploying a tobacco-focused patient navigator at community-based primary care practice sites. A self-administered survey was mailed to providers serving Medicaid populations in New York City's Upper Manhattan and areas of the Bronx. Provider counseling practices were measured by assessing routine delivery (≥80% of the time) of a brief tobacco cessation intervention (i.e., "5 A's"). Provider attitudes were assessed by a decisional balance scale comprising 10 positive (Pros) and 10 negative (Cons) perceptions of tobacco cessation counseling. Of 254 eligible providers, 105 responded (41%). Providers estimated 22% of their patients currently use tobacco and nearly half speak Spanish. A majority of providers routinely asked about tobacco use (92%) and advised users to quit (82%), whereas fewer assisted in developing a quit plan (32%) or arranged follow-up (21%). Compared to providers reporting <80% adherence to the "5 A's", providers reporting ≥80% adherence tended to have similar mean Pros and Cons scores for Ask, Advise, and Assess but higher Pros and lower Cons for Assist and Arrange. Sixty four percent of providers were interested in providing tobacco-related patient navigation services at their practices. Although most providers believe they can help patients quit smoking, they also recognize the potential benefit of having a patient navigator connect their patients with evidence-based cessation services in their community.

Healthcare professionals' intentions to use wiki-based reminders to promote best practices in trauma care: a survey protocol

BACKGROUND

Healthcare professionals are increasingly using wikis as collaborative tools to create, synthesize, share, and disseminate knowledge in healthcare. Because wikis depend on collaborators to keep content up-to-date, healthcare professionals who use wikis must adopt behaviors that foster this collaboration. This protocol describes the methods we will use to develop and test the metrological qualities of a questionnaire that will assess healthcare professionals' intentions and the determinants of those intentions to use wiki-based reminders that promote best practices in trauma care.

METHODS

Using the Theory of Planned Behavior, we will conduct semi-structured interviews of healthcare professionals to identify salient beliefs that may affect their future use of wikis. These beliefs will inform our questionnaire on intended behavior. A test-retest of the survey will verify the questionnaire's stability over time. We will interview 50 healthcare professionals (25 physicians and 25 allied health professionals) working in the emergency departments of three trauma centers in Quebec, Canada. We will analyze the content of the interviews and construct and pilot a questionnaire. We will then test the revised questionnaire with 30 healthcare professionals (15 physicians and 15 allied health professionals) and retest it two weeks later. We will assess the internal consistency of the questionnaire constructs using Cronbach's alpha coefficients and determine their stability with the intra-class correlation (ICC).

DISCUSSION

To our knowledge, this study will be the first to develop and test a theory-based survey that measures healthcare professionals' intentions to use a wiki-based intervention. This study will identify professionals' salient beliefs qualitatively and will quantify the psychometric capacities of the questionnaire based on those beliefs.

Psychometric properties of the Domestic Violence Survivor Assessment

Domestic Violence Survivor Assessment (DVSA) assesses the process of change using the Transtheoretical Model of Change for 12 issues conceptualized as relating to the relationship or the individual. This article presents the psychometric properties of the revised DVSA with a new item, "Control of Money." The factor analysis was done for 119 survivors resulting in a three-factor solution explaining 65.06% of the variance with a Chronbach's alpha of .89 and Mental Health as a separate, third factor. The DVSA's use for counseling and implications of the differences in responses by women and their counselors is discussed.

Is provider training effective? Changes in attitudes towards smoking cessation counseling and counseling behaviors of home health care nurses

OBJECTIVE

We prospectively examined whether training home health care nurses is associated with changes in attitudes towards smoking cessation counseling and counseling behaviors.

METHODS

We trained 98 home health care nurses to deliver cessation counseling to their patients. Measures were administered at pre-training, post-training, and 6 months later. This was part of a larger study conducted in Providence, RI, USA (1998-2002).

RESULTS

Compared with pre-training, at post-training, nurses reported significantly higher levels of self-efficacy to counsel, positive outcome expectations, optimism that patients would follow their advice, perceived worth of smoking counseling, perceived importance of quitting smoking, and perceived organizational support. These training effects were maintained 6 months later. Between the end of training and the 6-month follow-up, nurses reported significant increases in their perceived effectiveness to counsel smokers and confidence to encourage behavior change. Compared with pre-training, at 6 months of follow-up, nurses were significantly more likely to ask about smoking status, assess readiness to quit, advise to quit, assist with quitting, and arrange follow-up. Nurses spent significantly more time counseling smokers at 6 months than at pre-training, and were less likely to selectively counsel.

CONCLUSIONS

Brief training facilitates both short- and long-term changes in nurse attitudes and behaviors regarding smoking cessation counseling.

Meta-analytic examination of the strong and weak principles across 48 health behaviors

OBJECTIVE

The strong and weak principles of change state that progress from the precontemplation to the action stage of change is associated with a one standard deviation increase in the pros and a one-half standard deviation decrease in the cons of change. In this study these relationships, originally developed by Prochaska [Prochaska, J.O., 1994. Strong and weak principles for progressing from precontemplation to action on the basis of 12 problem behaviors. Health Psychology, 13, 47-51] based on an examination of 12 studies of 12 different behaviors, were re-examined using many more datasets and much more rigorous statistical methods.

METHODS

The current study analyzes 120 datasets from studies conducted between 1984 and 2003 across and within 48 health behaviors, including nearly 50,000 participants from 10 countries. The datasets were primarily analyzed utilizing meta-analytic techniques.

RESULTS

Despite the range of behaviors and populations, the results were remarkably consistent with the original results (pros=1.00 standard deviation, cons=0.56 standard deviation). Few potential moderators showed any impact on effect size distributions.

CONCLUSIONS

This updated and enhanced examination of two important principles of behavior change is a significant contribution to the field of multiple health risk behaviors, as it clearly demonstrates the consistency of the theoretical principles across multiple behaviors, which has implications for developing multiple health risk behavior interventions.

Prediction of health professionals' intention to screen for decisional conflict in clinical practice

OBJECTIVE

To identify the determinants of the intention of physicians to screen for decisional conflict in clinical practice.

BACKGROUND

Screening for decisional conflict is one of the key competencies when educating health professionals about shared decision making. Theory-based knowledge about variables predicting their intention to screen for decisional conflict in clinical practice would help design effective implementation interventions in this area.

DESIGN

Data of two cross-sectional surveys embedded within a large implementation study of the Ottawa Decision Support Framework (ODSF) in primary care.

SETTING AND PARTICIPANTS

In total, 122 health professionals from five family practice teaching units.

METHODS

Intention to screen for decisional conflict in clinical practice was defined as the intention to use the clinical version of the Decisional Conflict Scale (DCS) with patients at the end of the clinical encounter. It was assessed at the entry and the exit from this study. Both intentions were entered as a dependent variable in multivariate analyses.

MAIN RESULTS

At entry, the intention was influenced by: attitude (P < 0.001), subjective norm (P < 0.001), perceived behavioural control (P < 0.001) and clinical site (P < 0.05). On exit, it was influenced by: subjective norm (P < 0.001), perceived behavioural control (P < 0.001), clinical site (P < 0.05), international Continuing Medical Education (CME) (P < 0.05), other diplomas (P < 0.05) and intervention (P < 0.05). In post hoc analyses, there was a statistically significant difference between entry and exit in the impact of the level of exposure to the multifaceted implementation intervention on the intention (P = 0.003).

CONCLUSIONS

Variables predicting the intention of health professionals to screen for decisional conflict in clinical practice using the DCS change over time suggesting that effective implementation interventions in this area will need to be modified longitudinally.

The Domestic Violence Survivor Assessment (DVSA): a tool for individual counseling with women experiencing intimate partner violence

The Domestic Violence Survivor Assessment (DVSA) was developed to measure survivor movement toward a violence free life over time. This paper reports our testing of the validity and reliability of the DVSA. Exploratory factor analysis (n = 162) found a single factor explaining 66% of the variance. Hierarchical multiple regression indicated that physical abuse severity, survivor and perpetrator substance abuse, economic and citizenship dependency, and children under 18 at home explained 10% of the variance p > .05. A second model examined the strength of interventions for survivors, controlling for influencing factors; R(2) was.24 (p < .001). The strongest interventions were individual counseling (p < .001) and resource referrals and other services (p < .05). The DVSA was found to have construct validity, sensitivity to change over time, and reliability. A county agency that adopted the DVSA evaluated its programs using the DVSA change scores and used this evaluation for program improvement.

In the moment: attitudinal measure of pediatrician management of maternal depression

OBJECTIVE

Pediatricians are in a good position to identify women who struggle with depression, but studies show low rates of pediatrician identification and management. It is likely that pediatricians' management of maternal depression may vary on the basis of their attitudes, but no instrument has been developed to measure these attitudes. We sought to develop a measure of pediatricians' attitudes about managing maternal depression and to identify characteristics associated with pediatricians' attitudes about managing maternal depression.

METHODS

We conducted a cross-sectional analysis of data provided by 651 practicing, nontrainee pediatricians (response rate 57.5%) surveyed through an American Academy of Pediatrics 2004 Periodic Survey. An exploratory principal components analysis was used to investigate the interrelationships among the attitudinal items. Multivariable linear regression was used to assess the adjusted associations between physician and practice characteristics and attitudes.

RESULTS

The attitudinal measure consisted of 3 subscales: acknowledging maternal depression, perceptions of mothers' beliefs, and treating maternal depression. Clinical approaches (eg, interest in further education on identifying or treating maternal depression) and training and work characteristics were significantly related to pediatricians' attitudes; patient characteristics (eg, type of insurance and ethnicity/race) were not significantly associated with pediatricians' attitudes.

CONCLUSIONS

We developed a measure to assess pediatricians' attitudes about managing maternal depression. The findings from this study can be used to develop and assess interventions that improve pediatricians' attitudes about acknowledging maternal depression, perceptions of mothers' beliefs, and treating maternal depression.

Knowing how to help tobacco users

BACKGROUND

A U.S. Public Health Service-sponsored clinical practice guideline urges all health care providers to make tobacco-use cessation counseling a routine part of clinical practice. This study assessed practices of dentists in east Texas, their adherence to the guideline and barriers to adherence.

METHODS

A cross-sectional survey mailed September 2003 through January 2004 assessed demographic characteristics and knowledge, attitudes and activities of 783 dentists. The survey focused on familiarity with the guideline, adherence to the recommended steps (including the "5 A's" for tobacco users willing to quit and the "5 R's" for tobacco users unwilling to quit), perceived barriers and time spent counseling.

RESULTS

Most dentists were unfamiliar with the guideline and usually did not follow its recommended steps. Less than 20 percent of dentists spent three or more minutes per patient on counseling. Knowledge of and training in using the guideline were significantly associated with adherence and time spent counseling. Lack of training was cited as the greatest barrier.

CONCLUSIONS

Most dentists in east Texas are unaware of the clinical practice guideline. Lack of training is a major barrier to adherence. Practice Implications. Opportunities for improving patients' health through brief counseling interventions are missed. Measures are needed to increase dentists' familiarity with and adherence to the guideline.

Perceived preparedness to provide preventive counseling: reports of graduating primary care residents at academic health centers

OBJECTIVE

To assess the perceived preparedness of residents in adult primary care specialties to counsel patients about preventive care and psychosocial issues.

DESIGN

Cross-sectional national mail survey of residents (63% response rate).

PARTICIPANTS

Nine hundred twenty-eight final-year primary care residents in Internal Medicine (IM), family practice (FP), and Obstetrics/Gynecology (OB/GYN) at 162 U.S. academic health centers.

MEASUREMENTS

Residents self-rated preparedness to counsel patients about smoking, diet and exercise, substance abuse, domestic violence, and depression.

RESULTS

Residents felt better prepared to counsel about smoking (62%) and diet and exercise (53%) than about depression (37%), substance abuse (36%), or domestic violence (21%). In most areas, females felt better prepared than males. Rates of counseling preparedness varied significantly by specialty after adjustment for gender, race, medical school location, and percent of training spent in ambulatory settings. FP residents felt better prepared than OB/GYN residents to counsel about smoking, diet and exercise, and depression, while OB/GYN residents felt better prepared to address domestic violence than IM or FP residents. IM residents' perceptions of preparedness were between the other 2 specialties. Proportion of training spent in ambulatory settings was not associated with residents' perceived preparedness.

CONCLUSIONS

Physicians completing residencies in adult primary care did not feel very well prepared to counsel patients about preventive and psychosocial issues. Significant differences exist among specialties, even after adjusting for differences in time spent in ambulatory settings. Increasing residency time in ambulatory settings may not alone be sufficient to ensure that residents emerge with adequate counseling skills.

Wellness promotion beliefs and practices of pediatric physical therapists

PURPOSE

The purpose of this study was to elucidate wellness promotion beliefs and practices of pediatric physical therapists.

METHODS

From a random sample of 500 American Physical Therapy Association Pediatric Section active members, 257 physical therapists (51%) returned usable questionnaires designed to gather information on professional and personal wellness beliefs and practices.

RESULTS

Descriptive statistics and chi-square analyses were performed to describe current wellness promotion practices. Most participants considered wellness multidimensional, valued wellness, and incorporated wellness practices into their personal life. Only 54.5% of respondents, however, reported incorporating wellness into pediatric physical therapy practice. A third of the respondents identified themselves as either thinking or preparing to incorporate wellness promotion into practice. Factors associated with wellness promotion were older age group, knowledge, belief that wellness promotion was a physical therapy responsibility, and participation in personal wellness lifestyle activities. The most frequent barriers cited were external factors related to resources, time, and the child/family.

CONCLUSIONS

Current pediatric physical therapy practice reflects a more traditional model of care rather than a wellness promotion approach. With a paradigm shift in healthcare toward wellness promotion, pediatric physical therapists need to align practice with current societal needs and national healthcare campaigns. Continuing education programs that are participatory and well matched to the characteristics and needs of the attendees combined with collegial support may prove fruitful in providing pediatric physical therapists with the knowledge, motivation, and strategies needed to accomplish this goal.