Perceptions of health professionals towards the management of back pain in the context of work: a qualitative study Effectiveness of a learner-centred training programme for primary care physicians in using a patient-centred consultation style. Evaluation of a Theory-Informed Implementation Intervention for the Management of Acute Low Back Pain in General Medical Practice: The IMPLEMENT Cluster Randomised Trial Specific Collaborative Group Intervention for Patients with Medically Unexplained Symptoms in General Practice: A Cluster Randomized Controlled Trial An intervention modelling experiment to change GPs' intentions to implement evidence-based practice: using theory-based interventions to promote GP management of upper respiratory tract infection without prescribing antibiotics #2 Using nurse practitioners to implement an intervention in primary care for high-utilizing patients with medically unexplained symptoms. Factors affecting feasibility and acceptability of a practice-based educational intervention to support evidence-based prescribing: a qualitative study. The acceptability to primary care staff of a multidisciplinary training package on acute back pain guidelines. Evaluation of general practitioners' training: how to manage patients with unexplained physical symptoms. A randomized trial of physicians and physical therapists as instructors of the musculoskeletal examination. Testing the effectiveness of an innovative information package on practitioner reported behaviour and beliefs: The UK Chiropractors, Osteopaths and Musculoskeletal Physiotherapists Low back pain ManagemENT (COMPLeMENT) trial [ISRCTN77245761] General practitioners trained in motivational interviewing can positively affect the attitude to behaviour change in people with type 2 diabetes Development and evaluation of a multifaceted ergonomics program to prevent injuries associated with patient handling tasks. Involvement of general practitioners in managing alcohol problems: a randomized controlled trial of a tailored improvement programme. General practitioners’ views on the acceptability and applicability of a web-based intervention to reduce antibiotic prescribing for acute cough in multiple European countries: a qualitative study prior to a randomised trial Effects on Knowledge and Attitudes of Using Stages of Change to Train General Practitioners on Management of Depression: A Randomized Controlled Study Understanding effects in reviews of implementation interventions using the Theoretical Domains Framework
Background Musculoskeletal complaints have a significant impact on work in terms of reduced productivity , sickness absence and long term incapacity for work . This study sought to explore GPs ’ and physiotherapists ’ perceptions of  sickness certification in patients with musculoskeletal problems . Methods Eleven ( 11 ) GPs were sample d from an existing general practice survey , and six ( 6 ) physiotherapists were selected r and omly using ‘ snowball ’ sampling techniques , through established contacts in local physiotherapy departments .  Semi-structured qualitative interviews were conducted with respondents lasting up to 30 minutes . The interviews were audio recorded and transcribed verbatim , following which they were coded using N-Vivo qualitative software and analysed thematically using the constant comparative methodology , where themes were identified and contrasted between and within both groups of respondents . Results Three themes were identified from the analysis : 1 ) Approaches to evaluating patients ’ work problems 2 ) Perceived ability to manage ‘ work and pain ’ , and 3 ) Policies and penalties in the work-place . First , physiotherapists routinely asked patients about their job and work difficulties using a structured ( protocol -driven ) approach , whilst GPs rarely used such structured measures and were less likely to enquire about patients ’ work situation . Second , return to work assessment s revealed a tension between GPs ’ gatekeeper and patient advocacy roles , often resolved in favour of patients ’ concerns and needs . Some physiotherapists perceived that GPs ’ decisions could be influenced by patients ’ dem and for a sick certificate and their close relationship with patients made them vulnerable to manipulation . Third , the workplace was considered to be a specific source of strain for patients acting as a barrier to work resumption , and over which GPs and physiotherapists could exercise only limited control . Conclusion We conclude that healthcare professionals need to take account of patients ’ work difficulties , their own perceived ability to offer effective guidance , and consider the ‘ receptivity ’ of employment context s to patients ’ work problems , in order to ensure a smooth transition back to work OBJECTIVE The aim of the present study was to find out if a training programme adapted to family physicians with several years of clinical experience changes their behaviour when they deal with fibromyalgic patients in the sense of introducing the communication skills that define the ' patient-centred ' approach . METHODS A r and omized , and simple blind , educative study was carried out . Twenty full-time family physicians were invited to participate . They were allocated r and omly to two groups : an intervention and a control group . A total of 110 patients were recruited from people attending physicians ' surgeries for the first time and who complained of generalized pain that finally fulfilled criteria for generalized musculoskeletal chronic pain/fibromyalgia . This was done for an entire year . The intervention group received an 18 hour intensive course . One week after the course , all doctors carried out a video-recorded encounter with a patient who played the part of a typical fibromyalgia clinical case . The interviews were coded by an observer blind to the training status of the participants , using the GATHARES-CP question naire . All patients were contacted by telephone during a 1 - 2-month period by a different interviewer who was ' blinded ' to the patient 's experimental status . They were asked to respond to three questions that represent the key components of patient-centred style . RESULTS The average score on the GATHARES-CP question naire was 11.3 + /- 0.9 and 9 + /- 2.3 , for doctors from the intervention and control groups , respectively ( P < 0.01 ) . For 11 items , scores were higher in the intervention group . The patients ' answers to all three questions showed statistically significant differences in a positive direction for the trained doctors . CONCLUSIONS The doctors improved the use of strategies and skills for carrying out patient-centred consultations after they had received an interactive course . The doctors ' behaviour appeared to have changed as much in a more experimental situation as in the actual consultations . Moreover , the gain was observed immediately after the intervention was completed , and after having run for a variable period of time up to 1 year Introduction This cluster r and omised trial evaluated an intervention to decrease x-ray referrals and increase giving advice to stay active for people with acute low back pain ( LBP ) in general practice . Methods General practice s were r and omised to either  access to a guideline for acute LBP ( control ) or facilitated interactive workshops ( intervention ) . We measured behavioural predictors ( e.g. knowledge , attitudes and intentions ) and fear avoidance beliefs . We were unable to recruit sufficient patients to measure our original primary outcomes so we introduced other outcomes measured at the general practitioner ( GP ) level : behavioural simulation ( clinical decision about vignettes ) and rates of x-ray and CT-scan ( medical administrative data ) . All those not involved in the delivery of the intervention were blinded to allocation . Results 47 practice s ( 53 GPs ) were r and omised to the control and 45 practice s ( 59 GPs ) to the intervention . The number of GPs available for analysis at 12 months varied by outcome due to missing confounder information ; a minimum of 38 GPs were available from the intervention group , and a minimum of 40 GPs from the control group . For the behavioural constructs , although effect estimates were small , the intervention group GPs had greater intention of practising consistent with the guideline for the clinical behaviour of x-ray referral . For behavioural simulation , intervention group GPs were more likely to adhere to guideline recommendations about x-ray ( OR 1.76 , 95%CI 1.01 , 3.05 ) and more likely to give advice to stay active ( OR 4.49 , 95%CI 1.90 to 10.60 ) . Imaging referral was not statistically significantly different between groups and the potential importance of effects was unclear ; rate ratio 0.87 ( 95%CI 0.68 , 1.10 ) for x-ray or CT-scan . Conclusions The intervention led to small changes in GP intention to practice in a manner that is consistent with an evidence -based guideline , but it did not result in statistically significant changes in actual behaviour . Trial Registration Australian New Zeal and Clinical Trials Registry Background : Patients with medically unexplained symptoms ( MUS ) are frequent in primary care and substantially impaired in their quality of life ( QoL ) . Specific training of general practitioners ( GPs ) alone did not demonstrate sustained improvement at later follow-up in current review s. We evaluated a collaborative group intervention . Methods : We conducted a cluster r and omized controlled trial . Thirty-five GPs recruited 304 MUS patients ( intervention group : 170 ; control group : 134 ) . All GPs were trained in diagnosis and management of MUS  (  control  condition ) . Eighteen r and omly selected intervention GPs participated in training for a specific collaborative group intervention . They conducted 10 weekly group sessions and 2 booster meetings in their practice s , together with a psychosomatic specialist . Six and 12 months after baseline , QoL was assessed with the Short-Form 36 . The primary outcome was the physical composite score ( PCS ) , and the secondary outcome was the mental composite score ( MCS ) . Results : At 12 months , intention-to-treat analyses showed a significant between-group effect for the MCS ( p = 0.023 ) but not for the PCS ( p = 0.674 ) . This effect was preceded by a significant reduction of somatic symptom severity ( 15-item somatic symptom severity scale of the Patient Health Question naire , PHQ-15 ) at 6 months ( p = 0.008 ) that lacked significance at 12 months ( p = 0.078 ) . As additional between-group effects at 12 months , per- protocol analyses showed less health anxiety ( Whiteley-7 ; p = 0.038 ) and less psychosocial distress ( PHQ ; p = 0.024 ) ; GP visits were significantly ( p = 0.042 ) reduced in the intervention group . Conclusions : Compared to pure GP training , collaborative group intervention achieved a progressive , clinical ly meaningful improvement in mental but not physical QoL. It could bridge gaps between general practice and mental health care Background Psychological theories of behaviour may provide a framework to guide the design of interventions to change professional behaviour . Behaviour change interventions , design ed using psychological theory and targeting important motivational beliefs , were experimentally evaluated for effects on the behavioural intention and simulated behaviour of GPs in the management of uncomplicated upper respiratory tract infection ( URTI ) . Methods The design was a 2 × 2 factorial r and omised controlled trial . A postal question naire was developed based on three theories of human behaviour : Theory of Planned Behaviour ; Social Cognitive Theory and Operant Learning Theory . The beliefs and attitudes of GPs regarding the management of URTI without antibiotics and rates of prescribing on eight patient scenarios were measured at baseline and post-intervention . Two theory-based interventions , a " grade d task " with " action planning " and a " persuasive communication " , were incorporated into the post-intervention question naire . Trial groups were compared using co-variate analyses . Results Post-intervention question naires were returned for 340/397 ( 86 % ) GPs who responded to the baseline survey . Each intervention had a significant effect on its targeted behavioural belief : compared to those not receiving the intervention GPs completing Intervention 1 reported stronger self-efficacy scores ( Beta = 1.41 , 95 % CI : 0.64 to 2.25 ) and GPs completing Intervention 2 had more positive anticipated consequences scores ( Beta = 0.98 , 95 % CI = 0.46 to 1.98 ) . Intervention 2 had a significant effect on intention ( Beta = 0.90 , 95 % CI = 0.41 to 1.38 ) and simulated behaviour ( Beta = 0.47 , 95 % CI = 0.19 to 0.74 ) . Conclusion GPs ' intended management of URTI was significantly influenced by their confidence in their ability to manage URTI without antibiotics and the consequences they anticipated as a result of doing so . Two targeted behaviour change interventions differentially affected these beliefs . One intervention also significantly enhanced GPs ' intentions not to prescribe antibiotics for URTI and result ed in lower rates of prescribing on patient scenarios compared to a control group . The theoretical frameworks utilised provide a scientific rationale for underst and ing how and why the interventions had these effects , improving the reproducibility and generalisability of these findings and offering a sound basis for an intervention in a " real world " trial . Trial registration Clinical trials.gov Patients with medically unexplained symptoms ( MUS ) often are a source of frustration for clinicians , and despite high quality biomedical attention and frequent diagnostic tests , they have poor health outcomes . Following upon progress in depression treatment approaches , we developed a multidimensional treatment protocol for deployment by primary care personnel . This multi-faceted intervention for MUS patients emphasized cognitive-behavioral principles , the provider-patient relationship , pharmacological management , and treating comorbid medical diseases . We deployed it in an HMO using  nurse practitioners ( NP )  to deliver the intervention to 101 patients , while 102 controls continued to receive medical care from their usual primary care physician . Successful deployment of the intervention required training the NPs , continuing support for the NPs in their management of this difficult population , and establishing strong communication links with the HMO . This paper addresses the practical considerations of using primary care personnel to implement a complex intervention in primary care , and it includes a discussion of special challenges encountered as well as solutions developed to overcome them BACKGROUND Inappropriate and costly GP prescribing is a major problem facing Primary Care Trusts .  Educational outreach into practice s , alongside other measures , such as audit and feedback , have the potential to enable GP prescribing to become more evidence based . High GP prescribing costs are associated with GPs who see drug company representatives ; tend to end consultations with prescriptions ; and ' try out ' new drugs on an ' ad hoc basis ' and use this as evidence of the drug 's effect . An educational intervention called ' reflective practice ' was developed to meet these and other educational needs . The design of the intervention was informed by studies that have identified the pre-requisites of successful behaviour change in general practice . OBJECTIVES The study investigated the following : ( i ) Is it feasible for GPs to attend the sessions included in the educational intervention ? ( ii ) Is the intervention acceptable to the participants and the session facilitators ? ( iii ) What are the barriers to the group educational processes , and how can these be overcome ? METHODS Four practice s were recruited in South West Engl and , all of them experiencing problems with prescribing appropriateness and cost .  Reflective practice sessions ( including a video-taped scenario ) were run in each of these practice s and qualitative methods were used to explore the complex attitudes and behaviour of the participants . A research er observed and audio-taped sessions in each practice . At the end of the programme , a sample of doctors and all the facilitators were interviewed about their experiences . The recorded data were transcribed and analysed using st and ard qualitative methods . RESULTS The doctors in the largest partnerships were those who had the greatest difficulty in attending the sessions . Elsewhere , doctors were also reluctant to become involved because of previous experience of top-down managerial initiatives about prescribing quality . Facilitators came from a broad range of professional background s. While knowledge of prescribed drug management issues was important , the professional background of the facilitator was less important than group facilitation skills in creating a group process which participating GPs found satisfactory . The video-taped scenario was found to be useful to set the scene for the discussion . Preserving the anonymity of responses of the GPs in the initial stages of the sessions was important in ensuring honesty in the discussion . Reaching a consensus on management of common conditions was sometimes difficult , partly because the use of the term ' best buy ' implies economic pressures , rather than benefits to patients , and partly because of the value with which GPs regard the concept of clinical autonomy . ' Reflective Practice ' appeared to have the potential to make GPs aware of the link to be made between their clinical management decisions and the evidence provided by the British National Formulary and Clinical Evidence . CONCLUSION The study indicates the importance of preparing the practice adequately , including providing protected time for all GPs to attend the educational intervention . Scenarios and the structure of the sessions need to make more explicit the links between everyday practice and published evidence of effectiveness . Emphasis on cost-effectiveness may be counterproductive and wider benefits need to be emphasized . We have also identified the skill profile of the facilitator role . Our study indicates a need for a clearer underst and ing of GPs ' perception of clinical autonomy and how this conflicts with the goal of agreement on practice guidelines for treatment . The intervention is now ripe for further development , perhaps by integrating it with other interventions to change professional behaviour . The improved intervention should then be evaluated in a r and omized controlled trial BACKGROUND Implementing clinical guidelines is more likely to be successful when the whole practice team is committed to the process . Practice s from the MRC General Practice Research Framework in two distinct geographical centres in the UK ( West Yorkshire and Greater Manchester ) participated in the feasibility study for the UK Back pain Exercise And Manipulation ( UK BEAM ) trial . Practice teams were r and omized to continue with their usual care for back pain patients , or to be trained in managing back pain in line with national guidelines . Those r and omized to the intervention arm of the trial were invited to attend training , delivered by either a generic trainer or a back pain expert . OBJECTIVES Our aims were to assess the general acceptability of the training package to staff , to assess the acceptability of the multidisciplinary approach and to determine if a generic primary care educator could deliver the training as effectively as a clinical back pain expert . METHODS All staff ( clinical and non- clinical ) from intervention practice s were invited to attend multidisciplinary training sessions on the active management of back pain .  Practice staff in West Yorkshire were trained by a generic primary care educator and practice staff in Greater Manchester were trained by a clinical back pain expert . The content of sessions was st and ardized for both trainers and included didactic and interactive components and small group , case study discussion s. Detailed notes were taken of observations made of participants during sessions , and evaluation forms were completed by all those who attended . RESULTS The majority of participants found the training useful and said that the session had lived up to their expectations . Most found that the session was well planned and that they had sufficient opportunity to participate in learning . The training package was well received by clinical staff , but was less acceptable to non- clinical staff . GPs dominated the small group work discussion s. No differences were found between the preferences of participants for the two different trainers . CONCLUSION The training package was appropriate for clinical staff , but did not always meet the needs of non- clinical staff and may require modification for this group . A generic educator can successfully lead multidisciplinary educational sessions addressing clinical issues Patients with unexplained physical symptoms ( " somatoform disorders " ) tend to overuse the healthcare system . Therefore , the authors aim ed to assess whether a training session for general practitioners ( GPs )  on managing patients with unexplained physical symptoms would be acceptable to GPs and lead to improvements in patient care . In a r and omized clinical trial ( GPs r and omized ) , GPs got a 1-day training session and additional material s. Included were 26 GP offices in primary care and 295 patients with unexplained physical symptoms ( minimum of two symptoms required ) . Outcome measures were healthcare utilization ( number of doctor visits ) 6 months before and 6 months after the index visit to the GP , somatization severity , depression , and hypochondriacal fears at the index visit to the GP 's office and 6 months later . Training GPs to manage these patients led to significant reductions in healthcare utilization ; patients of untrained GPs showed comparable attendance rates in the 6 months before and after the index visit . Differences in depression , somatization , and hypochondriacal fears , however , could not be attributed to the GP training . GPs rated the training as being highly relevant for their everyday practice s , underlining the need for and acceptance of the training . Training GPs in managing patients with unexplained physical symptoms seems to be helpful for the reduction of excessive healthcare utilization . These 1-day workshops have high acceptability , so this approach could be a good model for empirically-vali date d continuing-education programs OBJECTIVE To evaluate the effectiveness of physicians vs physical therapists as instructors of the musculoskeletal examination to second year medical students . METHODS A r and omized trial conducted over 3 consecutive years in a physical diagnosis course at The University of North Carolina . During the first ( baseline ) year , medical students received education about the musculoskeletal examination from a lecture and supervision by clinical preceptors . This increased in the second and third ( intervention ) years where r and om halves of each class received supplementary clinical instruction which included a structured manual , a videotape , and supervised practice with either general internal medicine physicians or physical therapists . Outcomes were measured from student performance on a practical test of clinical skills , and by written student evaluations of the supplementary instruction . RESULTS As measured on the clinical examination , performance during the intervention years improved over that during the baseline year in both intervention groups . Measures of medical students ' clinical skills did not correlate with measures of academic aptitude . CONCLUSIONS Clinical education about the musculoskeletal examination should be structured and systematic . Medical students prefer clinical education that is active , provides clear directions , and gives them performance feedback Background Low back pain ( LBP ) is a common and costly problem . Initiatives design ed to assist practitioner and patient decisions about appropriate healthcare for LBP include printed evidence -based clinical guidelines . The three professional groups of chiropractic , osteopathy and musculoskeletal physiotherapy in the UK share common ground with their approaches to managing LBP and are amongst those targeted by LBP guidelines . Even so , many seem unaware that such guidelines exist . Furthermore , the behaviour of at least some of these practitioners differs from that recommended in these guidelines .Few r and omised controlled trials evaluating printed information as an intervention to change practitioner behaviour have utilised a no-intervention control . All these trials have used a cluster design and most have method ological flaws . None specifically focus upon practitioner behaviour towards LBP patients . Studies that have investigated other strategies to change practitioner behaviour with LBP patients have produced conflicting results . Although numerous LBP guidelines have been developed worldwide , there is a paucity of data on whether their dissemination actually changes practitioner behaviour . Primarily because of its low unit cost , sending printed information to large numbers of practitioners is an attractive dissemination and implementation strategy . The effect size of such a strategy , at an individual practitioner level , is likely to be small . However , if large numbers of practitioners are targeted , this strategy might achieve meaningful changes at a population level . Methods The primary aim of this prospect i ve , pragmatic r and omised controlled trial is to test the short-term effectiveness ( six-months following intervention ) of a directly-posted information package on the reported clinical behaviour ( primary outcome ) , attitudes and beliefs of UK chiropractors , osteopaths and musculoskeletal physiotherapists . We sought to r and omly allocate a combined sample of 1,800 consenting practitioners to receive either the information package ( intervention arm ) or no information above that gained during normal practice ( control arm ) . We collected question naire data at baseline and six-months post-intervention . The analysis of the primary outcome will assess between-arm differences of proportions of responses to questions on recommendations about activity , work and bed-rest , that fall within categories previously defined by an expert consensus exercise as either ' guideline -consistent ' and ' guideline -inconsistent ' Objective . To examine whether training GPs in motivational interviewing ( MI ) can improve type 2 diabetic patients ’ ( 1 ) underst and ing of diabetes , ( 2 ) beliefs regarding prevention and treatment , and ( 3 ) motivation for behaviour change . Methods . A r and omized controlled trial including 65 GPs and 265 type 2 diabetic patients . The GPs were r and omized in two groups , one with and one without MI training . Both groups received training in target-driven intensive treatment of  type 2 diabetic patients . The intervention was a 1½-day residential course in MI with ½-day follow-up twice during the first year . The patient data stemmed from previously vali date d question naires . Main outcome measures . The Health Care Climates Question naire assesses the patient – doctor relationship and type of counselling . The Treatment Self-Regulation Question naire assesses the degree to which behaviour tends to be self-determined . The Diabetes Illness Representation Question naire assesses beliefs and underst and ing of type 2 diabetes . The Summary of Diabetes Self Care Activities assesses the extent of various self-care activities related to type 2 diabetes . Results . The response rate to our question naires was 87 % . Patients in the intervention group were significantly more autonomous and motivated in their inclination to change behaviour after one year compared with the patients from the control group . Patients in the intervention group were also significantly more conscious of the importance of controlling their diabetes , and had a significantly better underst and ing of the possibility of preventing complications . Conclusion . MI improved type 2 patients ’ underst and ing of diabetes , their beliefs regarding treatment aspects , their contemplation on and motivation for behaviour change . Whether our results can be sustained long term and are clinical ly relevant in terms of changes in risk profile advocates further research PROBLEM STATEMENT Nurses have one of the highest rates of work-related musculoskeletal injury of any profession . Over the past 30 years , efforts to reduce work-related musculoskeletal disorders in nurses have been largely unsuccessful . SPECIFIC AIMS The primary goal of this program was to create safer working environments for nursing staff who provide direct patient care . Our first objective was to design and implement a multifaceted program that successfully integrated evidence -based practice , technology , and safety improvement . The second objective was to evaluate the impact of the program on injury rate , lost and modified work days , job satisfaction , self-reported unsafe patient h and ling acts , level of support for program , staff and patient acceptance , program effectiveness , costs , and return on investment . INTERVENTION The intervention included six program elements : ( 1 ) Ergonomic Assessment Protocol , ( 2 ) Patient H and ling Assessment Criteria and Decision Algorithms , ( 3 ) Peer Leader role , " Back Injury Re source Nurses " , ( 4 ) State-of-the-art Equipment , ( 5 ) After Action Review s , and ( 6 ) No Lift Policy . METHODS A pre-/post design without a control group was used to evaluate the effectiveness of a  patient care ergonomics program  on 23 high risk units ( 19 nursing home care units and 4 spinal cord injury units ) in 7 facilities .  Injury rates , lost work days , modified work days , job satisfaction , staff , and patient acceptance , program effectiveness , and program costs/savings were compared over two nine month periods : pre-intervention ( May 2001-January 2002 ) and post-intervention ( March 2002-November 2002 ) . Data were collected prospect ively through surveys , weekly process logs , injury logs , and cost logs . RESULTS The program elements result ed in a statistically significant decrease in the rate of musculoskeletal injuries as well as the number of modified duty days taken per injury . While the total number of lost workdays decreased by 18 % post-intervention , this difference was not statistically significant . There were statistically significant increases in two subscales of job satisfaction : professional status and tasks requirements . Self-reports by nursing staff revealed a statistically significant decrease in the number of ' unsafe ' patient h and ling practice s performed daily . Nurses ranked program elements they deemed to be " extremely effective " : equipment was rated as most effective ( 96 % ) , followed by No Lift Policy ( 68 % ) , peer leader education program ( 66 % ) , ergonomic assessment protocol ( 59 % ) , patient h and ling assessment criteria and decision algorithms ( 55 % ) , and lastly after action review s ( 41 % ) . Perceived support and interest for the program started at a high level for managers and nursing staff and remained very high throughout the program implementation . Patient acceptance was moderate when the program started but increased to very high by the end of the program . Although the ease and success of program implementation initially varied between and within the facilities , after six months there was strong evidence of support at all levels . The initial capital investment for patient h and ling equipment was recovered in approximately 3.75 years based on annual post-intervention savings of over $ 200,000/year in workers ' compensation expenses and cost savings associated with reduced lost and modified work days and worker compensation . CONCLUSIONS This multi-faceted program result ed in an overall lower injury rate , fewer modified duty days taken per injury , and significant cost savings . The program was well accepted by patients , nursing staff , and administrators . Given the significant increases in two job satisfaction subscales ( professional status and task requirements ) , it is possible that nurse recruitment and retention could be positively impacted AIMS To assess the effect of a tailored multi-faceted improvement programme on  general practitioners ' ( GPs ' ) behaviour towards prevention of hazardous and harmful alcohol consumption . The improvement programme consisted of activities aim ed at the GP , organization and patient . Educational training sessions and visits by a facilitator were tailored to the GPs ' needs and attitudes . DESIGN Cluster r and omized controlled trial . SETTING General practice s in the Netherl and s. PARTICIPANTS Seventy-seven general practice s ; 119 GPs participated . Data from 6318 patients were available , of whom 765 ( 12.1 % ) were at risk . A total of 1502 patients ' electronic medical records were review ed . MEASUREMENTS The primary outcome was the number of eligible patients who received screening and advice .  FINDINGS Difficulties in recruiting GPs and in motivating GPs for participation in the tailored parts of the programme impeded optimal implementation of the programme . Although GPs in both groups became more involved after enrolment , this improvement waned during the trial . The quality improvement programme enhanced the initial improvement in behaviour and it tempered waning ( intervention group ) , compared to our control condition , result ing in average improvement rates of 5 % ( screening ) and 2 % ( advice-giving ) at 12-month follow-up ( not significant ) . CONCLUSIONS A tailored , multi-faceted programme aim ed at improving general practitioner management of alcohol consumption in their patients failed to show an effect and proved difficult to implement . There remains little evidence to support the use of such an intensive implementation programme to improve the management of harmful and hazardous alcohol consumption in primary care Background Interventions to promote prudent antibiotic prescribing by general practitioners ( GPs ) have often only been developed for use in one country . We aim ed to develop an intervention which would be appropriate to implement in multiple European countries in order to offer greater benefit to practice whilst using fewer re sources . The INTRO ( INternet TRaining for antibiOtic use ) intervention needed to deliver training to GPs in the use of C-Reactive Protein ( CRP ) near patient tests to help diagnose acute cough and in communication skills to help explain prescribing decisions to patients . We explored GPs ’ views on the initial version of INTRO to test acceptability and potentially increase applicability for use in multiple countries before the start of a r and omised trial . Method 30 GPs from five countries ( Belgium , Engl and , the Netherl and s , Pol and and Spain ) , were interviewed using a “ think aloud ” approach . GPs were asked to work through the intervention and discuss their views on the content and format in relation to following the intervention in their own practice . GPs viewed the same intervention but versions were created in five language s. Data were coded using thematic analysis . Results GPs in all five countries reported the view that the intervention addressed an important topic , was broadly acceptable and feasible to use , and would be a useful tool to help improve clinical practice . However , GPs in the different countries identified aspects of the intervention that did not reflect their national culture or healthcare system . These included perceived differences in communication style used in the consultation , consultation length and the stage of illness at which patient typically presented . Conclusion An online intervention to support evidence -based use of antibiotics is acceptable and feasible to implement amongst GPs in multiple countries . However , tailoring of the intervention to suit national context s was necessary by adding local information and placing more emphasis on the fact that GPs could select the communication skills they wished to use in practice . Using think aloud methods to complement the development of interventions is a powerful method to identify regional context ual barriers to intervention implementation 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 st and ard continuing medical education , for general practitioners ( GPs ) in primary care in Iran . Method : Using a r and omized controlled trial , a total of 192 GPs were evenly r and omized 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 question naire 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 question naires were vali date d. 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 Background Behavioural theory can be used to better underst and the effects of behaviour change interventions targeting healthcare professional behaviour to improve quality of care . However , the explicit use of theory is rarely reported despite interventions inevitably involving at least an implicit idea of what factors to target to implement change . There is a quality of care gap in the post-fracture investigation ( bone mineral density ( BMD ) scanning ) and management ( bisphosphonate prescription ) of patients at risk of osteoporosis . We aim ed to use the Theoretical Domains Framework ( TDF ) within a systematic review of interventions to improve quality of care in post-fracture investigation . Our objectives were to explore which theoretical factors the interventions in the review may have been targeting and how this might be related to the size of the effect on rates of BMD scanning and osteoporosis treatment with bisphosphonate medication . Methods A behavioural scientist and a clinician independently coded TDF domains in intervention and control groups . Quantitative analyses explored the relationship between intervention effect size and total number of domains targeted , and as number of different domains targeted . Results Nine r and omised controlled trials ( RCTs ) ( 10 interventions ) were analysed . The five theoretical domains most frequently coded as being targeted by the interventions in the review included “ memory , attention and decision processes ” , “ knowledge ” , “ environmental context and re sources ” , “ social influences ” and “ beliefs about consequences ” . Each intervention targeted a combination of at least four of these five domains . Analyses identified an inverse relationship between both number of times and number of different domains coded and the effect size for BMD scanning but not for bisphosphonate prescription , suggesting that the more domains the intervention targeted , the lower the observed effect size . Conclusions When explicit use of theory to inform interventions is absent , it is possible to retrospectively identify the likely targeted factors using theoretical frameworks such as the TDF . In osteoporosis management , this suggested that several likely determinants of healthcare professional behaviour appear not yet to have been considered in implementation interventions . This approach may serve as a useful basis for using theory-based frameworks such as the TDF to retrospectively identify targeted factors within systematic review s of implementation interventions in other implementation context
The 12 remaining studies across all musculoskeletal conditions showed little or no improvement in GP behaviour and patient outcomes .The direction of the targeted behaviour ( i.e. increasing or decreasing a behaviour ) does not seem to affect the effectiveness of an intervention .
There is good- quality evidence that a GP alerting system with or without patient-directed education on osteoporosis improves guideline -consistent GP behaviour , result ing in better diagnosis and treatment rates .
Interventions such as GP reminder messages and GP feedback on performance combined with guideline dissemination may lead to small improvements in guideline -consistent GP behaviour with regard to low back pain , while GP education on osteoarthritis pain and the use of educationally influential physicians may lead to slight improvement in patient outcomes and guideline -consistent behaviour respectively .
BACKGROUND Musculoskeletal conditions require particular management skills .
Identification of interventions which are effective in equipping general practitioners ( GPs ) with such necessary skills could translate to improved health outcomes for patients and reduced healthcare and societal costs .
OBJECTIVES To determine the effectiveness of professional interventions for GPs  that aim to improve the management of musculoskeletal conditions in primary care .
We investigated whether the direction of the targeted behavioural change affects the effectiveness of interventions .