Changing attitudes to infection management in primary care: a controlled trial of active versus passive guideline implementation strategies

C W Onion, C A Bartzokas
Family Practice 1998, 15 (2): 99-104

BACKGROUND AND OBJECTIVES: When attempting to implement evidence-based medicine, such as through clinical guidelines, we often rely on passive educational tactics, for example didactic lectures and bulletins. These methods involve the recipient in relatively superficial processing of information, and any consequent attitude changes can be expected to be short-lived. However, active methods, such as practice-based discussion, should involve recipients in deep processing, with more enduring attitude changes. In this experiment, the aim was to assess the efficacy of an active strategy at promoting deep processing and its effectiveness, relative to a typical passive method, at changing attitudes between groups of GPs over 12 months across an English Health District.

METHODS: All 191 GPs operating from 69 practices in the Wirral Health District of Northwest England were assigned, with minimization of known confounding variables, to three experimental groups: active, passive and control. The groups were shown to have similar learning styles. The objective of the study was to impart knowledge of best management of infections as captured in a series of locally developed clinical guidelines. The passive group GPs were given a copy of the guidelines and were invited to an hour-long lecture event. The GPs in the deep group were given a copy of the guidelines and were invited to engage in an hour-long discussion about the guideline content at their own premises. The control group received neither the guidelines nor any educational contact regarding them. Three months before and 12 months after the interventions, all GPs were sent a postal questionnaire on their preferred empirical antibiotic for 10 common bacterial infections. The responses were compared in order to ascertain whether increased knowledge of best clinical practice was evident in each group.

RESULTS: Seventy-five per cent (144/191) of GPs responded to the pre-intervention questionnaire, 62 % (119/191) post-intervention. Thirty-four per cent (22/64) of GPs in the passive group attended the lecture; 91% (60/66) of the active group engaged in discussion at meetings with the authors. A significantly higher proportion of the active group participants' speaking time, during a sample of four visits, was devoted to verbal indicators of active processing than the passive group lecture attenders (difference = 55%, Fisher's exact test P = 0.002, OR = 11.5, 95% CI 2.1-113.4). Inter-observer agreement on the classification of the verbal evidence was highly statistically significant for all classes (Pearson's product moment correlation, P < 0.0005, r = +0.893 to +0.999) except repetition (P > 0.05, r = +0.407). Median compliance of responses with the guidelines improved by 2.5% within the control group and 4% within the passive, but by 23% within the active. The difference between the changes in the active and control groups was highly statistically significant at 17.5% (Mann-Whitney test, P = 0.004, 95% CI 6-29%). However, for the 10 infections, the median difference between the changes in the passive and control groups was not significant at 3% (P = 0.75, 95% CI -8 to +12. The median difference between changes in the active and passive groups was significant at 17% (P = 0.015, 95% CI 7-24%) in favour of the active.

DISCUSSION: An active educational strategy attracted more participation and was more effective at generating deep cognitive processing than a passive strategy. A large improvement, lasting for at least 12 months, in attitude-compliance with guidelines on the optimal treatment of infections was imparted by the active processing method. A typical passive method was much less popular and had an insignificant impact on attitudes. The findings suggest that initiatives aiming to implement evidence-based guidelines must employ active educational strategies if enduring changes in attitude are to result.

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