Teaching evidence based practice in physical therapy in a developing country: a national survey of Philippine schools

BACKGROUND

Early education on the foundations of evidence based practice (EBP) is advocated as a potent intervention toward enhancing EBP uptake among physical therapists. Little is known about the extent to which EBP is integrated in educational curricula in developing countries where the benefits of EBP are more acutely needed. This study sought to describe EBP education in Philippine physical therapy schools, including the challenges encountered by educators in teaching EBP.

METHODS

A national survey of higher education institutions offering an undergraduate degree program in physical therapy was conducted from August 2011 through January 2012. A 35-item questionnaire was developed to gather data on whether or not EBP was taught, specific EBP content covered and courses in which content was covered, teaching and evaluation methods, and challenges in teaching EBP. Data were analyzed descriptively.

RESULTS

The study had a response rate of 55.7% (34/61). Majority of the participating educational institutions (82%, 28/34) reported teaching EBP by incorporating EBP content in the professional courses. Among those that did not teach EBP, inadequate educator competence was the leading barrier. Courses commonly used to teach EBP were those on research (78.6%, 22/28), therapy planning (71.4%, 20/28), treatment skills (57.1-64.3%, 16-18/28), and undergraduate thesis (60.7%, 17/28). Various EBP contents were covered, with statistical concepts more frequently taught compared with critical EBP content. Lectures and journal reports were the usual teaching methods (96.4%, 27/28 and 89.3%, 25/28, respectively) while written examinations, completion of an undergraduate thesis, and oral reports (82.1%, 23/28, 78.6%, 22/28, and 78.6%, 22/28, respectively) were often used in evaluation. Students' inadequate knowledge of statistics and lack of curricular structure for EBP were identified as leading challenges to teaching (75%, 21/28 and 50%, 14/28, respectively).

CONCLUSIONS

Many physical therapy faculties across the Philippines are incorporating EBP content in teaching. However, there is arbitrary and fragmented coverage of EBP content and inadequate emphasis on clinically oriented teaching-learning and assessment methods. These findings suggest the need to design appropriate entry-level educational programs on EBP. Effective 'educating the educators' strategies are urgently needed and can have far-reaching positive repercussions on EBP uptake in physical therapist practice.

Do structured arrangements for multidisciplinary peer group supervision make a difference for allied health professional outcomes?

Peer group supervision, particularly in multidisciplinary formats, presents a potential means of providing professional support, and specifically clinical supervision, for allied health professionals. Debate exists regarding the extent to which the activities of these groups should be formalized. Results drawn from an evaluation of a large-scale peer group supervision initiative are described. Analysis of 192 responses from professionals involved in peer groups indicates that participants in groups that used formal documentation – which adopted the tools provided in training, and particularly those that used formal evaluation of their groups – rated their groups as having better processes and greater impact. Interestingly, multidisciplinary peer groups were rated as having similar impacts, processes, and purposes as the more homogenous single-discipline groups. It is concluded that the implementation of formal arrangements enhances the processes and outcomes of peer groups implemented for professional support and clinical supervision. Multidisciplinary membership of such groups is perceived as equally beneficial as single-discipline groups.

Public health dental hygiene: an option for improved quality of care and quality of life

PURPOSE

The purpose of this research was to document quality of life (QoL) and quality of care (QoC) measures for families receiving care from dental hygienists within public health departments, and to consider if oral health for families with economic disparities and cultural differences was improved.

METHODS

A descriptive research study using a retrospective record review was conducted considering QoC. A review of state epid "Do preventive oral health programs based in local health departments provide quality care services, thus impacting QoL for underserved populations?"

RESULTS

A dental hygienist working in public health made significant contributions to improving access to care and QoL in a rural, socioeconomically disadvantaged community. A total of 2,364 children received education, 1,745 received oral screenings and 1,511 received dental sealants. Of these, 804 children with caries were referred, with 463 receiving restorations and follow-up care. QoL metrics basis assessed Health Outcomes & Health Determinants. Initial QoL data was ranked in the bottom half of the state, while 70% of original determinant data was also ranked in the bottom half of reported metrics.

CONCLUSION

Dental hygienists in public health settings can positively affect patients offering preventive care outreach services. Education and sealant placement were considered effective as measured by access, delivery and, when required, referral for restorative care. Improvement in QoL for individuals was noted through improved health outcomes and determinant metrics.

Research evidence uptake in a developing country: a survey of attitudes, education and self-efficacy, engagement, and barriers among physical therapists in the Philippines

RATIONALE AND OBJECTIVE

Use of evidence from systematic research is critical in evidence-based physical therapy, yet this has not been described well in developing countries where its purported benefits are most needed. This study explored research evidence uptake among physical therapists in the Philippines.

METHOD

A probability survey of practitioners in tertiary hospitals in the Philippines' National Capital Region was conducted.

RESULTS

Of the 188 questionnaires distributed, 152 were returned for an 81% response rate. Positive attitudes were consistently reported (78-93%), although education and self-efficacy related to key dimensions such as searching, appraising and integrating evidence were varied (53-82%). Less than 50% reported using research evidence routinely in five of six dimensions of clinical practice, except in selecting treatments (53%). Textbooks, own observations and expert opinion were consistently relied upon (74-96%) while average-month approximations of engagement in relevant activities such as searching, reading, appraising and applying research literature were low (10-18%). Participants faced a number of barriers such as lack of time, resources, skills, access to research literature, supporting administrative policies, in-service training and authority in decision making.

CONCLUSIONS

The low research evidence uptake and heavy reliance on potentially biased evidence sources strongly indicate the need for effective professional education for practitioners to address current barriers as well as early intensive undergraduate education for students to ensure adequate preparation on being effective research evidence consumers. Given the profile of Filipino physical therapists, alternatives to 'from scratch' evidence searching and appraisal are required if widespread uptake is envisaged.

Positioning occupational therapy as a discipline on the research continuum: results of a cross-sectional survey of research experience

BACKGROUND/AIM

Evidence-based practice and research are beginning and endpoints on a research continuum. Progression along the continuum builds research capacity. Occupational Therapy has a low evidence base, thus, clinicians are not implementing evidence-based practice or publishing research. Barriers to implementing evidence-based practice and engaging in research include a lack of confidence. This research gauged Occupational Therapists' research experience, support needs and barriers, and compared levels of research anxiety between allied health disciplines.

METHODS

A cross-sectional survey was sent to Health Practitioners in northern Queensland in May-June 2011. Responses about experience, support needs and barriers, between Occupational Therapists, were analysed using Chi-square 'goodness of fit' tests. Multivariate analysis compared responses between disciplines about research anxiety. This paper reports results for the subset of Occupational Therapists.

RESULTS

The whole population, consisting of 152 Occupational Therapists, was sent a questionnaire, from which 86 responded. More Occupational Therapists than not had experience of evidence-based practice and less support was required, but they had little experience of producing research and required more support. The amount of support required for activities along the research continuum was inversely related to the level of experience in these tasks. Barriers included lack of staff and time. Occupational Therapists were more anxious about research (53 of 79, 67%) than all other Health Practitioner disciplines combined (170 of 438, 39%, P < 0.0001).

CONCLUSION

A cohesive strategy should focus on consolidating Occupational Therapists' evidence-based practice skills and building confidence. Clinicians wishing to engage in research need access to academic support. Academics and clinicians should work closely to produce clinically relevant research.

Assessing patient preferences for the delivery of different community-based models of care using a discrete choice experiment

OBJECTIVES

To assess patient preferences for different models of care defined by location of care, frequency of care and principal carer within community-based health-care services for older people.

DESIGN

Discrete choice experiment administered within a face-to-face interview.

SETTING

An intermediate care service in a large city within the United Kingdom.

PARTICIPANTS

The projected sample size was calculated to be 200; however, 77 patients were recruited to the study. The subjects had recently been discharged from hospital and were living at home and were receiving short-term care by a publicly funded intermediate care service.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

The degree of preference, measured using single utility score, for individual service characteristics presented within a series of potential care packages.

RESULTS

Location of care was the dominant service characteristics with care at home being the strongly stated preference when compared with outpatient care (0.003), hospital care (<0.001) and nursing home care (<0.001) relative to home care, although this was less pronounced among less sick patients. Additionally, the respondents indicated a dislike for very frequent care contacts. No particular type of professional carer background was universally preferred but, unsurprisingly, there was evidence that sick patients showed a preference for nurse-led care.

CONCLUSIONS

Patients have clear preferences for the location for their care and were able to state preferences between different care packages when their ideal service was not available. Service providers can use this information to assess which models of care are most preferred within resource constraints.

Ten principles of good interdisciplinary team work

BACKGROUND

Interdisciplinary team work is increasingly prevalent, supported by policies and practices that bring care closer to the patient and challenge traditional professional boundaries. To date, there has been a great deal of emphasis on the processes of team work, and in some cases, outcomes.

METHOD

This study draws on two sources of knowledge to identify the attributes of a good interdisciplinary team; a published systematic review of the literature on interdisciplinary team work, and the perceptions of over 253 staff from 11 community rehabilitation and intermediate care teams in the UK. These data sources were merged using qualitative content analysis to arrive at a framework that identifies characteristics and proposes ten competencies that support effective interdisciplinary team work.

RESULTS

Ten characteristics underpinning effective interdisciplinary team work were identified: positive leadership and management attributes; communication strategies and structures; personal rewards, training and development; appropriate resources and procedures; appropriate skill mix; supportive team climate; individual characteristics that support interdisciplinary team work; clarity of vision; quality and outcomes of care; and respecting and understanding roles.

CONCLUSIONS

We propose competency statements that an effective interdisciplinary team functioning at a high level should demonstrate.

Exploring the individual determinants of evidence uptake in allied health using a journal club as a medium

PURPOSE

A recent trial which examined the impact of a structured model of journal club (JC) demonstrated variability in evidence-based practice (EBP) outcomes across allied health disciplines. The aim of the current study was to determine if there are individual practitioner characteristics that could explain this variability and identify potential predictors of EBP outcomes.

METHOD

This exploratory study used the data obtained from the JC trial. The predictive value of practitioner-related variables including academic degree, previous exposure to EBP training, and previous research involvement was analyzed using univariate logistic regression models. The dose of intervention was also included in the exploratory analysis.

RESULTS

The change in self-reported knowledge, evidence uptake, and attitude following participation in a JC was influenced by individual practitioner characteristics including their discipline, academic background, previous EBP training, previous research involvement, and JC attendance. Improvement in objective knowledge did not seem to be affected by any of these variables. Whether these individual characteristics have the ability to predict who will achieve less than, or greater than, 50% change in knowledge, attitude, and evidence uptake, is not known, except for academic background which predicted physiotherapists' improvement in attitude.

CONCLUSION

Participation in a structured JC can lead to significant improvements in EBP knowledge irrespective of the characteristics of individual practitioners. The change in attitude and evidence uptake, however, may be influenced by individual characteristics which will therefore require careful consideration when designing EBP interventions. An EBP intervention is likely to be successful if a systematic assessment of the barriers at different levels (ie, individual, organizational, and contextual) informs the choice of evidence implementation strategy.

Barriers to the routine collection of health outcome data in an Australian community care organization

For over a decade, organizations have attempted to include the measurement and reporting of health outcome data in contractual agreements between funders and health service providers, but few have succeeded. This research explores the utility of collecting health outcomes data that could be included in funding contracts for an Australian Community Care Organisation (CCO). An action-research methodology was used to trial the implementation of outcome measurement in six diverse projects within the CCO using a taxonomy of interventions based on the International Classification of Function. The findings from the six projects are presented as vignettes to illustrate the issues around the routine collection of health outcomes in each case. Data collection and analyses were structured around Donabedian's structure-process-outcome triad. Health outcomes are commonly defined as a change in health status that is attributable to an intervention. This definition assumes that a change in health status can be defined and measured objectively; the intervention can be defined; the change in health status is attributable to the intervention; and that the health outcomes data are accessible. This study found flaws with all of these assumptions that seriously undermine the ability of community-based organizations to introduce routine health outcome measurement. Challenges were identified across all stages of the Donabedian triad, including poor adherence to minimum dataset requirements; difficulties standardizing processes or defining interventions; low rates of use of outcome tools; lack of value of the tools to the service provider; difficulties defining or identifying the end point of an intervention; technical and ethical barriers to accessing data; a lack of standardized processes; and time lags for the collection of data. In no case was the use of outcome measures sustained by any of the teams, although some quality-assurance measures were introduced as a result of the project.

Assessing the implementation process and outcomes of newly introduced assistant roles: a qualitative study to examine the utility of the Calderdale Framework as an appraisal tool

Internationally, the health workforce has undergone rapid transformation to help meet growing staffing demands and population requirements. Several tools have been developed to support workforce change processes. The Calderdale Framework (CF) is one such tool designed to facilitate competency-based training by engaging team members in a seven step process involving awareness raising, service and task analysis, competency identification, establishing support systems, training, and sustaining. This paper explores the utility of the CF as an appraisal tool to assess whether adherence to the tool influences outcomes. The CF was applied retrospectively to three complete evaluations of allied health assistant role introduction: a new podiatry assistant role (Australia), speech pathology assistant (Australia), and occupational therapy assistant practitioner role (UK). Adherence to the CF was associated with more effective and efficient use of the role, role flexibility and career development opportunities for assistants, and role sustainability. Services are less likely to succeed in their workforce change process if they fail to plan for and use a structured approach to change, assign targeted leadership, undertake staff engagement and consultation, and perform an initial service analysis. The CF provides a clear template for appraising the implementation of new roles and highlights the potential consequences of not adhering to particular steps in the implementation process.

Systematic review of knowledge translation strategies in the allied health professions

BACKGROUND

Knowledge translation (KT) aims to close the research-practice gap in order to realize and maximize the benefits of research within the practice setting. Previous studies have investigated KT strategies in nursing and medicine; however, the present study is the first systematic review of the effectiveness of a variety of KT interventions in five allied health disciplines: dietetics, occupational therapy, pharmacy, physiotherapy, and speech-language pathology.

METHODS

A health research librarian developed and implemented search strategies in eight electronic databases (MEDLINE, CINAHL, ERIC, PASCAL, EMBASE, IPA, Scopus, CENTRAL) using language (English) and date restrictions (1985 to March 2010). Other relevant sources were manually searched. Two reviewers independently screened the titles and abstracts, reviewed full-text articles, performed data extraction, and performed quality assessment. Within each profession, evidence tables were created, grouping and analyzing data by research design, KT strategy, targeted behaviour, and primary outcome. The published descriptions of the KT interventions were compared to the Workgroup for Intervention Development and Evaluation Research (WIDER) Recommendations to Improve the Reporting of the Content of Behaviour Change Interventions.

RESULTS

A total of 2,638 articles were located and the titles and abstracts were screened. Of those, 1,172 full-text articles were reviewed and subsequently 32 studies were included in the systematic review. A variety of single (n = 15) and multiple (n = 17) KT interventions were identified, with educational meetings being the predominant KT strategy (n = 11). The majority of primary outcomes were identified as professional/process outcomes (n = 25); however, patient outcomes (n = 4), economic outcomes (n = 2), and multiple primary outcomes (n = 1) were also represented. Generally, the studies were of low methodological quality. Outcome reporting bias was common and precluded clear determination of intervention effectiveness. In the majority of studies, the interventions demonstrated mixed effects on primary outcomes, and only four studies demonstrated statistically significant, positive effects on primary outcomes. None of the studies satisfied the four WIDER Recommendations.

CONCLUSIONS

Across five allied health professions, equivocal results, low methodological quality, and outcome reporting bias limited our ability to recommend one KT strategy over another. Further research employing the WIDER Recommendations is needed to inform the development and implementation of effective KT interventions in allied health.

Measuring the impact of allied health research

BACKGROUND

Excellence in Research for Australia (ERA) rankings are given to academic journals in which Australian academics publish. This provides a metric on which Australian institutions and disciplines are ranked for international competitiveness. This paper explores the issues surrounding the ERA rankings of allied health journals in Australia.

METHODS

We conducted a broad search to establish a representative list of general allied health and discipline-specific journals for common allied health disciplines. We identified the ERA rankings and impact factors for each journal and tested the congruence between these metrics within the disciplines.

RESULTS

Few allied health journals have high ERA rankings (A*/A), and there is variability in the impact factors assigned to journals within the same ERA rank. There is a small group of allied health researchers worldwide, and this group is even smaller when divided by discipline. Current publication metrics may not adequately assess the impact of research, which is largely aimed at clinicians to improve clinical practice. Moreover, many journals are produced by underfunded professional associations, and readership is often constrained by small numbers of clinicians in specific allied health disciplines who are association members.

CONCLUSION

Allied health must have a stronger united voice in the next round of ERA rankings. The clinical impact of allied health journals also needs to be better understood and promoted as a research metric.

A systematic review of the individual determinants of research evidence use in allied health

Background:

The use of evidence-based practice (EBP) is often not reflected in allied health (AH) practitioners’ day-to-day practice (the research-practice gap). Research suggests that considerable differences between and within AH disciplines exist, which require different approaches in order to influence practice behavior. It is therefore important to develop a better understanding of what influences individual AH practitioners’ adoption of evidence into daily practice.

Objective:

This systematic review aims to examine the individual characteristics of AH practitioners which determine their uptake of evidence into practice.

Methods:

Studies which examined individual factors or variables that influence research evidence use by any AH practitioner were included in the review. The methodological quality of the included papers was assessed using the Quality Assessment and Validity Tool for Cross-sectional Studies. A narrative summary of the findings was presented.

Results:

Six studies were included and the methodological quality scores indicated that two were weak and the remainder had moderate–weak quality. The review demonstrated that factors such as educational degree or academic qualification, involvement in research or EBP-related activities, and practitioners’ perceptions, attitudes and beliefs about research and EBP are significant predictors of self-reported research evidence use in AH. The effect of other factors such as professional characteristics, clinical setting/work environment, information-seeking behavior and sociodemographic variables are less clear. Whether there is an interaction effect between evidence-uptake factors has not been tested.

Conclusion:

Improving the research knowledge of clinicians and overcoming negative attitudes toward EBP have the potential to move AH practitioners towards regularly utilizing evidence in practice. Allied health practitioners may benefit from participation in regular educational opportunities such as case studies or journal clubs which can put them at the same level of thinking and awareness of research evidence. Future research should aim to review organizational and contextual factors and explore their interaction with individual determinants of research evidence use.

Age and gender as predictors of allied health quality stroke care

Background:

Improvement in acute stroke care requires the identification of variables which may influence care quality. The nature and impact of demographic and stroke-related variables on care quality provided by allied health (AH) professionals is unknown.

Aims:

Our research explores the association of age and gender on an index of acute stroke care quality provided by AH professionals.

Methods:

A retrospective clinical audit of 300 acute stroke patients extracted data on AH care, patients’ age and gender. AH care quality was determined by the summed compliance with 20 predetermined process indicators. Our analysis explored relationships between this index of quality, age, and gender. Age was considered in different ways (as a continuous variable, and in different categories). It was correlated with care quality, using gender-specific linear and logistic regression models. Gender was then considered as a confounder in an overall model.

Results:

No significant association was found for any treatment of age and the index of AH care quality. There were no differences in gender-specific models, and gender did not significantly adjust the age association with care quality.

Conclusion:

Age and gender were not predictors of the quality of care provided to acute stroke patients by AH professionals.

Complex interventions required to comprehensively educate allied health practitioners on evidence-based practice

There is currently no strong evidence regarding the most effective training approach for allied health professionals that will support them to consistently apply the best research evidence in daily practice. Current evidence-based practice training tends to be 'one size fits all', and is unlikely to be appropriate for all allied health disciplines because of the variability in their tasks and scope of practice. The scant body of evidence regarding the effectiveness of evidence-based practice training for allied health practitioners provides some support for improving knowledge and skills, but equivocal evidence about influencing behaviors and attitudes. We propose a new model of evidence-based practice training, based on the concept of complex interventions reported in the literature. We believe that by offering training in evidence-based practice based on complex interventions relevant to the needs of the attendees, using fixed and variable components, there may be greater success in significantly influencing knowledge skills, attitudes, and behaviors.

Public health nutrition: the accord of dietitian providers in managing medicare chronic care outpatients in Australia

Medicare Australia: Chronic Disease Management program subsidizes allied health consultations for eligible outpatients with chronic disease or complex needs. In an evaluation study, private practice dietitians (n = 9) were interviewed to explore their patient management strategies including consultation time-allocation and fees. Time allocation was fee-based. Short first consultations were seen as meeting patients’ needs for low-cost services but were regarded by dietitians as ineffective, however longer initial consultations increased cost to patients. No strategy in use was optimal. There is a need for change in Medicare policy to meet the needs of both dietitians and patients in achieving the behaviour change goals of patients.

Evaluating distance learning in health informatics education

The purpose of this study was to compare academic performance between distance-learning and on-campus health informatics students. A quantitative causal-comparative research design was utilized, and academic performance was measured by final GPA scores and Registered Health Information Administrator certification exam scores. Differences in previous academic performance between the two groups were also determined by comparing overall admission GPA and math/science admission GPA. The researchers found no difference in academic performance between the two groups when final GPA scores and total certification scores were compared. However, there were statistically significant differences between the two groups in 4 of the 17 sub-domains of the certification examination, with the on-campus students scoring slightly higher than the distance students. Correlation studies were also performed, and the researchers found significant correlations between overall admission GPA, math/science admission GPA, final GPA, and certification scores.

Can factors related to self-regulated learning and epistemological beliefs predict learning achievement in undergraduate asynchronous Web-based courses?

This study examined the effects of self-regulated learning (SRL) and epistemological beliefs (EB) on individual learner levels of academic achievement in Web-based learning environments while holding constant the effect of computer self-efficacy, reason for taking an online course, and prior college academic achievement. The study constituents included 201 undergraduate students enrolled in a variety of asynchronous Web-based courses at a university in the southeastern United States. Data was collected via a Web-based questionnaire and subjected to the following analyses: separate exploratory factor analyses of the self-regulated learning and the epistemological beliefs question items, correlations between the independent variables and the dependent variable, and linear regression of final course grades with all the variables in the model. Analysis of the data revealed that three independent variables (GPA, Expectancy, and GPA_Exp) were significant predictors in the model of learning achievement in asynchronous online courses. Discussion of the study's predictive model follows.