Knowledge Translation and Evidence-Based Practice: A Qualitative Study on Clinical Dietitians' Perceptions and Practices in Switzerland

Translating Evidence for a Mediterranean-Style Dietary Pattern into Routine Care for Coronary Heart Disease and Type 2 Diabetes: Implementation and Evaluation in a Targeted Public Health Service in Australia

Background: A Mediterranean-style dietary pattern (MDP) is embedded across coronary heart disease (CHD) and type 2 diabetes (T2D) clinical guidelines. However, MDP evidence has not consistently been translated into practice. This study aimed to develop, integrate and evaluate implementation strategies to support clinicians in translating MDP evidence into routine care for CHD and T2D in the local context of a public health service. Methods: This study documents the implementation and evaluation phases of a broader knowledge translation project guided by the Knowledge-to-Action cycle. Multi-disciplinary clinicians in the cardiology and diabetes services of two large metropolitan hospitals and a post-acute community service were targeted. Strategies were prioritised utilising theory and stakeholder engagement and included facilitation, building a coalition, the engagement of clinical champions and local opinion leaders, educational meetings, consensus discussions, sharing local knowledge, consumer consultation, and the development and distribution of education materials. Surveys were conducted with clinicians and patients of targeted services to evaluate the reach, acceptability, feasibility, adoption and perceived sustainability of MDP in practice. Results: In total, 57 clinicians (7 dietitians, 29 nurses/diabetes educators, 15 doctors and 6 other allied health professionals) and 55 patients completed post-implementation evaluation surveys. The majority of clinicians agreed an MDP is appropriate to recommend in their clinical setting (95%), and most of the time/always their advice (85%) aligns. Education sessions were attended by 65% of clinicians, of which the majority indicated improved knowledge (100%) and change in practice (86%). Factors deemed most important to maintaining an MDP approach in practice were hard-copy education materials (85%) and access to a dietitian (62%). Of the patients who had received care from a dietitian of targeted services (n = 32, 58%), 100% recalled having discussed ≥1 MDP topic and 89% received education material. Of the patients who had received dietary advice from non-dietetic clinicians (n = 33, 60%), 67% recalled having discussed ≥1 MDP topic and 70% received education material. Conclusions: Targeted and theory-informed implementation reached the majority of surveyed clinicians and patients, and positively influenced the adoption, acceptability and feasibility of an MDP approach in routine care. Ongoing sustainability strategies are crucial with rotating clinician roles.

Development and Validation of a Decision Support Tool for Baby Formula Prescription

INTRODUCTION

Although there are acceptable medical reasons for the use of food supplements, most prescriptions for newborns do not comply with current recommendations, putting continued breastfeeding at risk. This study aimed to create and validate a flowchart for newborn supplement prescription.

METHODS

The flowchart was created and submitted to two rounds of assessments by a panel of judges, who calculated the content validity index (CVI) (acceptable > 0.80). Flowchart use in clinical practice (applicability) was validated by professional prescribers through the resolution of 3 clinical cases. Data were analyzed using Pearson`s chi-squared test (p < 0.05).

RESULTS

The flowchart was assessed by 17 judges and validated regarding its content (CVI = 0.84). Took part in validating the applicability of this study 169 doctors and nutritionists who work in maternal and child health. There was a statistical association between correct case resolution and flowchart utilization in two of the three clinical cases (p < 0.05). In situation 1, the use of a validated flowchart increased the likelihood of correct answers 7.76 times.

DISCUSSION

Prescribing baby formula is complex and requires careful assessment of several factors. Thus, knowledge translation is an effective intervention to eliminate the gaps between knowledge and clinical practice. The validated flowchart allows more assertive conduct regarding breastfeeding management and food supplement prescription for newborns.

Exploring Australian Dietitians' knowledge, experience and perspectives of time-restricted eating in private practice: A qualitative study

Time-restricted eating is a novel nutrition intervention with evidence of beneficial effects on weight loss, blood glucose management, and other metabolic health outcomes. Adherence to time-restricted eating is higher than some traditional nutrition interventions to support individuals living with overweight/obesity and type 2 diabetes mellitus. However, there may be an evidence-practice gap of time-restricted eating in Australian dietetic practice. The present study aimed to explore dietitians' knowledge, experiences, and perspectives of time-restricted eating and timing of eating advice in practice. Semi-structured interviews with 10 private practice dietitians across Australia were conducted. Audio recordings were transcribed and analysed thematically. Six themes were identified: (i) distinction of time-restricted eating to other fasting protocols; (ii) knowledge of health benefits of time-restricted eating; (iii) patient-led advice frequently given: timing of breakfast and dinner; (iv) dietitian-led advice frequently given: eating cut-off time to avoid late night snacking; (v) barriers and facilitators to offering time-restricted eating or timing of eating advice; (vi) timing of eating advice within professional guidelines and resources. These findings suggest the need for development of professional resources and educational development tools for dietitians on time-restricted eating.

Factors Influencing the Translation of Evidence Into Clinical Practice for Hospital Allied Health Professionals in Terms of the Domains of Behaviour Change Theory: A Systematic Review

This systematic review provides an overview of the unique challenges allied health professions face in the translation and implementation of evidence into practice, which remain relatively under reported and uninformed by a theoretical basis of behaviour change. MEDLINE, EMBASE, CINAHL and Scopus databases from 2010 to 2022 were searched for primary study designs resulting in 21 articles included in this review (PROSPERO: 2022 CRD42022314996). Allied health disciplines reported in the review were mainly from occupational therapy, physiotherapy, dietetics, and speech pathology. The most frequently reported implementation determinants across the Theoretical Domains Framework were identified as 'environmental context and resources', and 'knowledge'. The results also identified a greater influence of 'social influences' and 'beliefs about consequences' in implementation. Implementing evidence into clinical practice is a multifaceted, complex process, and the use of the Theoretical Domains Framework provided a systematic approach to understanding the drivers behind the target behaviours. However, there is a paucity of studies across the allied health professions that describe implementation strategies used and their impact. Many of the studies focused on implementation by the individual clinician rather than the role organizations can play in the translation of evidence into practice.

Empowering healthcare professionals in West Africa-A feasibility study and qualitative assessment of a dietary screening tool to identify adults at high risk of hypertension

Dietary risks significantly contribute to hypertension in West Africa. Food frequency questionnaires (FFQs) can provide valuable dietary assessment but require rigorous validation and careful design to facilitate usability. This study assessed the feasibility and interest of a dietary screening tool for identifying adults at high risk of hypertension in Nigeria. Fifty-eight (58) consenting adult patients with hypertension and their caregivers and 35 healthcare professionals from a single-centre Nigerian hospital were recruited to complete a 27-item FFQ at two-time points and three 24-hour recalls for comparison in a mixed method study employing both quantitative questionnaires and qualitative techniques to elicit free form text. Data analyses were conducted using R software version 4.3.1 and NVivo version 14. The trial was registered with ClinicalTrials.gov: NCT05973760. The mean age of patients was 42.6 ± 11.9 years, with an average SBP of 140.3 ± 29.8 mmHg and a BMI of 29.5 ± 7.1 Kg/m2. The adherence rate was 87.9%, and the mean completion time was 7:37 minutes. 96.6% of patients found the FFQ easy to complete, comprehensive, and valuable. A minority reported difficulty (3.4%), discomfort (10.3%), and proposed additional foods (6.9%). Healthcare professionals considered the dietary screening tool very important (82.9%) and expressed a willingness to adopt the tool, with some suggestions for clarification. Patients and healthcare professionals found the screening tool favourable for dietary counselling in hypertension care. The tailored dietary screening tool (FFQ) demonstrated promising feasibility for integration into clinical care as assessed by patients and healthcare professionals. Successful implementation may benefit from proactive time management and addressing training needs. This user-centred approach provided key insights to refine FFQ and set the foundation for ongoing validity testing and evaluation in clinical practice.

Descriptive and Content Analysis of Questionnaires Used to Assess Evidence-Based Practice Among Dietitians: A Systematic Review

BACKGROUND

Evidence-based practice (EBP) is described as the integration of the following 3 main dimensions in health professionals' decision making: best currently available research evidence, professional expertise, and patient's values and circumstances. Barriers to EBP at an individual level have been assessed using questionnaires. Knowing which EBP dimensions are actually explored in these questionnaires is essential to promote EBP and its adoption.

OBJECTIVE

The aim of this review was to identify and describe questionnaires that have been used among dietitians to evaluate knowledge, skills, attitudes, and/or behaviors related to EBP, and to perform a content analysis of these, drawn on the EBP dimensions explored.

METHODS

Questionnaires were identified through a systematic review in MEDLINE, Embase and the Cumulative Index to Nursing and Allied Health Literature (last search was November 2022). Eligibility criteria were studies using, evaluating, or developing questionnaires meant to evaluate knowledge, skills, attitudes, and/or behaviors related to EBP among dietitians. The content analysis was conducted to identify the EBP dimensions explored (ie, research evidence, professional expertise, and/or patient's values and circumstances). Questionnaire items were categorized as follows: 1 sole EBP dimension, a combination of dimensions, or no identifiable dimension.

RESULTS

Thirty reports (25 studies) were included. The analysis of the 847 items extracted from the 25 questionnaires used showed that the main EBP dimension explored was the integration of research evidence into decision making, found in 75% of items, solely or in combination with another dimension. Professional expertise was explored in 18% of the items, patient's values and circumstances were found in 3%, and the combination of these 3 dimensions was found in <1%.

CONCLUSIONS

The important imbalance of explored EBP dimensions in the questionnaires used may lead to a partial and misleading evaluation that prevents efficient strategies to foster EBP. There is an important need to develop more integrative and accurate evaluations of EBP targeting dietitians to promote and develop high-quality dietetics practice.

Validity and reliability of a questionnaire measuring EBDPs among registered dietitian nutritionist

BACKGROUND

There is a lack of a valid and reliable instrument that measures objective and subjective knowledge of evidence-based dietetic practices (EBDP) among registered dietitian nutritionists (RDNs). The present study aimed to develop and assess the validity and reliability of an EBDP Questionnaire (EBDPQ) with objective knowledge items (i.e., quiz items) among RDNs in the USA.

METHODS

Subscales from four existing evidence-based practice (EBP) instruments were combined and modified for dietetics. Content and face validity and internal consistency were used to assess the full survey. Survey responsiveness and test-retest reliability were evaluated within the objective knowledge subscale. Content experts (n = 11) and nutrition professionals (n = 16) completed validation reviews. Doctoral students enrolled in a research course (n = 12) were used to analyse survey responsiveness. Internal and test-retest relability analyses utilised RDN participants (time point 1, n = 482; time point 2, n = 335).

RESULTS

Content validation resulted in a 38-item questionnaire. Average percent agreement among face validity reviewers was 95.1%. Only the pre-validation version of the objective knowledge subscale resulted in significantly higher post-course scores (Mdn = 11.50) compared to the pre-course (Mdn = 9.75, p = 0.05). The validated instrument had excellent internal consistency (Cronbach's α = 0.91); however, the objective knowledge subscale was low (Cronbach's α = 0.41). A good degree of reliability was found between the two time points (intraclass correlation coefficient = 0.71).

CONCLUSIONS

The EBDPQ demonstrated adequate validity and reliability among RDNs. Future research should assess construct validity, with the responsiveness and objective knowledge subscale requiring additional evaluation through an EBDP course.

Self-reported attitudes, skills and use of evidence-based practice among Swiss chiropractors: a national survey

STUDY OBJECTIVES

The high burden of disease associated with musculoskeletal disorders severely impacts patients' well-being. As primary care providers, Swiss chiropractors ought to contribute towards identifying and using effective treatment strategies. An established approach is the full integration of evidence-based practice (EBP). This study aimed to investigate the attitudes, skills and use of EBP among Swiss chiropractors, as well as investigating potential facilitators and barriers for its adoption.

METHODS AND MATERIAL

All 329 members of the Swiss Association of Chiropractic (ChiroSuisse) were invited in March 2021 to participate in this cross-sectional survey. Data were acquired anonymously online, using the Evidence-Based practice Attitude and utilization SurvEy (EBASE). The survey encompassed 55 questions measuring attitudes (n = 8, response range 1-5; total score range of 8-40), skills (n = 13, response range 1-5; total score range of range of 13-65) and use of EBP (n = 6, response range 0-4; total score range of 0-24).

RESULTS

228 (69.3%) chiropractors returned complete EBASE questionnaires. This sample was representative of all ChiroSuisse members with respect to gender, age groups and proportion of chiropractic residents. Respondents generally held positive attitudes towards EBP, as indicated by the high mean (31.2) and median (31) attitude sub-score (range 11-40). Self-reported skills had a mean sub-score of 40.2 and median of 40 (range 13-65). Knowledge about EBP-based clinical practice had been primarily obtained in chiropractic under- or postgraduate education (33.8% and 26.3%, respectively). Use of EBP achieved a lower sub-score, with mean and median values of 7.4 and 6, respectively (range 0-24). The most commonly identified barriers preventing EBP uptake were lack of time (67.9%) and lack of clinical evidence in chiropractic/manual therapy-related health fields (45.1%).

CONCLUSION

Swiss chiropractors held favourable attitudes and reported moderate to moderate-high skill levels in EBP. Nevertheless, similar to chiropractors in other countries, the self-reported use of EBP was relatively low, with lack of time and lack of clinical evidence being the most named barriers.

Determinant factors associated with the use of evidence-based dietetics practice among registered dietitian nutritionists

AIMS

There is a lack of research assessing perceived and actual evidence-based dietetics practice knowledge among registered dietitian nutritionists. This cross-sectional research examined the association between determinant factors (i.e., education attainment) and objective knowledge (i.e., quiz items) of evidence-based dietetics practices. Other determinant factors associated with perceived knowledge and skill, attitudes, behaviours and outcomes related to evidence-based dietetics practice were also assessed. Perceived knowledge items were compared to objective knowledge items to evaluate the accuracy of self-assessed evidence-based dietetics practice knowledge among dietitians in the United States.

METHODS

A modified and adapted evidence-based practice survey was emailed to registered dietitian nutritionists in the United States via the Commission on Dietetic Registration database between November and December 2020. Analysis of variance assessed the relationship between highest degree held and actual knowledge of evidence-based dietetics practices. Multiple linear regression and ordinal logistic regression determined participant-level characteristics associated with survey subscales and survey items, respectively. Pearson's correlation coefficient evaluated the relationship between subjective and objective items.

RESULTS

Four hundred and eighty-two dietitians completed the survey. Each increase in degree type was associated with an increase in objective knowledge score (all comparisons p < 0.001). Other determinants included recency of degree completion and peer-reviewed publications. Moderate positive associations (r = 0.35, p < 0.001) were found between subjective and objective measures.

CONCLUSION

Graduate-level education, recency of degree completion and peer-reviewed publications were supportive of evidence-based dietetics practice-related outcomes. Future research should evaluate the efficacy of training, particularly among those further from their highest completed degree.

A knowledge implementation model in health system management based on the PARIHS model

BACKGROUND

The gap between knowledge and practice, along with postponing or not implementing research findings in practice and policy-making, is one of the reasons for low-quality services. Hence, this study aimed at presenting a model of knowledge implementation in health system management in Iran.

METHODS

The present two-phase study was first performed qualitatively using a directive content analysis approach based on the Promoting Action on Research Implementation in Health Services (PARIHS) model. The researchers extracted the barriers and facilitators by conducting semi-structured individual interviews. Then, in a three-stage Delphi study, 25 health experts determined the barrier removal strategies. Data were analysed using MAXQDA10 software.

RESULTS

 The content analysis of the interviews led to the emergence of 1212 codes under three categories of evidence, context and facilitation. The findings indicate that health managers make fewer decisions based on research findings. Instead, they make decisions regarding the experiences of service providers and organization data. In addition to the subcategories in the PARIHS model, the researchers extracted political, social and administrative factors under the context category. The relationships between the features of evidence, context, facilitation, barriers and strategies were presented in the final model.

CONCLUSION

 The presented model comprehensively emphasizes the evidence resources, context preparation, and facilitation of the knowledge implementation process.

The therapeutic relationship between a client and dietitian: A systematic integrative review of empirical literature

Aim

Scientific evidence underpins dietetics practice; however, evidence of how the therapeutic relationship influences outcomes is limited. This integrative review aims to provide a comprehensive overview of the topic of the therapeutic relationship between clients and dietitians in the individual counselling context by summarising empirical literature into qualitative themes.

Methods

An electronic literature search of the Cumulative Index of Nursing and Allied Health Literature, PsychInfo, Scopus and Web of Science databases was conducted in October 2018 and repeated in February 2021. Studies were included if they explicitly referred to the therapeutic relationship (or associated terms), were based on study data and available in full text. Extracted data were checked by a second researcher and the methodological quality was evaluated independently by two researchers using the Mixed Methods Appraisal Tool. An iterative process of qualitatively coding, categorising and comparing data to examine recurring themes was applied.

Results

Seventy‐six studies met the inclusion criteria. Five themes were identified which showed the extent and nature of research in this area. Studies revealed the therapeutic relationship: (i) is valued within clinical dietetic practice, (ii) involves complex and multifactorial interactions, (iii) is perceived as having a positive influence, (iv) requires skills training and (v) is embedded in practice models and tools.

Conclusion

Studies show the therapeutic relationship is a valued and multifactorial component of clinical dietetic practice and is perceived to positively influence the client and dietitian. Observational data are needed to assess the extent to which the strength of the therapeutic relationship might contribute to clients' health outcomes.

Need and Importance of Nutrition Informatics in India: A Perspective

Nutrition informatics (NI) is the effective retrieval, organization, storage, and optimum use of information, data and knowledge for food-and-nutrition-related problem-solving and decision-making. There is a growing opportunity to facilitate technology-enabled behavioral change interventions to support NI research and practice. This paper highlights the changing landscape of food and nutrition practices in India to prepare a NI workforce that could provide some valuable tools to address the double burden of nutrition. Management and interpretation of data could help clarify the relationships and interrelationships of diet and disease in India on both national and regional levels. Individuals with expertise in food and nutrition may receive training in informatics to develop national informatics systems. NI professionals develop tools and techniques, manage various projects and conduct informatics research. These professionals should be well prepared to work in technological settings and communicate data and information effectively. Opportunities for training in NI are very limited in developing countries. Given the current progress in developing platforms and informatics infrastructure, India could serve as an example to other countries to promote NI to support achieving SDGs and other public health initiatives.

'Focus on diet quality': a qualitative study of clinicians' perspectives of use of the Mediterranean dietary pattern for non-alcoholic fatty liver disease

Practice guidelines for non-alcoholic fatty liver disease (NAFLD) recommend promoting the Mediterranean dietary pattern (MDP) which is cardioprotective and may improve hepatic steatosis. This study aimed to explore multidisciplinary clinicians' perspectives on whether the MDP is recommended in routine management of NAFLD and barriers and facilitators to its implementation in a multi-ethnic setting. Semi-structured individual interviews were conducted with fourteen clinicians (seven doctors, three nurses, three dietitians and one exercise physiologist) routinely managing patients with NAFLD in metropolitan hospital outpatient clinics in Australia. Interviews were audio-recorded, transcribed and analysed using thematic content analysis. Clinicians described that lifestyle modification was their primary treatment for NAFLD and promoting diet was recognised as everyone's role, whereby doctors and nurses raise awareness and dietitians provide individualisation. The MDP was regarded as the most evidence-based diet choice currently and was frequently recommended in routine care. Facilitators to MDP implementation in practice were: improvement in diet quality as a parallel goal to weight loss; in-depth knowledge of the dietary pattern; access to patient education and monitoring resources and; service culture, including an interdisciplinary clinic goal, and knowledge sharing from expert dietitians. Barriers included perceived challenges for patients from diverse cultural and socio-economic backgrounds and limited clinician training, time and resourcing to support behaviour change. Integration of MDP in routine management of NAFLD in specialist clinics was facilitated by a focus on diet quality, knowledge sharing, belief in evidence and an interdisciplinary team. Innovations to service delivery could better support and empower patients to change dietary behaviour long-term.

Perceptions About Health, Nutrition Knowledge, and MyPlate Food Categorization Among US Adolescents: A Qualitative Study

OBJECTIVE

To understand how adolescents define related nutrition terms and use food groups to classify commonly consumed foods into the MyPlate food groups.

DESIGN

Qualitative study with telephone interviews.

SETTING

Houston metropolitan area in Texas.

PARTICIPANTS

A convenience sample of 21 adolescents from a volunteer database of the research center.

MAIN OUTCOMES MEASURES

Sociodemographic questions were asked before semiquantitative structured interviews. The interview focused on understanding how adolescents defined health, other nutrition terms, and food groups, and how to use the MyPlate icon in categorizing commonly consumed foods into groups.

ANALYSIS

Hybrid thematic approach with inductive and deductive analyses.

RESULTS

Adolescents defined being healthy in terms of wellness-type behaviors (eg, diet, physical activity, and sleep). They perceived clear differences between terms such as healthy vs unhealthy food but struggled to define others (eg, energy-dense foods and processed foods). Mixed dishes, hard candies, chocolate chip cookies, and potato chips were the most difficult foods for the adolescents to classify into the MyPlate food groups, whereas apple, lettuce, and milk were easily classified.

CONCLUSIONS AND IMPLICATIONS

Food guidance systems, public health policies, and behavioral nutrition programs targeting adolescents might use health and nutrition terms and prescriptive food categories more clearly understood by adolescents.

Investigating Whether the Mediterranean Dietary Pattern Is Integrated in Routine Dietetic Practice for Management of Chronic Conditions: A National Survey of Dietitians

Evidence supports recommending the Mediterranean dietary pattern (MDP) in the management of cardiovascular disease (CVD), type 2 diabetes (T2D), non-alcoholic fatty liver disease (NAFLD) and solid organ transplant (SOT). However, the evidence-practice gap is unclear within non-Mediterranean countries. We investigated integration of MDP in Australian dietetic practice, and barriers and enablers to MDP implementation for chronic disease management. Dietitians managing CVD, T2D, NAFLD and/or SOT patients (n = 182, 97% female) completed an online survey in November 2019. Fewer than 50% of participants counsel patients with CVD (48%), T2D (26%), NAFLD (31%) and SOT (0–33%) on MDP in majority of their practice. MDP principles always recommended by >50% of participants were promoting vegetables and fruit and limiting processed foods and sugary drinks. Principles recommended sometimes, rarely or never by >50% of participants included limiting red meat and including tomatoes, onion/garlic and liberal extra virgin olive oil. Barriers to counselling on MDP included consultation time and competing priorities. Access to evidence, professional development and education resources were identified enablers. An evidence-practice gap in Australian dietetic practice exists with <50% of participants routinely counselling relevant patient groups on MDP. Strategies to support dietitians to counsel complex patients on MDP within limited consultations are needed.