Understanding physicians' decision to perform a clinical examination on an HIV seropositive patient

Integrating Risk Perception Attitude Framework and the Theory of Planned Behavior to Predict Mental Health Promotion Behaviors among Young Adults

Mental disorder is a pressing public health issue in Singapore, especially among young adults. By integrating the risk perception attitude (RPA) framework and the theory of planned behavior (TPB), this study examines psychosocial factors underlying two mental health promotion behaviors - seeking counseling and employing self-help methods - among young Singaporeans. The results of an online survey (n = 232) showed that, as predicted by RPA framework, perceived risk interacted with self-efficacy to affect behavioral intention to seek counseling. However, this interaction existed only among individuals with favorable attitudes toward counseling-seeking behavior and not among those with unfavorable attitudes. In addition, the interaction between perceived risk and self-efficacy was not significant for the intention to perform self-help methods. The current findings demonstrated that the nature of focal behavior and attitudes are boundary conditions of the interaction effect between perceived risk and efficacy, which is the core premise of the RPA framework. These findings offer practical implications for developing campaign strategies to promote mental well-being among young adults in Singapore.

What influences general practitioners' use of exercise for patients with chronic knee pain? Results from a national survey

Background

Exercise is a recommended ‘core’ treatment for chronic knee pain (CKP), however it appears to be underused by general practitioners (GPs). While behavioural theories suggest that attitudes and beliefs influence behaviours, no single theory reliably predicts GPs’ behaviours. A theoretical analysis framework, developed from sociocognitive theories, was used to underpin investigation of the key influences associated with GPs’ use of exercise for patients with CKP, to inform future interventions to optimise GPs’ use of exercise.

Methods

A cross-sectional postal questionnaire survey investigated UK GPs’ reported use of exercise based on a patient case vignette. Factors influencing GPs’ exercise use (behaviour) were examined using attitude statements, free-text questions and multiple response option questions related to factors within the analysis framework. Unadjusted logistic regression analyses explored the associations between GPs’ attitudes/beliefs and behaviour.

Results

From a total sample of 5000 GPs, 835 (17%) returned a questionnaire. Most respondents (n = 729, 87%) reported that they would use exercise. Factors significantly associated with exercise use (OR (95% CI)) included GPs’ beliefs about their role (belief that GPs should give information on type, duration and frequency of exercise (30.71 (5.02,188.01)), beliefs about consequences (agreement that knee problems are improved by local (3.23 (1.94,5.39)) and general exercise (2.63 (1.38,5.02))), moral norm (agreement that GPs should prescribe all patients local (3.08 (1.96,4.83)) and general exercise (2.63 (1.45,4.76))), and GP-related beliefs about capabilities (prior experience of insufficient expertise to give detailed exercise information (0.50 (0.33,0.76)). Whilst perceived time limitations were not associated with exercise use (1.00 (0.33,3.01)), GPs who disagreed that they experienced time limitations were more likely to suggest general (2.17 (1.04,4.55)), or demonstrate local (2.16 (1.06,4.42)), exercises.

Conclusion

GPs’ attitudes and beliefs are associated with their use of exercise for patients with CKP, particularly beliefs about role, responsibilities and skills in initiating exercise, and about the efficacy of exercise. Although the low response risks response bias, these results can inform future interventions to optimise GPs’ behaviour. The role of GP uncertainty and influences on clinical decision-making need further exploration, thus an amended analysis framework is suggested, which should be tested in future research.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0570-4) contains supplementary material, which is available to authorized users.

Impact of Implementing a Wiki to Develop Structured Electronic Order Sets on Physicians' Intention to Use Wiki-Based Order Sets

BACKGROUND

Wikis have the potential to promote best practices in health systems by sharing order sets with a broad community of stakeholders. However, little is known about the impact of using a wiki on clinicians' intention to use wiki-based order sets.

OBJECTIVE

The aims of this study were: (1) to describe the use of a wiki to create structured order sets for a single emergency department; (2) to evaluate whether the use of this wiki changed emergency physicians' future intention to use wiki-based order sets; and (3) to understand the impact of using the wiki on the behavioral determinants for using wiki-based order sets.

METHODS

This was a pre/post-intervention mixed-methods study conducted in one hospital in Lévis, Quebec. The intervention was comprised of receiving access to and being motivated by the department head to use a wiki for 6 months to create electronic order sets designed to be used in a computer physician order entry system. Before and after our intervention, we asked participants to complete a previously validated questionnaire based on the Theory of Planned Behavior. Our primary outcome was the intention to use wiki-based order sets in clinical practice. We also assessed participants' attitude, perceived behavioral control, and subjective norm to use wiki-based order sets. Paired pre- and post-Likert scores were compared using Wilcoxon signed-rank tests. The post-questionnaire also included open-ended questions concerning participants' comments about the wiki, which were then classified into themes using an existing taxonomy.

RESULTS

Twenty-eight emergency physicians were enrolled in the study (response rate: 100%). Physicians' mean intention to use a wiki-based reminder was 5.42 (SD 1.04) before the intervention, and increased to 5.81 (SD 1.25) on a 7-point Likert scale (P =.03) after the intervention. Participants' attitude towards using a wiki-based order set also increased from 5.07 (SD 0.90) to 5.57 (SD 0.88) (P =.003). Perceived behavioral control and subjective norm did not change. Easier information sharing was the most frequently positive impact raised. In order of frequency, the three most important facilitators reported were: ease of use, support from colleagues, and promotion by the departmental head. Although participants did not mention any perceived negative impacts, they raised the following barriers in order of frequency: poor organization of information, slow computers, and difficult wiki access.

CONCLUSIONS

Emergency physicians' intention and attitude to use wiki-based order sets increased after having access to and being motivated to use a wiki for 6 months. Future studies need to explore if this increased intention will translate into sustained actual use and improve patient care. Certain barriers need to be addressed before implementing a wiki for use on a larger scale.

How well do the theory of reasoned action and theory of planned behaviour predict intentions and attendance at screening programmes? A meta-analysis

Meta-analysis was used to quantify how well the Theories of Reasoned Action and Planned Behaviour have predicted intentions to attend screening programmes and actual attendance behaviour. Systematic literature searches identified 33 studies that were included in the review. Across the studies as a whole, attitudes had a large-sized relationship with intention, while subjective norms and perceived behavioural control (PBC) possessed medium-sized relationships with intention. Intention had a medium-sized relationship with attendance, whereas the PBC-attendance relationship was small sized. Due to heterogeneity in results between studies, moderator analyses were conducted. The moderator variables were (a) type of screening test, (b) location of recruitment, (c) screening cost and (d) invitation to screen. All moderators affected theory of planned behaviour relationships. Suggestions for future research emerging from these results include targeting attitudes to promote intention to screen, a greater use of implementation intentions in screening information and examining the credibility of different screening providers.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusions

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

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

Healthcare professionals' intentions and behaviours: a systematic review of studies based on social cognitive theories

BACKGROUND

There is an important gap between the implications of clinical research evidence and the routine clinical practice of healthcare professionals. Because individual decisions are often central to adoption of a clinical-related behaviour, more information about the cognitive mechanisms underlying behaviours is needed to improve behaviour change interventions targeting healthcare professionals. The aim of this study was to systematically review the published scientific literature about factors influencing health professionals' behaviours based on social cognitive theories. These theories refer to theories where individual cognitions/thoughts are viewed as processes intervening between observable stimuli and responses in real world situations.

METHODS

We searched psycINFO, MEDLINE, EMBASE, CIHNAL, Index to theses, PROQUEST dissertations and theses and Current Contents for articles published in English only. We included studies that aimed to predict healthcare professionals' intentions and behaviours with a clear specification of relying on a social cognitive theory. Information on percent of explained variance (R(2)) was used to compute the overall frequency-weighted mean R(2) to evaluate the efficacy of prediction in several contexts and according to different methodological aspects. The cognitive factors most consistently associated with prediction of healthcare professionals' intention and behaviours were documented.

RESULTS

Seventy eight studies met the inclusion criteria. Among these studies, 72 provided information on the determinants of intention and 16 prospective studies provided information on the determinants of behaviour. The theory most often used as reference was the Theory of Reasoned Action (TRA) or its extension the Theory of Planned Behaviour (TPB). An overall frequency-weighted mean R(2) of 0.31 was observed for the prediction of behaviour; 0.59 for the prediction of intention. A number of moderators influenced the efficacy of prediction; frequency-weighted mean R(2) varied from 0.001 to 0.58 for behaviour and 0.19 to 0.81 for intention.

CONCLUSION

Our results suggest that the TPB appears to be an appropriate theory to predict behaviour whereas other theories better capture the dynamic underlying intention. In addition, given the variations in efficacy of prediction, special care should be given to methodological issues, especially to better define the context of behaviour performance.

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

OBJECTIVE

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

BACKGROUND

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

DESIGN

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

SETTING AND PARTICIPANTS

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

METHODS

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

MAIN RESULTS

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

CONCLUSIONS

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

Barriers to success for an evidence-based guideline for chronic obstructive pulmonary disease

OBJECTIVES

To evaluate 1) barriers to clinical guideline use and 2) the relationship between guideline use and inpatient outcomes in chronic obstructive pulmonary disease (COPD).

METHODS

1) Four focus groups of specific health professions (n = 30), from three metropolitan hospitals, and interview of 99 medical officers (MOs), linked to 349 admissions, both guided by behavioural modelling theory; 2) association between guideline use and patient outcomes (length of hospital stay > or = 14 days, and readmission within 28 or 90 days) was evaluated in a cohort of 405 COPD patients.

RESULTS

1) In focus groups, nurses and allied health professionals emphasized facilitation issues including paperwork duplication and time limitations as barriers, but considered improved patient care outcomes as the major guideline use determinant. There were similar findings in junior MOs (nonconsultants) by both focus group and interview, with the addition of a need for a sense of ownership. Senior MOs (consultants) greatly emphasized sense of ownership. Barriers to guideline use varied between types of units. Behavioural modelling explained 49% of the variation in intention to use the guideline for MOs. For nonconsultants, habit and intention were significantly associated with extent of guideline use. 2) Patient outcomes: guideline use was not associated with length of stay or readmission.

CONCLUSIONS

1) Guideline implementation should address issues relevant to different health professions, units and seniority of profession. 2) Guideline use was not associated with reductions in readmission or length of stay.

Factors associated with Army obstetricians-gynecologists' practice of HIV prevention education during routine gynecologic care

The authors evaluate obstetricians-gynecologists' (OB-GYNs') anxiety about clinical uncertainty and patient, physician, and organizational factors associated with their selection of HIV-related educational activities for high-risk and low-risk written case simulations. A total of 117 U.S. Army OB-GYNs completed a mailed, anonymous questionnaire. Overall, informants were much less likely to educate in response to the low-risk simulation; however, more informants who were anxious about uncertainty were more likely to do so in a model that included supportive institutional policies, willingness to educate despite patient barriers, and comfort with the topic. OB-GYNs were more likely to educate in response to the high-risk simulation given greater willingness to discuss HIV despite organizational barriers, supportive policies, and comfort. Findings suggest a need to better understand the role that anxiety about uncertainty plays in HIV prevention and the need to promote organizational policies that support and remove barriers to clinically based education.

Comparing predictors of willingness to treat HIV+ patients for New York City male and female general practice dentists 50 years of age or younger

OBJECTIVES

This article develops and compares gender-specific predictive models for willingness to treat HIV-infected patients (PHIV+) for male and female private general practice dentists (GPDs).

METHODS

Based on mail survey data collected in Manhattan and Queens, New York City (73.3% response rate), hierarchical multiple regression analyses were conducted for male and female dentists 50 years of age or younger (n = 763) and for those in solo practice.

RESULTS

The gender-specific predictive models (R2s = 0.72) do not differ, except for the influence of practice viability, a moderately strong, statistically significant predictor for men, while the least powerful, statistically nonsignificant predictor for women. This distinction remains for solo male and female practitioners. Informal/formal collegial norms are more influential predictors within the solo female model than within the solo male model.

CONCLUSIONS

Findings are encouraging for further work in developing predictive models for clinician subpopulations, with an eye toward developing intervention strategies that reflect key predictive factors for each group.

The theory of planned behavior: a review of its applications to health-related behaviors

PURPOSE

To review applications of Ajzen's theory of planned behavior in the domain of health and to verify the efficiency of the theory to explain and predict health-related behaviors.

METHODS

Most material has been drawn from Current Contents (Social and Behavioral Sciences and Clinical Medicine) from 1985 to date, together with all peer-reviewed articles cited in the publications thus identified.

FINDINGS

The results indicated that the theory performs very well for the explanation of intention; an averaged R2 of .41 was observed. Attitude toward the action and perceived behavioral control were most often the significant variables responsible for this explained variation in intention. The prediction of behavior yielded an averaged R2 of .34. Intention remained the most important predictor, but in half of the studies reviewed perceived behavioral control significantly added to the prediction.

CONCLUSIONS

The efficiency of the model seems to be quite good for explaining intention, perceived behavioral control being as important as attitude across health-related behavior categories. The efficiency of the theory, however, varies between health-related behavior categories.

Assessing HIV-related attitudes and orientations of male and female general dentists

This article examines differences between male and female general practitioners in private practice in New York City with regard to their attitudes and orientations toward treating HIV-infected patients. The survey asked about willingness to treat such patients and perceptions that might influence that willingness, particularly those related to safety and self-efficacy and risk of occupationally acquiring HIV. Possible explanations for gender-related differences are considered. Implications of these findings for the development of HIV-related continuing education programs are discussed.