Enhancing prevention in primary care: are interventions targeted towards consumers’ and providers’ perceived needs?

Abstract

Objective

To explore perceived barriers to the implementation of prevention guidelines, with a particular interest to perceived information needs from the point of view of health professionals and consumers.

Study Design

Focus group.

Setting and Participants

Eight focus groups were held in three Canadian cities: three with consumer, three with family physician, and two with primary care nurses.

Analysis

Inductive analysis based on transcribed interviews. The material was analysed by two of the investigators. Agreement on interpretation was checked independently by three other researchers on 10% of the material.

Results

Lack of motivation, discontinuity of care and lack of adequate remuneration were perceived as the strongest barriers to prevention implementation. Computerized information management systems were not perceived by physicians and nurses as strong facilitating factors. Consumers expressed strongly a need for information on non‐traditional preventive interventions. Physicians and nurses expressed a need for patient education material more than for practice guidelines. Research evidence was not considered as the first criteria to judge the value of preventive information.

Conclusions

Evidence‐based medicine has triggered a massive effort to develop technologies to support the dissemination of evidence‐based information on the assumption that poor access to such information is an important barrier to implementation of effective practices. Our results suggest that such an assumption may not be correct. Providing only evidence‐based information from the realm of traditional medicine will appear restrictive to most users, particularly to consumers, and may not be as valued as anticipated considering the expressed scepticism toward research evidence.

Introduction

The enthusiasm for ‘evidence‐based medicine’ and ‘evidence‐based decision‐making’ has triggered a massive effort to develop technologies to support the dissemination of evidence‐based information to providers and consumers, on the assumption that poor access to such information is responsible for the slow implementation of effective practices. ¹ , 2, 3, ^–4 The world of prevention has been one of the most active scenes of such efforts since the publication of the first evidence‐based guidelines from the Canadian Task Force on Preventive Health Care (CTFPHC) in 1979 (previously known as the Canadian Task Force Periodic Health Examination), which was followed by similar publications in following years. ⁵ , 6, ^–7

However, such assumptions rest on scarce conceptual research, which may explain the mitigated results of many interventions based on various information reminders and reaching out strategies. ^{8 , 9} Studies suggest that clinicians often do not implement the recommended preventive strategies, mainly because they do not believe in the benefits of prevention or are sceptical of the recommendations. It has also been suggested that clinicians may have difficulty organizing their practices to deliver preventive care, or are worried about raising issues related to unhealthy behaviour as it may damage rapport with their patients. ^{9 , 10} , 11, 12, 13, 14, ^–15 Research on consumers’ expectations for preventive care and information is even more scarce. ^{15 , 16}

This project was initiated through the Health Evidence Application and Linkage Network (HEALNet), which links centres of excellence for research on the diffusion of evidence‐based health information. HEALNet is committed to the concept of evidence‐based medicine and devoted to the development of information technologies to support the diffusion and implementation of effective health‐care from the perspectives of decision‐makers, providers and consumers.

The objective of this study is to explore the perceived barriers encountered by a group of health professionals and consumers in their efforts to implement prevention activities as recommended by the CTFPHC (which include immunizations, screening and counselling), with a particular interest in their perceived information needs in order to guide further work on information technology and on systems to support practice organization.

Methods

It was decided to conduct eight focus groups in three different Canadian cities in order to take into account the potential impact of regional and cultural differences. Montreal is in the province of Québec which is a French speaking province. Toronto is the larger Canadian city and Calgary, located in western Canada, is representative of medium size cities closely surrounded by rural settings. The study sample comprised 23 consumers, 22 family physicians (FP), and 13 nurses. The focus group with nurses in Montreal was cancelled at the last minute due to the launching of a special immunization programme for hepatitis A and B. This was due to the fact that in Montreal the majority of primary care nurses work in public community health centres.

The health professionals were selected through four of the seven primary care networks affiliated with HEALNet: the networks of the Family Medicine Departments at the Universities of Montreal, Sherbrooke and Toronto, and the Alberta Primary Care Research Unit (APCRU) network. They were informed that the objective of the study was to gain a better understanding of the barriers they encounter in their attempts to integrate prevention to their daily clinical practice in order to develop interventions or tools which could assist them and which they would be invited to test in the future. Physicians and nurses were chosen to balance gender, age, range of professional experience, practice setting (solo, group, community health centres), university affiliation, and practice computerization in each group, which was composed of people who did not work together. The family physicians’ mean age was 43 (range: 30–60). There were 12 men and 10 women; 13 had completed residencies in family medicine. Nine worked in community practices and five worked in university‐affiliated teaching practices. The nurses’ mean age was 41 (range: 31–58); there was one man and 12 women. Two worked in fee‐for‐service private practices.

In Montreal, consumers were recruited from a list of individuals who had responded to advertisements in two large newspapers and two community journals for a previous study on similar issues but who had not been selected. In Toronto and Calgary, consumers were identified by the staff members, who recruited acquaintances not working in health‐care. In all three cities consumers were invited to participate in a study, the aim of which was to better understand how to improve the integration of prevention within the health‐care system. Groups were balanced for age and gender. The consumers’ mean age was 47 (range, 26–69). There were 11 men and 12 women; 15 had completed university, six high school, and two primary school; 20 reported a regular source of health‐care.

The focus group interviews followed a pre‐established scenario, lasting approximately 90 min (Table 1). The two principal investigators (MDB and YT) conducted the interviews. The interviewers took notes during the interviews which were also tape‐recorded.

Table 1.

 Overview of the areas explored during the focus group discussions

Each session was followed by a recorded debriefing session between the two investigators, at which each investigator also took notes. All sessions were then transcribed and transferred to NUDIST software for data management.

Analysis was based on transcriptions of the group discussions and debriefing sessions, and on the investigators’ notes. The two investigators who attended all focus groups both reviewed the transcripts in their totality and elicited themes independently before sharing their interpretations. In addition, two investigators (ARJ and MX) who had not participated in the focus group sessions were asked independently to review about 10% of the interview transcripts and to identify major themes. The validation of the coding was done by comparing the results of the coding among the two principal investigators (MDB and YT) and their colleagues (ARJ and MX) on these segments. Their analysis was compared and shared for discussion. There was an overall 80% agreement on the coding (transcript breakdown and theme identification). No statistical measure of agreement was performed.

The protocol was accepted by the ethics committees of the faculties of medicine at the Universities of Montreal and Toronto.

Results

Remarkable consistency in the opinions expressed was observed within each category of respondents in the three cities. Consumers, though recruited through different methods, were comparable for their interest in ‘alternative’ medicine and also for a certain disappointment towards physicians. Most expressed a strong sense of autonomy towards medical matters. They felt able to judge medical information and make decisions for themselves. Physicians and nurses, although recruited for their interest to be involved in developing tools to support prevention implementation, appeared disillusioned about the value of such tools.

Barriers and facilitating factors in implementing preventive practices

The major findings are summarized in Table 2. They can be categorized as consumer, professional and system related factors.

Table 2.

 What is prevention and how is it implemented?

Consumer‐related factors

All consumer and professional groups recognized a lack of motivation and a low priority given to prevention as the two principal consumer‐related barriers.

Professional‐related factors

Time and money were identified as the most important professional‐related barriers by all respondents and consumers questioned whether physicians were truly interested in prevention issues or not. Some reported more fulfilling experiences with nurses. Physicians and nurses perceived comparable time pressures. Most professionals were unhappy with their own preventive care.

System‐related factors

Respondents identified many system‐related factors. Lack of time is identified as the most important factor by physicians.

On busy days, when I’m going fast, I get into that mindset and I’ve got people waiting and you’ve got to keep moving and it’s a different way of thinking. I think it takes for you to add on something or it takes a little bit of time, even starting the conversation. I don’t know, sometimes I don’t want to start conversations, I want to get on to the next patient. So I think time and manpower is an issue.

All mentioned the importance of continuity of care. For consumers, continuity appears the only way to achieve the knowledge and trust necessary for good preventive care. To the physicians interviewed, continuity is necessary if one is to invest ‘emotionally’ and financially in prevention. Both physicians and consumers perceived lack of continuity as a problem, particularly in urban settings where ‘doctor shopping’ is frequent. As one physician put it:

I mean, to me it doesn’t make sense to attempt to do health promotion when clients or patients use walk‐in clinics and other health‐care professionals and get all these interventions and tests done.

Physicians stated that they feel they are asked to assume responsibility for prevention on their own. All considered unacceptable any cost of ‘getting organized’ to deliver preventive care. When asked what would help them most to implement preventive care in their practices, physicians and nurses responded:

A person. Not a package; a person.

Although they recognized that office systems can help, they did not see them as facilitating factors that could overcome the main barriers. Some physicians mentioned that they would rather pay for an employee than for an office system. Indeed, two physicians in private practice (one in Toronto and one in Montreal) were paying a nurse to assist with preventive care.

Although physicians recognized the value of patient reminders, many expressed concern about such active strategies, which they perceived as intrusive and ‘disempowering.’ Fewer nurses expressed this concern, while most consumers found the idea of reminders appealing.

Physicians also identified controversies and changes in recommendations as major difficulties. To them, controversies undermine the medical community’s credibility. Consumers did not mention controversies as a source of difficulty. It appeared to us that they were less aware of the controversies. For example, all physicians spontaneously talked about their difficulties in dealing with the controversial recommendations about screening mammography for women aged 40–49 years and Prostatic Specific Antigen (PSA) for prostate cancer when no consumers raised the issues.

Both FPs and nurses were very sensitive to the fact that consumers’ needs vary across population groups and are constantly changing. In particular, nurses who had been involved in individual and group interventions were very aware of this phenomenon and had experienced various disappointments in organizing events such as patient‐group discussions on issues like menopause, nutrition, etc.

Information needs and sources

The major findings are summarized in Table 3. They can be categorized as related to the type of information needed and to the preferred ways of accessing and of assessing information.

Table 3.

 Information needs

The type of information needed

For me, prevention is to go and get information—information on nutrition, sleep, and exercise.

This opinion was expressed in all of the consumer focus groups. To patients, information is empowering. Consumers expressed a very holistic concept of prevention. Consequently, they expressed a need for all kinds of health information, and a need to be able to discuss this information with their physicians. Nutrition, and stress‐management were ranked first, followed by the classical healthy behaviours. They gave high priority to measures fostering a ‘healthy mind’. They perceived nurses and pharmacists as important sources of health information, more than physicians.

Consumers appeared to give equal importance to information about traditional and alternative interventions. They want access to scientific evidence on the effectiveness of ‘natural medicine’, and are concerned that natural and traditional medicine seem opposed to one another. For some, practitioners of alternative medicine were an important source of advice on prevention.

Nurses and physicians saw prevention principally as lifestyle counselling. Physicians valued their role as educators highly, and took a broad approach to counselling. They saw anticipatory guidance and working with young families as major preventive activities. They mentioned immunization, Pap smear testing, and mammography as their principal screening activities.

Physicians appeared to want various types of information, including scientific information and clinical practice guidelines, as well as patient education materials. They also stated that they wanted information on various community resources. Nurses expressed, almost exclusively, a need for patient education materials. Very few expressed interest in information on alternative medicine.

Accessing information

We explored how consumers would prefer to access information. Television ranked first, followed by written material. When they have to make a specific decision, consumers said they prefer print rather than audio‐visual material. Print was perceived to be accessible at ‘your own speed’. It was also suggested that important portions can be reviewed, and can be brought in for discussion with one’s physician. It is also easier to assess the validity of printed information. Respondents did, however, acknowledge that printed material may be inappropriate for people with reading or perceptual difficulties.

Some consumers used the Internet for information, but acknowledged that this medium was unavailable to large groups of people. Consumers believed an important source of information would be ‘user‐friendly’ computers like the government kiosks in shopping malls, which give information on job openings. This suggestion was proposed spontaneously by some of the consumers without probing by the interviewers. Consumers gave priority to the development of interactive television stations providing medical information over Internet or personal computer software, which were not considered accessible to the majority of the population. In their opinion, such development would permit information retrieval to be consumer‐driven.

Most consumers identified the physician’s waiting room as one of the most useful potential sources of information, but also one of the least exploited. Consumers said they would like to find print and audio‐visual materials in the waiting room, although few would feel comfortable using interactive software without assistance. Nonetheless, they showed great interest in self‐administered questionnaires to help them evaluate their health status or risks. Physicians, however, did not spontaneously consider the waiting room to be a preferred site for patient education. They appeared to see the waiting room as a ‘no man’s land’, in which an investment in educational materials is not worthwhile.

For physicians and nurses, computerization was clearly valuable: it permitted more convenient storage of information (medical information, community resources, and patient education materials), ready access to information, and the ability to link different sources of information. Many physicians, but few nurses, already used computers for such purposes. The use of computers for this purpose was perceived as feasible and affordable because it did not involve major organizational changes. Most physicians questioned the need for expensive software, as some clinical recommendations quickly become obsolete and most guidelines are already available through the Internet.

Assessing information

All groups perceived the difficulty of distinguishing useful information from that which is useless or harmful, and believed sources must be evaluated for potential conflicts of interest. However, both professionals’ and consumers’ attitudes depended on their comfort with uncertainty. These attitudes ranged from ‘healthy scepticism’ to complete acceptance.

Consumers considered the most reliable source of information to be a friend or someone with a similar experience. Many were suspicious of and had difficulty accepting scientific information unsupported by personal experience and popular wisdom.

New information, I seem to hear there’s a degree of scepticism about that. About whether you believe the information the first time you hear because in a month or two down the road you’re going to here something that’s contradictory so time has a way of sifting that information till we have stuff that we all kind of universally believe about what’s good for us and what isn’t.

Many consumers said that, unless trust had been established, they would challenge a professional giving scientific information which would contradict their perceived knowledge. Consumers said they could accept an FP as a privileged source of information, if the relationship were stable and trust had been established.

In general, the physicians said they felt at ease in judging the credibility of information more than the nurses and saw as less valuable the sense of security gained from a purchased programme ‘rubber stamped’ by expert committees. We did not perceive that the physicians were less willing than nurses to express uncertainty. The fact that physicians feel more secure in front of scientific data is not surprising considering the importance given to appraisal of the medical literature in the last 10 years.

Evidence‐based information did not appear to necessarily alleviate scepticism, as science appears suspect to many consumers and to some physicians. As one physician said:

I am not convinced that there is only a purely scientific side to all of this. I think that there is an underlying financial aspect to it.

Such opinion was not expressed as strongly by the nurses. Physicians, nurses and consumers were also sensitive to the transient nature of scientific findings. As one woman said:

I can remember the doctor coming in and the baby was beside me in the Hospital and he said never ever put a baby on its back! And now that’s the way they do it, you know. You get bewildered sometimes with all this.

All categories of respondents perceived information from the pharmaceutical industry or specialist societies as more likely to be biased. Like consumers, the physicians and nurses we have met gave more weight to personal experience and were inclined to dismiss scientific data which contradicted acquired knowledge.

Discussion

This exploratory study suggests that the heavy emphasis put on information management and practice organization systems as a means to improve the delivery of effective preventive care in clinical practices does not address the main barriers experienced by health providers and consumers. Those barriers pertain much more to motivation issues and system‐related factors such as the difficulties to foster continuity of care and the lack of financial incentives. Difficulties in accessing and assessing information as well as a lack of practice organization were not perceived as important.

We observed many interesting differences between the consumers and the physicians on some important issues. Physicians and consumers differed in what they said about reminders, use of waiting rooms and alternative medicine and in their perception of what prevention is. Physicians questioned their responsibility to remind patients of the various prevention activity schedules, some almost considering this is an insult to their patients’ autonomy. We believe, however, that statements about the ‘disempowering’ nature of reminder systems are a way of rationalizing lack of interest, rather than a true concern about patients’ autonomy. Consumers actually found reminders attractive.

The discrepancies that we observed between consumers and physicians on the perceived usefulness of the waiting room must be underlined. Work on sophisticated computerized systems may have distracted professionals from simpler, but maybe more effective, ways to convey information on prevention such as the waiting room. Similarly, our observations suggest that different communication media may be more effective for different purposes. Television, for example, could be highly effective in attracting attention, but print could be the most effective format helping consumers make health‐related decisions. The cost implications are high, necessitating a source of funding that would also have implications for acceptance of the information.

The need for information on prevention was strongly expressed by all respondents, but consumers differed from professionals in the kind of information needed and in how they wanted to access it. Information provided must go beyond the traditional messages of both the CTFPHE and the USPSTF, particularly for consumers who appeared to have a much broader definition of prevention than physician and to highly value alternative medicine as a source of prevention.

We accept that the study groups were a unique population. The consumers we met were obviously interested in prevention. All were well educated and very articulate about medical information. They represented people who had adopted new information technologies early in life and are, therefore, certainly not representative of consumers in general. However, they also made interesting suggestions on ways to develop consumer‐driven information tools. On the other hand, we were surprised by professionals’ low level of enthusiasm, especially as we had solicited their participation because they were involved in primary care research and had expressed an interest in prevention and our research programme.

Would we have obtained a different picture if we had opted for individual instead of group interviews? Focus group methodology is particularly appropriate because individuals develop their opinions by interacting with other people. By permitting interaction, focus groups widen the range of responses and help participants recall forgotten details. Focus groups also, however, produce censoring effects, and do not allow an in‐depth exploration of values. ^{17 , 18} Because of the group dynamics, some participants may not have expressed their point of view. This is more likely to have occurred in the consumer groups where we observed that some of the participants who were more critical of medicine were more likely to try to convince the other participants of the rightfulness of their own opinions. We tried to avoid this by asking regularly that all participants give their opinion. Also, participants expressed many negative opinions about prevention and scientific knowledge, suggesting that they felt at ease departing from the group’s ‘social norm’. The fact that the opinions expressed by the French and English speaking respondents were comparable must be noted. Some concerns have been expressed about the reliability of the interpretation of focus group data. Weinberger and coworkers reported disagreements ranging from 32% to as high as 56%. ¹⁹ This was not our experience.

How do those results contribute to a better understanding of the issues at stake in the area of disease prevention? To our knowledge, we are the first to report observations suggesting some important differences between consumers and physicians on prevention, particularly on the issues consumers may be seeking counselling for. Like others, we observed that physicians tended to underestimate the capacity of office systems to support their work in prevention. ^{14 ,   15} The direct and indirect costs attached to computerization appeared unacceptable to most of the physicians we met, unless organizational and financial incentives were offered.

But what appears as the most striking observation is the low value given to the strength of the scientific evidence as a criteria to judge of the quality of the information provided compared to the source of information and its congruence with personal experience and popular wisdom. We are not the first to report observations suggesting that science is suspect to many consumers and physicians. ⁹ , 10, 11, 12, 13, 14, ^{–15 , 20} Health providers, patients and researchers all operate in different worlds.

In the light of this observation, one must question the emphasis given to the development of information management tools for consumers, providers and decision‐makers relying almost exclusively on evaluation of the quality and strength of scientific data and dismissing contextual information. Rather than fostering the dissemination of new scientific evidence into practices, this may widen the gap between two apparently opposing approaches to medical decision‐making: one which relies on the grading of scientific evidence and the other one relying on the analysis of contextual and anecdotal information. Still, it is now recognized that good decision‐making necessitates the effective integration of both kinds of information. ^{21 , 22} This research complements a growing body of research which identify challenges and difficulties in bridging the gap between the science and the art of medicine.

Acknowledgements

We thank all participants in the focus groups, as well as staff members of the four primary care networks who helped recruit participants: the networks of the Departments of family medicine at the Universities of Montreal, Sherbrooke and Toronto, and the Alberta Primary Care Research Unit (APCRU) network. ARJ was supported in part by funds from the program in Evidence‐based care, Cancer Care Ontario. He holds a National Health Scholar Award from health Canada. This study was funded by a HEALNet grant. HEALNet (Heath Evidence Application and Linkage Network is a network of the Centers of Excellence of the Medical Research Council).