CHANGING ATTITUDES TO INFECTION MANAGEMENT IN PRIMARY-CARE - A CONTROLLED TRIAL OF ACTIVE VERSUS PASSIVE GUIDELINE IMPLEMENTATION STRATEGIES

Background and objectives. When attempting to implement evidence-based medicine, such as through clinical guidelines, we often rely on passi ve educational tactics, for example didactic lectures and bulletins. T hese methods involve the recipient in relatively superficial processin g of information, and any consequent attitude changes can be expected to be short-lived. However active methods, such as practice-based disc ussion, should involve recipients in deep processing, with more enduri ng attitude changes. In this experiment, the aim was to assess the eff icacy of an active strategy at promoting deep processing and its effec tiveness, relative to a typical passive method, at changing attitudes between groups of GPs over 12 months across an English Health District . Methods. All 191 GPs operating from 69 practices in the Wirral Healt h District of Northwest England were assigned, with minimization of kn own confounding variables, to three experimental groups: active, passi ve and control. The groups were shown to have similar learning styles. The objective of the study was to impart knowledge of best management of infections as captured in a series of locally developed clinical g uidelines. The passive group GPs were given a copy of the guidelines a nd were invited to an hour-long lecture event. The GPs in the deep gro up were given a copy of the guidelines and were invited to engage in a n hour-long discussion about the guideline content at their own premis es. The control group received neither the guidelines nor any educatio nal contact regarding them. Three months before and 12 months after th e interventions, all GPs were sent a postal questionnaire on their pre ferred empirical antibiotic for 10 common bacterial infections. The re sponses were compared in order to ascertain whether increased knowledg e of best clinical practice was evident in each group. Results. Sevent y-five per cent (144/191) of GPs responded to the pre-intervention que stionnaire, 62% (119/191) post-intervention. Thirty-four per cent (22/ 64) of GPs in the passive group attended the lecture; 91% (60/66) of t he active group engaged in discussion at meetings with the authors. A significantly higher proportion of the active group participants' spea king time, during a sample of four visits, was devoted to verbal indic ators of active processing than the passive group lecture attenders (d ifference = 55%, Fisher's exact test P = 0.002, OR = 11.5, 95% CI 2.1- 113.4). Inter-observer agreement on the classification of the verbal e vidence was highly statistically significant for all classes (Pearson' s product moment correlation, P < 0.0005, r = + 0.893 to +0.999) excep t repetition (P > 0.05, r = + 0.407). Median compliance of responses w ith the guidelines improved by 2.5% within the control group and 4% wi thin the passive, but by 23% within the active. The difference between the changes in the active and control groups was highly statistically significant at 17.5% (Mann-Whitney test, P = 0.004 95% CI 6-29%). How ever, for the 10 infections, the median difference between the changes in the passive and control groups was not significant at 3% (P = 0.75 , 95% CI -8 to +12. The median difference between changes in the activ e and passive groups was significant at 17% (P = 0.015, 95% CI 7-24%) in favour of the active. Discussion. An active educational strategy at tracted more participation and was more effective at generating deep c ognitive processing than a passive strategy. A large improvement, last ing for at least 12 months, in attitude-compliance with guidelines on the optimal treatment of infections was imparted by the active process ing method. A typical passive method was much less popular and had an insignificant impact on attitudes. The findings suggest that initiativ es aiming to implement evidence-based guidelines must employ active ed ucational strategies if enduring changes in attitude are to result.